I think that a lot of people these days have forgotten that people should be
allowed to die with dignity. Just because we CAN do something, doesn't
necessarily mean that we SHOULD do something. Each resuscitation attempt
needs to be viewed in its own setting. I would agree with Adrian that most
patients in asystole have an appalling outcome, and if the paramedics
haven't got anywhere by the time they get to the ED then the best thing is
to stop.
Someone once told me that life is a sexually transmitted terminal disease
contracted at birth. I think that helps to keep a bit of perspective.
Simon Ødum
-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]]On Behalf Of [log in to unmask]
Sent: 04 February 2003 20:06
To: [log in to unmask]
Subject: Re: Guidelines
> from: Fred Cartwright <[log in to unmask]>
> subject: Re: Guidelines
>
> I don't think you could include this in any guideline
> unless you want them to run to many pages!! In the
> same way that none of the surgical textbooks in the
> department discuss which patients you should NOT
> operate on!!
Not quite true Fred. Much of a surgeon's training concentrates on when to
operate, rather than how to operate. You know the saying, "choose well, cut
well, get well". The surgical exit exams contain very little in the way of
"operating" content, but a considerable amount of time is devoted to the
"choosing" areas of their craft, together with postoperative care.
> Most of
> the drive for introduction of DNR orders and the
> general awareness of when not to resuscitate has come
> from the resus department!
Only to be politically correct, I get the impression Fred! Even then the
emphasis is wrong, it suggests the "default" mode is to resuscitate and an
active decision has to be made to not resuscitate. This is fundamentally
flawed. The default mode in many patients surely must be to die, and an
active decision should be made to resuscitate, not the other way round.
Otherwise you end up with scenarios like the one I described.
In many situations, such as terminal cancer, it's completely wrong to even
consider resuscitation, and it's usually cruel to discuss this with the
patient, let alone force them to sign some sort of document to that effect.
Oncologists and palliative care doctors don't need to write DNR orders. It's
taken as read that their patients are going to die some day.
Adrian Fogarty
|