Presented by David Crippen.
Bill Clark:
Is noninvasive face mask ventilation possible? I know it becomes difficult when respiratory rate become high but still can be doable.
David Crippen:
Patient is so weak that he cannot really comply with BiPap which pretty much requires a fair amount of coordination with the plan. In addition, this disorder is progressive. There is no hump to get over followed by improvement.
Jeff Whitnack:
I would like to provide a slightly different angle on this question. I agree that a better system would be one in which such a decision for a futile, costly, and ultimately painful and inhumane course would not be an option. But it is an option, and apparently this patient has chosen it. But why would he choose such a course?
He has AIDS, PCP. He has no doubt spent many a day and night already in the hospital (s). And he has probably already visited many a friend and/or loved one whom has traversed this same path. So this patient has been around the hospital block. Perhaps he waited too long for someone to answer his call bell while on the floor a while back. Perhaps he knows that if he is made a "no-code", some case manager will have him unceremoniously taken out like so much trash. And he will then sit lingering on some floor unit where the staffing is woefully inadequate and he will get no attention (I don't mean this to be hospital specific, but it is a pattern I have seen.
So many times I have taken care of ventilated patients, spoken with their families, etc, as they decided to have their family member be extubated and die with dignity--and of course they don't die right away always. Then later I see the family members outside the door of some floor unit room trying to flag down some very busy RN for basic care.).
At least if he is ventilated in the ICU he will go down with his name in ICU lights, running up one last big expense, alarming the ventilator, having a better legal staffing ratio. It will be his Last Picture Show. Perhaps he may even be aware that his deceased body will not lay on the ICU bed for the next shift to arrive, as the expensive ICU bed will mandate that he, even in death, be quickly taken care of.
Until we in the USA embrace Palliative Care as a specialty, realize that just because end-of-life care isn't critical it may still be intensive, we will pay this price. And that is why it makes sense to start Palliative Care units with, yes, ventilator patients and give them the status of full-tilt ICU's. This may seem strange to those of you living and working outside the USA. But it is a strange little fix we've gotten ourselves into here.
Jeff Salon:
I am quite suprised to learn that your group has no triage power in the ICU and are required to provide futile care.As it presently stand you are not prolonging vital signs as you have described a patient who is in respiratory "extremis" and is terribly tachypnic- you should have already intubated him if indeed that is the mission. Futility has already been established "by all the consultants" so I cannot buy the arguement that there is quibbling over the definition. This has been established by how many physicians that it is futile. I suggest that your facility has a unique definition of life which reflects only the quantity NOT QUALITY of that "life". You guys need to convene a task force to amend the definition of life to reflect current thinking and practice. I would advise that you include an ethicist in the task force.
Having said all that, I ask the following question: are you obliged legally or morally to provide futile care-NO. I believe that you are describing a situation that is indeed futile.
David Crippen:
I believe that the problem here is making a differentiation between pandering to desires and real futility. The reality of this situation is that I am not allowed under the current rules to turn down any request for an ICU bed, nor am I allowed to refuse a request for care which would prolong vital signs.....the definition of life under the current rules. Remember that futility is defined different ways by different people depending on their motives. If A patient demands that I bore a hole in his head with a power drill to let out evil vapors, I don't have to doit because it REALLY is futile. However, if a patient demands to be intubated to prolong a progressively fatal disease, I do not have the authority to resist that request because it is NOT futile. Intubating him WILL, indeed, prolong his vital signs, the current definition of life and as such is NOT futile treatment. Never mind that it won't do anything else and will probably facilitate the obligatory dying process in a much more uncomfortable mode.
The problem here is one of duplicity. Is it ethically dishonest to allow the family to change the rules after the patient becomes incompetent. He has stated his wishes plainly and he is lucid and understands the situation. Therefore, after he becomes incompetent, should they have the authority to alter his clearly expressed wish?
Dick Burrows:
Mabe FL should go for some beers There is obviously no reversible component in this particular case that would benefit from ICU therapy. It is not the patients decision to dictate what therapy he recieves, this must be a medical decision. Likewise, the relatives also have very little say as to whether treatment must be discontinued or not - it must be an expert medical decision, and not what commonly happens i.e. relatives asked to make or contribute to a difficult decision.
It is not the patients decision to force futile, unnecessary and potentially harmful treatments. If we allow that then we are no better than all those quacks who tout shark fin cartilage, laetrile, whatever - simply on the basis that anything in the face of death is better than nothing at all. What are the consquences of intubating your patient when all medical experts will agree that ICU treatment is futile?
You destroy your own credibility and integrity. You commit an ethical fraud. This is a dilemna that we will all be increasingly be faced with. Difficult choices will have to be made. Education in the broadest sense may ease the problem - adressing issues such as terminal disease states, care of the dying and the role of ICU therapy.
Education might ease the problem. Doesn't seem to have done so though. Why can't I have ECMO doc? Sometimes my lack of resources make things a little easier in as much as if a form of treatment is not in the loop it cannot give me angst. The decisions as to who to treat and who not to treat are still the same however.
However, this is not to say that we should be inflexible - but currently these type of issues are the biggest problem. It is not a question of being inflexible. It is a question of being allowed to make reasonable decisions and being given the authority to make those decisions.
Decisions are decisions in any walk of life - decisions have to be made and they do not become different merely because death enters the picture. A business colleague of mine makes decisions concerning retrenchment of staff - he agonises over such decisions as they will likely ruin peoples lives but make them he will - it's no different but I know of no other group of people like ourselves who, when faced with such decisions have allowed themselves to be so effectively emasculated and hijacked by individuals with no training and little ethical appreciation other than what the priests, popes, parents and their own selfishness have given them with the tacit approval of politicians. Big problem made bigger by refusing to confront the issues.
Errington Thompson:
Wait a minute. Let's walk thru this one. You do not have to intubate some one who is going to die. If the patient is clearly going to die with or without your intervention. If for example a patient has swallowed those 15 bags of cocaine and the bags were not sealed. You know that this patient is going to die, period. You do not have to intubate this patient. Intubation would be FUTILE.
David Crippen:
That line of reasoning is NOT true in our current socio-political climate. Intubation that prolongs vital signs for an additional 15 minutes is NOT futile under the current definitions. ANYTHING that is capable of prolonging vital signs is FAIR GAME.
Whether or not to intubate him is NOT the issue. He demands it. Intubation will prolong his vital signs. He will get intubated if he persists. Period. I didn't invent this game and I don't like playing it but I know the rules and how to play. If I buck it, my life will be made miserable by a LOT of other players who gain more by the "customer is always right" axiom than they lose by it. Dreamy platitudes about what I "ought" to do are not realistic. He wants it. The system supports his autonomy completely. Consult the "Ethics Committee"? Right. The Ethics Committee will RELIABLY take the position that he is an autonomous person and should get what he wants no matter how stupid it may be. I personally squelched the possibility of such a consult for that reason.
What I am asking you is how to do the right thing under the current rules.
Jeff Salon:
I don't buy it David. This is not an accepted idea of "not futile" anywhere I have been.Futility is based on real meaningful outcomes, not the next few minutes.
Dick Burrows:
Oh rubbish FL Your brain is spongioform I think You are once again looking for the too fine line of the golden mean. You cannot define words such as reasonable, quality, futile or fair any easier than you can define death short of decomposition. But that is what you are trying to do. Just as you wanted a data base system that took care of "everything" you want an ethical system wherein the definitions are equally as precise. It doesn't exist and never will.
All you can expect is that colleagues will look at the issues in a reasonable manner and allow you the authority to make a reasonable decision. But that does not seem to be what you want - you want the test of certainty - this side of the line he's alive that side dead and worse you want to allow him to make the medical decision so that if he croaks through his own stupidity well then its his own bloody fault - what a cop out In this instance he has tried to force your hand with a desperate plea for a miracle. If you work in miracles then go for it and if you have consistency in your miracles (p<0,00000000001) then I'll kiss your bloody feet.
Whether or not to intubate him is NOT the issue. He demands it. Intubation will prolong his vital signs. He will get intubated if he persists. Period. I didn't invent this game and I don't like playing it but I know the rules and how to play. If I buck it, my life will be made miserable by a LOT of other players who gain more by the "customer is always right" axiom than they lose by it. Dreamy platitudes about what I "ought" to do are not realistic. He wants it. The system supports his autonomy completely. Consult the "Ethics Committee"? Right. The Ethics Committee will RELIABLY take the position that he is an autonomous person and should get what he wants no matter how stupid it may be. I personally squelched the possibility of such a consult for that reason. Stand up for yourself and all of us at the same time.
David Crippen:
I have lived this for a long time and I see how it works in reality. And the way it works in reality is NOT outcome gated. If outcome were the whole issue, the whole system of critical care delivery would collapse. Patients with eventually fatal diseases would never be started on treatment because the outcome is known. It takes time to see if aggressive critical care will get patients over short term humps. I might intubate for a short term a patient I might not ordinarily consider that therapy for long term.
To your conjecture, I ask the following question. A patient with a progressively fatal disease process but clear mentation, five months into his projected six month post diagnosis lifespan is deteriorating and his one really big wish is to watch the last Superbowl of his life. It's the day before and he really isn't going to make it. He asks you to intubate him and support him just long enough for him to see the Superbowl on a small TV his family has rolled into the ICU. After the game, he then asks you to make him comfortable, pull the tube and let nature take it's course. Would you do it?
Andy Egol:
How would you ever conclude that this is a similar circumstance to the one being discussed. One is the compassionate request of a person for a finite period, the other is for an infinite request based on "because" without a goal in mind other than to avoid death. Not the same.
David Crippen:
This is presisely the point - it is making a reasonable balance between making a proper medical decision and allowing (or fighting for) the patient's reasonable requests. It is also part of the reason why futility of treatment has to be a plastic affair and not look for a set of precise circumstances wherein this side of the line he does and that side he lives.
Jeff Whitnack:
Dick Burrows said: "The fact that he is abandoned is unfortunate and not confined to the USA and it is as wrong here as it is in the US but to substitute high ratio nursing care and ventilators for that failure, to mind, represents the greatest tragedy of all - the substitution of technology for care".
Let's go back to the original case of that 34 year old. Remember that only because he requested to have "everything done" was a bed for him gotten in ICU. Then he changed his mind at the last minute. Had he been constantly in agreement for comfort care, would his end of life care have been the same? He may or may not have been consciously aware of it. But if it were my little brother, and if he were in certain hospital's floor wards I have worked at, I could imagine myself saying to him, "have them do everything for you until the very last moment. That way you'll get to die in the ICU where the staffing and nursing skill is the best".
The ICU's here have legal minimal staffing levels. The floors units do not, beyond what some lawyer could argue wasn't safe if it went to court. So I am constantly in the middle of the tension between floor nurses wanting to get a very intense care level patient transferred to a more critical care unit, and those ICU nurses being indignant that the patient "doesn't belong in ICU". The hospitals seem determined to hold the line on not, for instance, making a floor patient 1:1 RN care. So they pay the price of inappropriate ICU admissions.
I am a night shift Respiratory Therapist at a community hospital in which the MDs do not have 24 hr. coverage. There is an ER MD on duty 24 hrs., but he wants the primary MD to call him with a referral first before he will come up to the floor to see a patient. As most decompensations initially unveil themselves in a respiratory way, I'm the guy that gets called first. Albuterol everyone?
I agree that Palliative Care is something that every RN, MD, and RT should be cognizant of. I also feel it needs to be a specialty unto it's own right. I couldn't see intubating and ventilating a patient as a plan of palliative care. But I could see transferring an already ventilated patient to a Palliative Care unit as part of the process.
Andy Egol:
I did not know that this was a goal of "the game" To die in a place that has the best staffing? What happened to dying at home. What happened to loved ones being at the bedside to ease the emotional grief of the dying process. Hundreds of health care workers cannot take the place of a single caring and compassionate family member. The tasks of attention and patient care are well provided by health care workers. We cannot even approach the caring of a family member. Spend more money getting people home and in comfortable surroundings. Use the money you were going to spend building units where people go to die.
Dick Burrows:
I Disagree with Whitnack. Care should not be confused with surrogate "care" of ventilation. They are very different things. The fact that you stop or refuse ventilation does not allow you to abandon the patient in the sense that there is still more to be done in respect of care - palliation call it what you will. It is something that every doctor & nurse should be cognizant of. It should not degenerate into "call (turf to) palliation" like you "call (turf to) psych"
The fact that he is abandoned is unfortunate and not confined to the USA and it is as wrong here as it is in the US but to substitute high ratio nursing care and ventilators for that failure, to mind, represents the greatest tragedy of all - the substitution of technology for care.
Avi Roy-Shapira:
This is a clear case of futility, and the patient has no say in the decision which purely medical/technical. Patients have a right to refuse treatment, not to demand it. The father and the brother are not a factor here at all, and no "deals" with them are acceptable.
David Crippen:
Snort............you guys continue to be very blithe and cavalier in making black and white issues out of Technicolor ones. We are, after all, political animals and we rarely have the option of expressing our private wishes much less acting on them, lest we be unceremoniously be dumped. Many of you lift your noses and declare you ain't gonna do this and you ain't gonna do that, and it washes in a vacuum. However, in a society in which pleuralism rules, your isolated convictions must be read in context.
There are precious few people who have the luxury of ignoring their social context and getting away with it. Neil Young never paid the slightest attention to any other than his own calling in his entire life, and he has 33 or so platinum albums and each new one sells out before it's pressed. The reason he gets away with it is because the demand for his talent exceeds the propensity for throwing him in jail.
If left to my own devices, I would arrive at the hospital every day with jeans, a Twisted Sister T-shirt and an Axl Rose headband. Janis Joplin and Creedence would play continuously in my office, I would show up when I like and depart when I felt like it and I would tell them how it is to be according to the Crippen Rules. I can't get away with this because the incentive for the hospital suits to dump me exceeds my value to them if I more too far out of line. Therefore, if I want to be effective, I must compromise. I do not have the luxury of laughing out loud during "Continuous Quality Improvement" meetings. So I softly chuckle to myself and read a comic book hidden behind the report.
Therefore, my (and your) ability to function effectively entails manipulating capricious convention to make the best of it, not loudly demanding that I should prevail because I know I am right. I do not have the power to change things I don't like, but I do have the power to creatively contort them to more functional ends. THAT, I think, is part of the "Art of Medicine" in the 90's. The case in question is one in which I took an untenable situation and made it work.
Gert Liehn:
At which point comes the family into the game here? - I don't know the american jurisdiction, but german law says, that only the patient can give consent - when the patient is unconcious or sedated, relatives eventually can give informations about the will of the patient, but they surely cannot make any decisions. The will of the patient is absolutely clear in this case (which does not mean you have to follow his wishes, if they are nonsense), but i only could explain my decisions to family members or discuss with them, they cannot be involved in medical decisions. Is american legislation and jurisdiction that much different?
Tom Stinson:
Clearly, if the patient's demand to be treated with a full court press is valid while he is conscious and able to express the demand, then its validity should remain after he lapses into unconsciousness. Why can a patient demand treatment? Where does it say we are obligated to provide care on demand that is inappropriate. A more pertinent question is why to patients feel they have positive rights to demand care and why do we propagate that delusion by feeling it is appropriate. This propagates a myth of reversibility and offering a choice where there really is none.
By allowing treatments to be given that are of no benefit in reversing disease are we not by doing it implying that their choice was OK. What are the ethical implications of physicians supplying care on demand that we know to be useless. How will that affect the integrity, morale and attitude of physicians when we become merely a vehicle to carry out patient demands and are not cabable of doing what we are trained to do with respect to prognosis and treatment alternatives. This is mind-boggling and ridiculous! Advance directives were to let me understand what you did not want done, not what you demand be done. It appears we have lost sight of the real issues.
Chris Anstey:
What can you say !! This is clearly a futile case and ventilation is not only not indicated but more dangerous than usual ( barotrauma, volutrauma, oxygen toxicity, sputum retention, bacterial superinfection / nosocomial pneumonia - blah blah ). If you ventilate this man you may as well give him a lethal injection at the outset and this should be pointed out to him. He will go to sleep and die either way. Just because we can ventilate patients doesn't mean it is the correct option for all.
With respect this fudges the issues and looks for a reason not to ventilate based on a safety or balance of probabilities issue. The issue is an uneasonable request in the face of the fact that ventilation can not be expected to achieve any useful purpose i.e. is futile and should be dealt with as such. It is also very difficult to explain to the next patient why he/she can't be admitted because you gave your last bed to a hopeless case.
Don't really like this argument either as I think eack patient should be dealt with on his/her own recognizances. They should be treated fairly and equally and they should be able to place their trust in you to do just that. Otherwise they are placed in the situation of finding themselves switched off because the next patient has a better APACHE score or whatever. I think it is important to protect that trust - that your are the advocate of each patient - but that does not include giving him what he wants.
Finally, Intensive Care treatment is a privelege and not a right, just as none of us have the right to demand the best car, home etc. and it unfortunately falls to us, by and large, to apportion this privelege. Sorry to adopt such a dogmatic approach and I will take any and all criticism on the chin :-)
Stick it out. It is not a right in the absolute sense but each patient should be considered to have the right to be treated fairly and reasonably and be considered for treatment - despite his background etc. We get ourselves into deep deep trouble when we start talking about previledges - rather like quality of life. We may make reasonable medical decisions but when we start to consider people 'priviledged' to have medical treatment we are asking for trouble.
Dick Burrows:
You gave us the ludicrous and then you blast every opinion opposite to yours as unrealistic. You are falling into the trap that every individual falls into when heaccuses another of 'playing God' In other words the individual only plays God when I disagree with his decision.
A case can be put for ventilation just as a realistic case can be put for not ventilating. Where I disagree with your logic of agreeing to ventilation is because you made the decision on the basis of covering your own arse. You've been raped before it seems.
That is the wrong reasoning (although it is obviously a powerful argument in this modern world where nobody gives a raving rat's arse about the next guy) but it is precisely why we have been sidelined as useless wimps - no more than purveyors of vegetables in a side street. "Ventilation today sir" sez he with obsequious smile. "No - perhaps a little ECMO for your pleasure then".
Sad to say I don't think I'm too far different as if I am honest with myself it is my shortfall of resources which allows me my latitude but that does not make the argument right either.
David Crippen:
Dick Burrows said: "You gave us the ludicrous and then you blast every opinion opposite to yours as unrealistic".
I don't know that this is true. I simply desired people to quit advocating things that weren't realistic so we could get down to the business at hand, the business of what realistic options were open. I didn't "blast" them, I minimized them. I didn't say they were not valid. I said they were unrealistic, and they are in my milieu. A spade is a spade, even in 4 dimension Boolean geometry.
Burrows sez: "A case can be put for ventilation just as a realistic case can be put for not ventilating".
It might have been realistic in theory but not in actual practice so I cut it short after a reasonable length of discussion about it so I could get to the real meat of the matter, which was not what I ought to do but what I could do.
Burrows sez: "Where I disagree with your logic of agreeing to ventilation is because you made the decision on the basis of covering your own arse. You've been raped before it seems."
Covering my own arse is a part of it but not the whole. I am more than happy to cover my own arse if it comes to it, but I would have you believe that arse covering is not an ideal in itself, nor would I cover my arse to a patient's detriment. I am a part of a team, the other members of which have authority as well as I. I choose my battles carefully. Battles unlikely to go my way tend to generate more loss that benefit.
Looking to God for support is a very malleable proposition. Numerous tyrants through history have claimed to have God's permission to loot and pillage and no one could produce evidence to the contrary. If I were to stand in a conspicuous place in the ICU and declare that God has told me not to intubate this patient, I would be unceremoniously carted away. I have not been raped before, but I am very wary of horses behind me.
A 10,000 pound turbocharged Steamroller with 14 inch long fece covered spikes approaching me flat out at 10,000 RPM. I stand firm though with hand outstretched. "Stop in the name of righteousness" I declare.
Wrapup- David Crippen:
There are several problems here:
The patient's attending physician was unable or unwilling to confront the fundamental issue of impending death. In part, I think this is because of the current flavor of eying patients as "clients". Harbingering bad news is a big drag and makes everyone unhappy. Physicians like to keep their clients happy, like financial advisers. When bad news is inevitable, physicians like to share the suffering. So, when such patients can be admitted to another service (like the ICU) it sends signals that the attending physician is "concerned". Clients like to have their advisors "concerned". And another physician comes into play to share the pain (and the liability when unsatisfied customers complain).
Whether or not to intubate him on demand is not an issue. We have had this argument before, but the reality is that I am mandated to intubate him on demand as long as doing so has the potential to keep him "alive" in some malleable sense for a longer period of time than if I didn't. The real problem is how to eventually let him die, on or off the ventilator. He wants intubation and his family doesn't. They have no say in it as long as he is lucid. His reasons for desiring intubation don't have to make sense to me or the family UNLESS they can be demonstrated to be nonsense. Maintaining vital signs for a little longer makes perfect sense to every "Ethics Committee I have ever been involved with. Reimbursers will not balk at paying for it (clearly not an issue as far as I am concerned).
Technically, as his disease progresses, and he becomes incompetent, they cannot change his clearly elucidated wishes. However, I am mandated to continue mechanical ventilation only until a second echelon of "futility" has been reached. I may then discontinue his mechanical ventilation and render comfort measures when I have demonstrated that such treatment is ineffective in reversing a progressive disease process. Perhaps a subtle distinction, but an important one in a society where individual autonomy talks and paternalism walks.
For purposes of argument, take me on faith that the patient was truly terminal and no further therapy of any kind would have been in any sense beneficial. Here is how this case was handled. I approached the patient and his family at the bedside and drew the curtain. "Why do you want to have artificial ventilation". "I don't want to die".
"Mr. XXXXXXX........I am afraid it is my painful duty to tell you that life is not a viable option for you. You were diagnosed with AIDS in 1989, you have survived longer than most and now the time has irrevocably come as it did for Liberace, Freddy Mercury and Rock Hudson. When that time came, there was not one single thing anyone could do to prolong it one second. The reality is that you will die very soon and nothing can or will stop it."
"Further reality is that you have only two options. You can allow me to make you as comfortable as possible with sedatives and analgesics during the dying process or you can allow me to put you on a mechanical ventilator and make you as comfortable as possible with sedatives and analgesics during the dying process. If you desire me to put a breathing tube down your throat and breath for you, I am willing to do that, but I need you to know that this maneuver will not change the rest of my care plan nor will it prolong your short life expectancy."
"If you choose intubation and ventilation, I will demonstrate by assorted laboratory and clinical parameters that mechanical ventilation is not achieving any desirable goal and I will simply maintain it at whatever level might improve your comfort while I actively treat your dying process to insure your maximal comfort. If I perceive you have any discomfort at all during the dying process, I will aggressively move to mitigate that discomfort, even if it hastens your death. Mechanical ventilation will be used as a comfort measure only, not as a curative treatment."
Then the tears came.........all around. They elected full comfort measures and the patient expired with no evidence of distress several hours later.
Chris Anstey:
Common sense has finally prevailed. My limited experience with people leads me to believe that fear is generated from ignorance. Ignorance in this case from a misunderstanding of the true options available. Most people will accept their own mortality as long as they believe that their personal suffering can be eased, however that is achieved. We live our lives surrounded by others, but dying is an intensely personal and potentially very lonely process. It may be the loneliness and feelings of helplessness that feed the fearful emotions and part of our many duties as doctors is to ease this suffering. This type of deep communication can only be built on mutual trust and respect - it does not spring from committees, lawyers etc but from a one on one exchange.
Jeff Salon:
On the supposition that his care would be better in the ICU and that his dying would be "better" in the ICU......I RATHER DOUBT IT ! It is quite obvious that he is RESENTED(i.e. hated) for being there on his own "merits", his family is disliked at best, and he has personally compromised the lives and outcomes of potentially hundreds of other would-be ICU beneficiaries. He will receive suboptimal care in the ICU just as he did on the floor.
David Crippen:
Hmmmm.......I don't think this is true. No matter what the personal feelings of ICU staff are, the level of care is pretty much regimented and controlled around them. It would be rather difficult to give formal orders to "decrease level of care to dirtball level, and don't call me for this crap". Any informal such care would be cheerfully documented by the nursing staff and the local newspaper or TV investigative reporter would get an anonymous call.
I don't recall complaining about transferring this patient to the ICU, only about prolonging his death by intubating him. I don't have any problem titrating palliative care inthe ICU setting, because I can control it toward the patient's best interest. And, in fact, if you read the aftermath of this case, that's precisely what I did. The point was that the intubation was completely superfluous to the treatment plan.
And furthermore, the reality is that palliative care in the ICU can be, and usually is more effective than such care on the "floor" because it can be effectively titrated in real time at the bedside. Had the attending asked for the patient to be transferred to the ICU for titrated palliation of the dying process because he was awake and alert, I would have had no problem with that at all. I think I (we) can offer a very valuable service in that regard (awake patients). This is not to say that the ICU is the best place for that service; it happens to be the only place I have where I can currently provide it. Maybe Dana's palliative care area can combine one-step-up-from-hospice titrated care of the dying process in a cheaper and more comfortable environment, and I am interested to see how that goes down.
Jeff Salon:
I seriously doubt that all the hostility and anger he has engendered will be brushed aside and his care will be as good as that given to the "pretty"(sorry for being sexist) 17-year-old cheerleader trauma victim in the next bed who made it to the unit after being struck by a car while pushing a toddler and his puppy out of the way. Can any of us say that we have always been as kind and compassonate to the self-inflicted overdoses and "dirtballs" as we are to those "who truely needed us" ?????
David Crippen:
I have a lot pf personal feelings about stereotypes of ICU patients, especially overdoses, but none of these feelings translate to "quality" of care in the ICU. In fact, If I harbored such feelings and if I was aware of it, I would be on constant guard to insure none of them impacted patient care. It isn't my job to tailor my care to how I feel personally about patients. If any objective evidence could be discovered that I did so, I would be a serious risk of losing my job.