When I saw my first patient die, I was in shock. I knew that some will die but you are not really ready until you see one. You will never forget your first one, that always stays with you. When my first patient died during medical school; a young guy around forty. He died from complications of Endocarditis. He was fine in the afternoon, talking about his family and what he does, when I came back in the morning he was gone. I was shocked beyond words. Unfortunately with time and age you get used to it. We adapt and move on but still end of life issues are difficult to deal with, even for the most experienced doctors.
I wrote about the role of hospice here earlier. But there is a transition, a process which ends up with hospice or no code status, but this process starts when a physician starts talking about end of life issues.
During my training at UMASS, we were taught to always inquire about the code status at the completion of history and physical. This included either a Full code, DNR (do not resuscitate) or CMO (comfort measures only) status. However , most of the time this discussion is delayed until it is too late in the game.
Some of the pitfalls I see in this matter are:
1- Physicians are a little weary about inquiring the code status. There may be a certain level of apprehension as they think that the patient may loose confidence in them if they ask this question.
2- Patients may get angry as we all know that we will never die.
3- Often I hear physicians asking patients "do you want us to do everything". In this scenario physician assumes that the patient does not want to die. Information is not carried to the patient properly and the patient makes a vague statement "yes", But the question is yes to what? However, code status is entered in the medical record as Full code.
I am not saying that I am an expert in this issue. Usually this is how I ask them after I am finished with history and physical that "I would like to ask what I ask all my patients, what are your wishes in case your condition deteriorate, I don't want to do any thing which is against your believes and wishes".
You need to ask the patient how they feel or understand about their condition, otherwise it becomes a one sided discussion without giving the patient an opportunity to discuss their perspective.
If they decide to be DNR, then I go over various options which a person can choose from refusal to blood transfusions to refusal of basic CPR or intubation.
It is important to give patient time after each statement for two reasons a) It gives times for the information to sink in and b) it gives physician some time to read patients reaction and some space to to maneuver words to soften the impact.
All in all this is a very important process and physicians need to be more proactive about this process.
Blog you later.
About the picture: I woke up at 5 am to run to Na' Pali coast, Kauai when I saw this sunrise at the beach.