End-of-life conversations, as seen by the intensivist: Thoughts about Hospitals, Medicine and Health Care Issues

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End-of-life conversations, as seen by the intensivist: Thoughts about Hospitals, Medicine and Health Care Issues

by Paul Levy - January 13, 2012

Provided by Not Running a Hospital

My recent post on end-of-life care issues, "What if they had had to pay?," generated a lot of comments in the blogosphere and beyond. One intensive care doctor sent me a particularly poignant note. It gives a good sense of what it is like on this person's side of the bed. The note re-emphasizes the need for better end-of-life planning, for the sake of patients, families, and providers.

Here's my day so far. This is my first day of a 7-day stretch in a tertiary ICU. The average census in this ICU is 10, but today we have had to surge to 15.

Let me stop right there. This is doctor (and nurse) shorthand for, "I expect to be very busy, very tired, and very stressed out. I am going to have to make some highly critical clinical judgments, sometimes with very little time to react. I don't know anything about these patients beyond what is in the charts and what our care team sees and hears for themselves."

Two patients today coded in our hospital. One family wants "everything" done, and seemed shocked to learn that I don't think it is right to provide "everything." The other family wished someone from the healthcare team had bothered to ask them what their 89 year old dad would really like to accomplish from his hospital stay before he tried to die. We decided to let him finish dying.

And I had 3 other similar discussions with patients or their families about goals that can actually be achieved. All of them were already in the ICU, having had no real clear previous discussions. One of those patients was admitted last night, but the other 2 had been in our ICU for days....

Paul Levy is the former CEO of a large Boston hospital. He blogs to share thoughts about hospitals, medicine, and health care issues. Paul is an advocate for patient-driven care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement.

The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

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J.Leahy (Wisconsin)	on 18 Jan 2012 at 11:21 am

I have continually noted family difficulties in making these decisions, and I have tried to give good advice to the patient, and to their families. There really should be some education to medical students and residents on how to have these conversations. Not just general guidelines, but specifics, as in "how to approach the topic", perhaps with actual scripting of what to say. I feel it is my duty to my patient to know beforehand what their choice is for advanced directives, and then to be their advocate for them even in the face of their family wishes. I find it sad when my patient does not want anything done, and definitely no "lingering" in the dying process, but because they are not able to speak for themselves anymore, what their family wants determines the course of their care. I had one patient whose daughter decided she should be transferred to a higher level of care so "the rest of the family would have time to get there", before she died. It is hard to see your parent dying, and some of us refuse to consider that event and so demand the utmost in care for the parent, and some of us are just scared. Many years ago now, my mother was dying from cancer, and we (me, my brother, and my father) were asked if resucitation should be attempted if she coded. I knew she would not want it, but I could not force the words out my mouth. I turrned to my brother to answer, he looked at me for awhile, but he said nothing, and turned to my father. My father could not answer either. Luckily, the Attending was present and asked my mother's resident if he thought she was still competent to make that decision. He said, "yes", and went in to ask her. The Attending then kept us busy in other questions and conversation. I never did find out her answer, and she died about 12 hours later. I was thankful then, to be given a way out of answering that question, and so I also am thankful to that Attending. It is also why I ensure my patients' wishes are known and documented in the chart. When the time comes, I can be very sure in what the patient wants and communicate that to the family.