The patient’s heart was barely contracting under my ultrasound probe, like a limp handshake. He was in shock, his ineffective heartbeat unable to maintain the pressure necessary to keep his organs alive.

And now he was on full life support on my service in the intensive care unit.

Our ultrasound completed, the resident resumed her presentation of the case. The troops had already been called in, she assured me. The cardiologists were considering taking him for a heart catheterization to determine if there was a blockage that could be reversed. The respiratory therapists were fiddling with the knobs on the breathing machine. It hissed as it rhythmically inflated and deflated his lungs. The I.C.U. nurse was connecting a dobutamine drip to the large plastic catheter that had been inserted deep into a neck vein by the emergency room physician. This medication is like a shot of adrenaline to a dying heart, conjuring any remaining fumes of life to keep it beating until an intervention might solve or improve the problem. Unfortunately, and far too commonly, dobutamine simply serves to prolong the inevitable, and the patient’s heart, which would have tired and stopped long before, sputters along on this high-octane fuel. Our patient was tucked in as we awaited next steps.

“But,” my resident went on, looking at the floor, “the daughters are on their way in. Apparently the patient had told them no machines. They’re very upset.”

Suddenly, this case was turned on its head. What had just felt like a satisfying process may in fact have been assault and battery with a dose of hostage taking. None of it intentional. But the effect was the same.

The daughters arrived 20 minutes later. They’d received frantic phone calls from their mother as the paramedics were zapping her husband’s chest and performing chest compressions. Before they’d even hung up, he’d been whisked away into the night. They had spent an hour calling several local hospitals before tracking him to our I.C.U.

His wife had been too distraught and overwhelmed to tell the paramedics that her husband, an 86-year-old man with a chronic heart condition, multiple recent hospital admissions and I.C.U. stays at another hospital, had adamantly, repeatedly and clearly told his family he wanted no more of it. No more shocks, no more hospitalizations, no surgeries or catheterizations, no pacemakers.

His daughters rushed right into his room. “You’ve got to take him off,” one of them said. “He absolutely did not want to be on a machine. He made us promise.”

“I’m so sorry this is happening,” I said. “The good news is that he’s calm and sedated, so I think we have a little bit of time to decide how to proceed. The best thing we can do is to make sure we know what he would have wanted in this exact situation, where he was already on a machine and might die if it was removed. Did he ever write any of his thoughts down?”

“His doctor helped us fill out a form.”

“Was it a Polst form? A bright pink form that you attach to your fridge?” I asked.

“Bright pink? No. It was called an advance directive,” she said, digging around in her purse.

Ah. Mystery solved. This family had planned and communicated about end-of-life issues more than most ever do, but they still hadn’t been shown how to kick the ball through the goal post.

There is much confusion around this issue among patients and their families, and unfortunately among physicians as well. Which form is the right one? Who should have a copy? (…) Read Full Article Here

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