From Donald Murphy, MD
Two “firsts” for me, both in the same week.
Case A is Darleen, a healthy woman seen in clinic. I had extra time at the end of our visit, so decided to cover Advance Directives. Discussion of CPR suggested she might want this (though her ambivalence was apparent). Discussion of short-term mechanical ventilation was surprising. After I described a hypothetical scenario, she stated, “I’ve had this before [referring to seizure requiring mechanical ventilation, 5 years before] and don’t want to do this again.” First time I’ve heard a senior state this. I emphasized the importance of revisiting her preferences with her family, explaining that it will be very hard for them to accompany her to the ER with an acute, reversible illness and expect the treatment to be just morphine and other comfort measures. Advised that she have a DNR order, get a DNR bracelet or necklace, revisit options with her family, and that we discuss more later.
Case B is Therese, a woman in SNF who is near dying with glioblastoma. Her fellow parishioners (one serving as MDPOA) are very clear that they don’t want hospice and are hoping/praying for a miracle. They’ve had multiple talks with the palliative care team in the hospital and still insist on curative care. The MDPOA wonders what Therese would say if she “could wake up and tell us her preferences.” My solution was to share that I’ve met 1 in 5,000 patients in the last 25+ years who would opt for aggressive care in this situation. Doubt this will make a difference, but it was the one perspective that hadn’t been shared with this community. We’re developing a statement in our hospice consortium to address these similar conundrums. Stay tuned.