The Resuscitational Imperative, II

On the other hand, there is now definitely a culture (measured by off-hand comments by residents, facial expressions assumed when discussing families who do not make the "correct" decisions, and the like) which promotes the DNR order. It is taken by some as the very goal of goal-of-care discussions. If a patient is very sick, has been so for a long time, and the prospects for recovery of functional status (meaning a significant quality of life) are minimal, we are pleased when a DNR/DNI order is obtained, and even more pleased when comfort care is decided upon.

But I also want to talk to the patients fully and frankly about what "significant quality of life" means. If the patient (or her family) wants to be kept on a ventilator indefinitely, even if there is no chance of life off the machine, that would be valid - because medical futility, like all medical decision-making, involves ethical assumptions which patients and families might not share; and because health-care costs and resultant rationing, so often in the back or front of our minds when discussing such issues, are not significantly affected by long-term ventilator support. (See this brief article in the New England Journal for a discussion of both these issues.)

My goal this rotation, when I admit patients overnight at Bellevue, is to include as part of the problem list the category Goals of Care and to discuss these with the patient. This won't happen for everybody, and maybe for nobody (it gets busy). But it's something to work towards.

The Resuscitational Imperative

It's not a technological imperative that drives the resuscitation of so many patients who (if you had asked them while they were of sound mind and not about to die) would rather not have been resuscitated, it's a philosophical imperative. Most doctors, in my admittedly limited experience, are biased towards doing something rather than nothing. Or - rather - biased toward the assumption that taking a positive action is more helpful, because more active, than doing nothing. But sometimes doing nothing is not doing nothing at all. Letting someone die can sometimes accomplish more than a breathing tube or a defibrillator ever could.

Who will have a mandate for a mandate?

Laszewski says it again:

I worry that both [Clinton and Obama] have cost containment strategies that would do little more then dent the continued escalation in health care costs and undermine both of their guarantees for affordable coverage.

Applied Nostalgia

My daughter and I had a fight last night (she's four; it happens) and we made up with me singing songs to her. The songs were in Yiddish, the language we speak at home. I was randomly singing whichever Yiddish songs happened to come into my head, and in the middle I thought: Isn't this ridiculous? The last three songs were a Bund ballad about blowing up a German ammunition convoy; a paean to Vilna; and the Partisans' Song. (I'm not usually so historical, but there you are.) It struck me, not for the first time, how unrooted my Yiddish language and culture is in my individual, quite ordinary-American-Jewish experience, and how an outside, Eastern-European-born observer might think that my use of these historically freighted songs is disrespectful, jokey, or obscene. (Some do.) What do I know of guerilla warfare, Jewish Vilna (I mean its physical bricks-and-mortar), or the routes of the Baal Shem Tov (the subject of another song)?

I used to answer "No" (a little hurt) when asked if my attachment to things Yiddish was due to nostalgia. How can I be nostalgic for something I wasn't born into? But that's precisely the point. We yearn for what we are not conditioned against. The tension of my ideological attachment to Yiddish is to be aware of the sunken past while not drifting away from the present in which Yiddish, very much extant, is quite un-Eastern European.

As for nostalgia, Jews couldn't get along without it. One of my daughter's favorite songs is Yah Ribon, whose last verse recollects the Temple. I never saw that either.

Youth! Youth! Yeth?

Yugntruf gets its yugnt back. (Hat tip: Byuralistke.)

Distress and disease: inextricable

The important lesson to be drawn from studies of medical-psychiatric comorbidity is that distress and disease both produce physical symptoms. It is not productive to dichotomize symptoms as "somatogenic" and "psychogenic" because physiologic and psychological processes are involved in all symptom production and perception. "Rule out" diagnostic strategies that search for either a medical or a psychiatric cause of a physical symptom are not supported by epidemiologic findings of high rates of medical and psychiatric comorbidity.

-from Katon W, Sullivan M, Walker E. Medical symptoms without identified pathology. Ann Intern Med 2001;134:917.

I remember last year when I started the night float rotation; the interns passed around a handout, compiled a few years ago by some previous interns who were now attendings, about how to diagnose common inpatient complaints. Anxiety languished far at the bottom of the list for diagnoses explaining chest pain. "This is a diagnosis of exclusion!!" said the handout - the implication being that no one should ever diagnose anxiety (or other psychological complaints) on the hospital floors. The cultural supposition is that chest pain is either a heart attack, or an aortic dissection - or else it's "bullshit." (No one would write this, of course . . . it's understood.)

Unintended IRB humor

From the directions to an IRB form I'm filling out:

Describe potential benefit(s), if any, for subjects participating in the research. If there are no anticipated benefits, this should be stated. [Note: Payment to subjects is not considered to be a benefit of research (see Payment section below)].

What is payment to subjects if not a benefit? (Shades of "Guinea-pigging.")

R and R

Regret
slips its noose
around the neck.

Remorse
sinks its tooth
into the corpse.

-Samuel Menashe

There I was today (by now yesterday) at Rizzoli's in front of the poetry section on the third floor, the elevator doors open and an older man calls out, "You're right in front of my book and you don't even see it!" He plucked it off the shelf in front of me. "I saw you read at the Harvard Club," I said to him. "Yes, the place was packed," Menashe agreed. "Three hundred people, and for some reason they didn't let me sell any books there."

Now I feel guilty I didn't buy his book today. There's always next time! (I did buy this one, which bears some distant spiritual relation.)

(Oh, and I didn't embarrass myself by telling him I'm a poet. Personal Dignity 1, Networking 0.)

Cool vs. High-Strung

Obama has been anointed the Cool Candidate on the strength of his spellbinding stemwindery. I feel my inborn contrariness (rhymes with orneriness) pulling me away from Coolness and toward hard-bitten (maybe even a little embittered) experience. Hillary, anyone?

A shot of panic becomes the rustle of glucocorticoid

Speaking of Kathleen Graber, she has a great poem in the newest issue of the New Yorker.

Nothing To Complain About Right Now

Every biting winter
was fall's soft cliché,
every aperçu
was a drunken bawl.
The queer tongue of our ancestors
is enlivened by the dead
and cobbled by curses.
I've been to countries
where that all lives on.
They saddle up their sins
and shout after the nag:
Improvement by degrees!

Unfair One-Off Ignorant Assessments, and Short Snippets of Poetry (without line breaks), From Last Night's Readers

Kathleen Graber: thoughtful, careful, with an intermittently epic reach, sometimes too grounded. I bought her book because I wanted to get the best impression of her poetry. "The form of stone is the form of attrition. It becomes itself by what is lost."; "[...]delicate rigid body of a bird[...]"

Catherine Pierce: concrete, domestic, honest. From her love poem to America: "America teach me how to strut . . . I love how afterward you roll over and snore like a locomotive before I even catch my breath."

Shin Yu Pai: I didn't write anything down to quote. I learned from her that the food industry is bad-bad-bad!

[Christopher Stackhouse read after Pai, but I must have been sleeping after my one beer; I don't remember what I thought of him.]

John Keene: earnest, professorial. "Driving at what is arriving, you must parse it out."

Ross Gay: by turns terrifying (not him, but his poem about unspecified violent little creatures) and nastily funny (about his friend's racist girlfriend). From the former: "the little one sat curled in a lump pretending he was dead"; from the latter (the girlfriend, white, speaks to her black boyfriend about how he is not "street" enough): "What does your Hegel say about funk? Your Dubois? / I only date hood."

Daniel Nester: Definitely the guy I liked most. Funny, self-deprecating. When I went up to him afterward and asked him if he was selling anything, his look of mild surprise and unfeigned delight was a pleasure to behold. "I brought one copy of a book of mine, if you want to buy it for five dollars," he said - so I did. From a poem: "When I said you were as old as my mother I wasn't trying to make you old or make you my mother. I was trying to give you details."