Necessary conversations

Medical drama script excerpt:

Scene 1: Quiet post-op hospital room where healthy 60-year-old marathon runner lies post uneventful appendectomy. Enter stage right, extremely handsome, intelligent physician bathed in a heavenly light of healing.

“Bob, we need to talk about a serious matter,” states the angelic physician. “If your heart were to stop what would you like us to do about it?”

“What do you mean?” asks the concerned patient.

“Well, would you like to be resuscitated?” questions the physician.

“What are you trying to tell me?” stammers the increasingly alarmed patient. “Didn’t my appendectomy go well? Why would my heart stop?”

“It went fine, but we have to fill out this form regarding your wishes, which we keep on your chart,” explains the calm physician. 

Fade to black

I think we can all agree that having advanced directives for end-of-life care is a good idea. Previously, many elderly patients with numerous medical problems underwent unnecessary resuscitation attempts as this delicate subject was never discussed with them prior to their life-ending illness. Sometimes when one of these patients started to fade the nurses would add a note on the chart that would say something like, “code status?” This really meant that they didn’t agree with the current status of full code and wanted to ask you if you were out of your mind to try and resuscitate this 90-year-old with end-stage lung disease.

In my health region we have a document called Medical Orders for Scope of Treatment (MOST), which outlines the patient’s advance directives for CPR and range of desired medical treatments. It seems that the pendulum has swung a little too far in the other direction as this form appeared on my healthy 60-year-old athlete’s chart to complete when he presented with appendicitis. However, the trend toward advance planning is a good one, as I can remember being part of many apparently inappropriate resuscitations through the years. The MOST form has been a good reminder for me to discuss end-of-life planning with my patients. 

Probably the best place to discuss this issue is in our offices. I attended a GPSC PSP seminar on palliative care recently where GPs were encouraged to talk with their patients regarding their views on death, dying, and resuscitation. If you wouldn’t be surprised if a patient were to die in the next year, it’s likely time to have this discussion. I find that patients respond well to this dialogue, particularly if I present it as a routine part of my care plan for my elderly patients with complex medical problems. Many patients fear they will be kept alive on machines without consent and appreciate having their wishes heard. 

I am often surprised by the acceptance patients have about their possible impending death and their desire to be left alone in dignity while they die. Their biggest concern is that they might suffer needlessly, and once this fear is allayed they become very calm and rational about their plans. I would encourage each of you in primary care to start talking with patients about death and dying as, let’s face it, we are all going to be there one day. 

David R. Richardson, MD. Necessary conversations. BCMJ, Vol. 56, No. 1, January, February, 2014, Page(s) 4 - Editorials.

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