To resuscitate or not (bus stop spin off)

[Kiwiology]

You are correct that it'd better be a good decision hence why I'm saying when it's "clearly inappropriate" for example somebody who is on palliative care, has end stage co morbidities e.g. heart failure or COPD or has a clearly severely diminished health related quality of life e.g. somebody who is bed bound at the rest home who requires help to pee, poo, shower and feed and where the lights are on but nobody is home

I'm not talking about "playing God" but more about making the best informed choice you can about a situation where it is not in the best interest of the patient to put them through the horrendously undignified and invasive gauntlet of being resuscitated and ending up in ICU for a day or so only to die there rather than having some sort of dignified death at home.

Let's say you go round to Nana's house, Nana has end stage heart failure, can't take more than five steps without becoming short of breath and sounding like a dishwasher, has a catheter in situ because the physical act of walking to the loo and having a toidee is just too much for her to manage, can still sort of feed herself but it takes a while, takes a truck load of meds and finds it to physically stressful to have a shower so gets a body wash from the home carer who pops in to give Grandpa a hand with the various bits and pieces that Nana needs, oh and Nana has not left the house in a year since her last massive cardiac surgery because she is too weak. Where the fuck is the point in coding her? Seriously?

[Just Plain Ruff]

But Has anyone asked Nana what she wants done? I don't see that anyone has asked Good ole Nana what she wants done, have they Kiwi?.

Has anyone asked grandpa what he wants done? Kind of hard to ask after the arrest but prior to the arrest, a sit down with Nana would be most appropriate and say "Nana, when you go into cardiac arrest, and YES you will go into Cardiac arrest, not right now, not in the next 5 minutes but it's coming soon, what do you want done?" You outline what will happen when they code, what they EMS personnel will do to them if they haven't made plans to either allow it to happen or to keep it from happening and then have the game plan in place for when it does.

That is what I helped my father go through with his father. We sat down with my grandfather and I outlined what the paramedics and firefighters would do to him when and if they found him in cardiac arrest in his house. He didn't have to go through that, he stroked out and they went a different treatment route in the house. But a code would have been ruled out because we did a No Code Blue form that the State of Missouri had developed.

My grandfather passed peacefully without cpr in a nursing home at 3am one morning.

Edited May 15, 2012 by Captain Kickass

[Kiwiology]

Not everybody has an advanced directive/DNR/living will so it's more about those situations where none is in place; locally we're spoilt (or just sensible?) that "advanced directive" includes verbal directives but that's not really important, it's more about the general principle

[Just Plain Ruff]

I agree but we are skirting the issue Kiwi. We are leaving out the most important person. I know at the time of our coming into the situation the question is moot but what about pre-situation. That person who is in Nana's shoes. HAve we asked her what she wants done?

I'm sure that we have been to her house countless times. We know she's a waiting timebomb. Have we asked her or has the hospital asked her what she wants done?

Have we asked her if her point blank, what she wants done when her heart stops?

I have asked the patient who I know is getting ready to code, what they want done. Do they want me to code them, do they want CPR, do they want defibrillation and many times they have told me to let them go.

I then get on the phone to the ER and talk to medical control. Each time medical control has backed the patient and allowed me to provide comfort measures and not to code them.

Patient wishes trump family wishes every time in my book.

I had a patient tell me one day as he was in V-tach with a very very weak pulse, "If you code me, I will kill you" and I believed him. I asked him again if he wanted to be resuscitated and he said no. I put him in the ambulance, transported him the 35 minutes to the hospital, had orders to not resuscitate, provided comfort care and he passed away very peacefully 20 minutes into transport. It was a surreal situation.

[Kiwiology]

If Nana doesn't have a DNR et al then nobody has asked her which is actually pretty rare, most GPs and palliative care people are pretty damn onto it about these sort of things

Specifically regarding patients who are receiving end of life or "comfort care" it is overwhelmingly held here that it is inappropriate to instigate life prolonging treatment, which I think sums up this whole thing very nicely

[Just Plain Ruff]

but in your example of Nana, is she receiving comfort care? If she isn't, then we are right back to where this discussion began aren't we? If a care giver coming in is considered comfort care then why are you bringing coding Nana up?

[Bieber]

You'd have to ask him to know.

So the value of exerting the effort for CPR boils down to Kiwi's perception of one's quality of life?

And can you put that value into a protocol for me? I'm guessing it would sound something like, "I can't define quality of life, but I know it when I see it!"

What happens when Dylan codes, and you know from previous experience that he's living no kind of life that you consider to have quality? Does he not receive resusc attempts based on being autistic?

Grandma that chooses to get up every day despite her mental and physical frailties? I mean, hell, she's never going to golf again, let the bitch go.

And how will you judge that quality of life to make such a decision? Dispatch rarely knows what's going on, you can almost never get a decent story from people on scene. What information are you going to use to make your decision?

If I code in my living room I will gladly sell my soul and suck dicks in hell for eternity for the right to pry my eyelids open for just a few more minutes to see Babs and Dylan before I pass into nothingness.

I get where you're coming from, and I like the argument and discussion, but I find everything about choosing to work or not work on someone based on an outsiders, particularly a friggin' medical provider's, perceived quality of life offensive.

It's important to me that you all understand that my comments are not meant to be a holier than thou thread killer. I'm trying to be clear in order to contribute, not to try and pretend that I'm morally and ethically above such a conversation.

Hopefully such bullshit would never fly with this crowd anyway...

Dwayne

Dwayne, thanks for putting that much more eloquently and comprehensibly than I was able to!

Just like you said, bro, resuscitation decisions should be made based on patient viability and the chances of a good neurologic outcome, not based on our perceptions of their quality of life and how that may or may not translate to their will or right to live.

I hate hypothetical situations. However, let's make this hypothetical for a moment. Successful out of hospital resuscitation rates, with complete neurological function, are less than 10%. Were these numbers applied to a medication, meaning that administration of a particular medication worked less than 10% of the time, that medication would never see the light of day.

So if you are arguing for basing this on a numbers game, why do we try to resuscitate anyone at all?

Just playing devil's advocate. I understand, and to a large extent agree, with the argument Kiwi is making. I find the knee jerk reaction against his argument interesting. What I think those who disagree aren't clearly saying is that we as a society have placed such a high value on human life that we *must* try regardless of the circumstances. It becomes an interesting high wire act to balance one against the other.

edit: woefully misplaced comma.

We resuscitate because we know based on what we have learned over the last hundred years that the cessation of the heart does not have to be the end of life if prompt action is immediately taken to restore a pulse and create an environment conducive to restoring its automaticity. Our capabilities are limited currently, but they're improving every day as the science comes around.

Until we can convince people to no longer fight against the ultimately fatal clock of time, the expectation that we at least attempt to save those we can and the hope that we will improve those statistics won't change.

That doesn't mean we shouldn't be scientific about our practice, and there's ways to narrow down the list of patients who receive resuscitative care to only those whom we can reasonably expect to successfully revive.

[AnthonyM83]

Quality of life cannot be judged by someone and then used to decide whether to make attempts at resuscitation...ESPECIALLY by some guy with less hours of training than a beauty school graduate (cosmologist).

Each workup on someone who would not survive is training for when I run a code on someone who does have a good chance.

Code saves don't define you as paramedics, but preserving life is a big thing for us. Most calls with critical patients, we don't know whether they're going to die or not. In a code, they already did die, so it's already "confirmed" so to speak that this patient is "critical". If that makes sense.

Now don't go crazy and work up every single cardiac arrest, but if you've got something to work with, go with it. There's a difference between finding someone in asystole versus having a momentary asystole in the middle of a code with possible recent downtime with good CPR from your team (like in bus stop scenario).

BUT either way, judgment on quality of life gets to be a choice the patient makes, not us, sorry.