----- Original Message -----
From: "Fred Cartwright"
Subject: Re: Guidelines
> Knowing the individuals concerned I doubt that they
> would do ANYTHING for political correctness. When you
> go to every resus not just the odd few that most docs
> do you see some of the poor decisions to resus that
> are often made and want to do something to stop it!
Oh I agree Fred. I spend half my time in resus "stopping" resus!
> That is the default mode and there has been a lot of
> opposition amongst some of the medical staff that any
> of their patients should not be for resus! They want
> them all done however hopeless.
I know, medics are among the worst offenders when it comes to "resus" mode!
> What is terminal cancer? Anyone with cancer that is
> going to kill them however well they are? Let me give
> you an example. Someone with disseminated Ca, but
> otherwise well having first dose of chemo has an
> anaphylactic reaction. Do you stand back and let them
> die or treat them?
Of course there are exceptions Fred. But maximal conservative treatment is
also palliative. So, for example, it makes sense to maximally treat LVF in
the elderly, but not to proceed to intubation and ventilation in most of
them. The same goes for many treatments in terminal care. The other day I
was asked by a fellow consultant to offer some "palliative" treatment to a
breathless patient with laryngeal CA who had abnormalities on his CXR. But
on review he clearly had sudden dyspnoea due to airway obstruction, but the
signs were very subtle due to the laryngectomy i.e. no stridor, minimal
accessory muscle use, etc. Turns out his CXR changes were old. He made a
complete recovery when I removed the mucus plug from his trachea!
> > it's usually cruel to discuss this with the patient,
> > let alone force them to sign some sort of document
> > to that effect.
>
> Why? Is pretending it is not going to happen any
> better?
It's not about pretending, it's about common sense and humanity. Why should
a patient have to enter into a dialogue about resuscitation, if they've got
advanced terminal cancer? Fine, if they develop something easily treated as
discussed above (like anaphylaxis or mucus plug) then just go ahead and
treat it, there's no need to talk about it! If they've got terminal organ
failure, then don't. Again, no need for discussion! That's how I manage my
critically ill patients. If I believe a patient can be easily treated then
I'll do it; if I believe treatment is inappropriate or futile, then I won't.
I don't believe discussing resus status with a critically ill patient is
fair or humane. By all means let the physicians do it with their stable
patients on the wards, but it shouldn't occur in the resus room.
Adrian Fogarty
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