Tuesday, February 09, 2010

Doctor's orders

Sad ironies occur every now and then. Why do they feel ineluctable in health care settings?

Michael Howell is one of the BIDMC physicians who has been greatly involved in the enhancement of patient care in our ICUs. I sent him an email asking if he would review an article that IHI's Maureen Bisognano and I had written about this process. He received the note while accompanying his terminally ill grandfather to another hospital.

Here is his reply:

I am happy to review the article in the next day two. It is ironically appropriate: I am sitting in an ICU waiting room right now, excluded from visiting because it is not yet 10am. My 95 year old grandfather, who had an existing DNR/DNI order, was (presumably inadvertently) intubated and I am down in a small town in northern Alabama. It's my fourth or fifth time on this side of the ICU door. Terrifically challenging, since my dad had already gone through the difficult process of moving to comfort-focused care, and now we find my grandfather on life support against prior directives.


See the photo for the way visiting hour policies are conveyed here.



Mercifully, the funeral was recently held. We offer condolences to Michael and his family.

4 comments:

Anonymous said...

This is the second story in 24 hours I have heard regarding NH's ignoring DNR orders. Could this be another manifestation of defensive medicine? Consider the Medicare costs it is generating....

nonlocal

Jane Sarasohn-Kahn said...

My sympathies, as well. This happens so often. It happened to my Dad in 2007. Here's where I wrote about his story and the role of digital directives in iHealthBeat: http://www.ihealthbeat.org/Perspectives/2007/Digital-Directives-Could-Aid-EndofLife-Care.aspx
Paul, thanks for raising this issue yet again. Jane

Paul Levy said...

From facebook:

Jim: Very sad, my condolences to Dr. Howell and his family. Unfortunately, but understandably, ICUs are often psychologically constructed like trauma units. They have all of the most aggressive life saving techniques, drugs and machines at their fingertips and once trained, doctors and technicians are poised to use them and patients and their families are loathe to interfere. Sadly what we forget in that environment is that the end of life is not a sudden trauma, but a gradual realization even when it appears to be a sudden onset. The paradigm has been shifting, but word is not out everywhere and there is a natural resistance toward letting go. Thanks for sharing this Paul, it helps us to feel empowered by necessity and the recognition that no one is immune.

Anonymous said...

Unfortunately, a recurrant story. A few years ago my father, DNI/DNR, was a victim of the "911 disposal service" reflex that is common among many NH's. For an academic MD the event & the resultant mess was truly Kafka-esque. My sympathies.