Sunday, September 06, 2009

End-of-life Care Conversations

The Chicago Tribune highlights a discussion on DNRs in today's paper. The article looks at Gloria Hayes, a 77 year old with pancreatic cancer, her family, and palliative care team at Advocate Lutheran General Hospital. On a personal note, I met Dr. Preodor when he was the medical director for the hospice where I did my fieldwork placement; he stepped down from his position when I was a few months into it but I remember being impressed with his dedication to our patients and to further public understanding regarding end-of-life issues. Overall I thought the article was well done. The patient is very clear on what she wants. "Death is a certainty," she had said. "There's no sense in me fearing it. There's nothing I can do about it." Her family is more conflicted, hopefully illustrating the importance of these conversations ahead of time. The medical professionals clearly lay out the facts and their recommendations but also talk about abiding by whatever the patient wants.

Preodor then described cardio-pulmonary resuscitation in a way that sounded nothing like TV. A violent pounding on a fragile chest. A high probability of ending up on a ventilator in an intensive-care unit. No effect whatsoever on advanced pancreatic cancer. "It is not recommended for people with cancer," Preodor said. "My recommendation -- but it is something for you to think about."

When I first read that passage, I cringed knowing how the words might be interpreted. Unfortunately people often take TV-portrayals to be reality; the way the reporter writes, it might appear that Preodor is trying to scare the patient into signing the DNR. Of course, he is doing no such thing. The public is generally not aware of the side effects of CPR on a healthy person so why would they consider the risks to someone whose health is already compromised? I had to go through CPR certification for work a year or so ago and was surprised to learn that people often throw up while receiving CPR. I already knew that it's not uncommon for a rib to crack or break during the process. Yes, lives can be saved through CPR but it is not an easy, magical process. (At least from this social worker's perspective.) I think it is important for patients to be aware of how their condition affects the effectiveness of CPR.

The article then highlights Someone to Trust, which trains facilitators to lead advanced care planning conversations in the Chicago area. Their long-term goal is to significantly increase the number of Chicago-area residents participating in advance care planning prior to a healthcare crisis. Someone to Trust notes: "While advanced care planning (ACP) can include advance directive documents, it is also an ongoing, living conversation and decision-making process between patients, families, designated agents and medical practitioners where end-of-life medical wishes are discussed. If initiated while the individual is capable, these conversations provide needed information and give the individual time necessary to understand and interpret the information in the context of her or his own values and goals." It's important to have organizations out there that can assist people in formulating their wishes. These conversations must continue regardless of their coverage under the proposed health care plan.

Finally, yes, that is our very own healthcare blogger, Dr. David Fisher who is quoted in the article.

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