Moral distress

Doctors and nurses working with critically ill patients experience moral distress.

I was reading this article that someone had linked on Facebook. If you don’t have time to click through the link and read the whole thing, I’ll summarize: An anecdote about a doc who leaves work in the ICU after coding two frail elderly patients back-to-back. Followed by discussion about a Canadian research survey in which they examined attitudes about end-of-life care in caregivers. Questions focused on hypothetical situations like “providing false hope to patients” and “giving aggressive care even though it is only prolonging the dying process”. The conclusion of the study and the article was that mismatch between expectations (patients and family members) and abilities (of providers) causes a moral dilemma that leads to stress and “burnout”.

Of course ICU docs and nurses were not all fairytale and moonbeams, they are in the fucking trenches! That’s like asking Guantanamo bay prisoners their opinions on America’s foreign relations policies.

Several thoughts occurred to me:

1) These conversations take time. I recently had a long conversation with a patient and his wife about end-of-life care. He was recently started on warfarin for afib, had terrible heart failure, several recent trips to the hospital and intervening SNF for rehab, and now he was back with a GI bleed. He had a stress test scheduled and was being worked up, but was exhausted, and clearly wanted to be at home on hospice. The conversation took nearly an hour to clarify his goals of care. He had a POLST form (a type of directive unique to Oregon) that said “FULL CODE”. This was completed with his PCP 2-3 years ago, before he was diagnosed with terminal systolic heart failure.

2) Doctors don’t have time. That day I had 15 patients to see in a 12 hour shift and I was already behind an hour or two on my work. I spent 90 minutes with this patient coordinating his care plan, setting up hospice, talking with discharge planners, and doing his discharge.

3) Directives don’t mean shit. Clearly, code status is a moving target, and should be re-addressed when your condition changes. I address code status with every new admission. I don’t give them options about this or that, and there is no “modified code”. If your heart stops or you stop breathing in the hospital, we are either going to do everything to save you, or nothing, and let you pass peacefully. The other hospital in town is aggressive about obtaining POLST forms and making them available in the chart. I have found these to be misleading, and often when I ask someone what their wishes are, the form does not accurately reflect them. Sure, it makes your job easier when doing an admission, but it isn’t always right.


4) People are stupid. Perhaps that’s sensationalism, but the truth is probably that physicians don’t take time to thoroughly explain these things. Often I will get an admission, and I will see the POLST form that says “DNR/Comfort Care only”. I explain to the patient that this option is essentially hospice care and means that you don’t want to be transported to the hospital when Ill, or receive any kind of medical treatment other than for comfort. Patients are often dumbfounded, even when I show them the fine print on the form that says exactly that. Many will describe the situations under which they completed the form, saying that someone in the office just gave them the form and told them to fill it out with no guidance. Sometimes they say that the doctor sent them home with it and told them to bring it back or mail it in. This article advocates for PCP involvement in end-of-life decision making, but unfortunately I don’t think that’s enough.

5) Language influences people. I have heard there is a movement to change DNR (Do Not Resuscitate) to AND (Allow Natural Death). There are many other ways to influence decisions about care, and that is likely why I see so many people check the box next to “COMFORT”. Who the fuck doesn’t want to choose comfort? That’s like having a dial in your sports car with “economy” and “BAD ASS – BITCHIN’ FAST” settings. I know where my dial would be.

There was an intern in my class who always prided herself in making all her patients DNR. It’s not hard to talk people into it if that is your agenda, Sprinkle in some colorful language like “machines” “life support” “vegetable” and you can steer someone in that direction. Yes, I have heard people say “You don’t want us breaking all your ribs doing CPR, do you?”

6) CPR does work sometimes. Below are the results of a study on the survival rates for CPR done in-hospital. That’s a 76% chance of death if you need CPR (or you could look at it as a 24% chance of revival).

Attempts—–1——-2——3 or more
Survival —-24%—-12%——7%

(JHM 2014 Kazaure, Roman, Sosa )

7) Devil’s Advocate: There is truly value in being able to say to a loved one – “We did EVERYTHING we possibly could and your loved one died despite our best efforts. While we are jamming an ET tube into an airway full of vomitus and hearing ribs crackle and pop, looking at grey skin despite blasting in oxygen and blown pupils staring blankly…Family members see what they expect from TV drama, what popular culture has perpetuated, shocking asystole into a meaningful rhythm, and shaking your fist at the heavens, then bringing it down to the chest in a single, life-bringing compression. I think that seeing the heroic measures can help family members emotionally in some cases.

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