If a non-rabbi could decide what sofek pikuach nefesh means, could a doctor do it? I'm not sure, because I don't think the work of a doctor has much to do with calculating mortalities - that is more fittingly the work of an actuary or an epidemiologist. If you ask a doctor, given a certain presentation of symptoms, what is the chance that a certain patient sitting (or lying) in front of them will die, they will generally say, "It depends on the patient." Doctors are notoriously reluctant to give probabilities.
Even if doctors are reluctant to quote such possibilities, maybe they still practice according to them? The literature on medical decision-making gets broader every day, and I fear to tread where I am ignorant. I know enough though to say that it strongly depends on the specialty. Sometimes subspecialties of medicine differ so much from each other it's as if they are different professions altogether. The emergency-room doctor and the critical-care physician deal in life and death every day, while the outpatient practitioner has influence in the gradual development of healing or disease - these are broad generalizations, of course.
Showing posts with label death. Show all posts
Showing posts with label death. Show all posts
2/28/08
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.
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.
2/23/08
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.
8/9/06
Curriculum mori
...if my Latin is right.
Two or three courses in medical school could be usefully replaced by a course on death. We never learned much about it - its epidemiology (who dies, why, and when), its public health (how it can be prevented), its signs and symptoms in the hospital (how to know someone is dying), and, sometimes most important, how it's to be dealt with when nothing much can be done to prevent it. Who do you talk to? How do you approach a family of someone who's died? (Not all of them are "grieving," so I said it another way.) What will be your reaction? Who can you talk to?
It's one of the big subjects which we're supposed to learn on our own.
...if my Latin is right.
Two or three courses in medical school could be usefully replaced by a course on death. We never learned much about it - its epidemiology (who dies, why, and when), its public health (how it can be prevented), its signs and symptoms in the hospital (how to know someone is dying), and, sometimes most important, how it's to be dealt with when nothing much can be done to prevent it. Who do you talk to? How do you approach a family of someone who's died? (Not all of them are "grieving," so I said it another way.) What will be your reaction? Who can you talk to?
It's one of the big subjects which we're supposed to learn on our own.
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