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.

Advance Directives

One thought on “Advance Directives

  • June 26, 2014 at 5:42 pm

    The first part of the story is great and one more reason my belief is that the PROVIDER should ALWAYS be having the Advance Directive discussion with patient/family – not the nurse or social worker. These decisions are at least as important as choosing a medication or heroically digging to find out if they have small, dense lipoprotein or one more case of asymptomatic bacteriuria. How many of those persons to who we relegate advance directives discussions have ever done CPR and felt the flail chest as the ribs cracked, or been soaked in blood as the elder spits up blood with each compression Due to the rib that is now protruding through the lung or had to walk a family in to see the fresh, dead body, though now it has blood all over the room, tubes in the neck, ribs popping out and or a giant airway sticking out of the mouth. What a wonderful last sight of a loved one. No — this is MY privilege as the provider who has seen and done that took many times to ever let it happen again without the person or family knowing exactly what they are in for if they choose “Full COR”.

    As far as the second case, I should recuse myself because I know the case. I will say, though, that by simply offering to pray with and for the patient – and doing it because I meant it – I was able to establish a bond that allowed us to get way beyond discussions of the consistency of food to provide her or whether or not a miracle would occur. The proxies here are working diligently for one of their own, not giving up and making the best decisions they can with the beliefs they have. Nonetheless, each time I meet with them I do 2 minutes of education about how her kidneys are gradually failing and what that will look like in the coming weeks or how she likely bled around the glioblastomas last week as the cause of her seizures and what that is doing to her brain or…and then end with hope and a prayer that God will take her in His time, not man’s. We always leave with mutual respect.

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