Page 3 of 3 FirstFirst 123
Results 21 to 26 of 26

Thread: Hospitals considering universal DNR for covid patients.

  1. #21
    Troll Magnet Sparko's Avatar
    Join Date
    Jan 2014
    Faith
    Christian
    Gender
    Male
    Posts
    53,881
    Amen (Given)
    5498
    Amen (Received)
    23666
    Quote Originally Posted by JimboJSR View Post
    I read the article. There are a few separate issues here. Please note I'm a conservative (by british standards) christian, pro-life and anti-euthanasia or assisted-suicide. However I've also looked after a lot of criticially ill people, participated in many CPR scenarios, and seen many successful and unsuccessful outcomes.



    Er... we kinda do.

    1) We have decades of experience with CPR, and we have good predictors of success or failure. From the beginning, CPR has a low level of success.
    Additionally, the evidence so far seems to be that, if your Covid infection is severe enough to cause cardiac arrest, your chances of leaving hospital alive are smaller still. Finally, one of the strongest influences on the success of CPR is the speed and quality of chest compressions - any delay in starting CPR following cardiac arrest, and survival rates drop precipitously. Put all three together, and I can completely understand the hospital's reasoning. Rolling out this policy to EVERY patient I think is too much - for example, even in this scenario, a 30 year old would have some chance of survival, abeit a small one, whilst a 70 year old is likely beyond our help - but the decision making process is basically sound. That's why the article quotes medical staff:



    We've seen this. Lots and lots of times. We have a decent idea of what work and what doesn't, and medical / nursing staff tend to be much more realistic in the odds of CPR success than the public.

    2) Another factor is the safety of hospital staff. CPR is a aerosol-generating procedure and carries a high risk of infecting medical staff, unless full PPE is worn. Commencement of CPR will inevitably be delayed as staff done PPE. If full PPE is not available, are your eally going to ask docs and nurses to risk their own life by not protecting themselves? This brings the hospital to consider what would happen if they are running low on PPE - do they use up precious equipment to do something with is almost certainly not going to get a heartbeat back and even less likely to result in the patient acually leaving hospital alive? Because if they run out of kit smashing up the ribs of a 70-year old corpse, they then have nothing to use when the 30-year old comes in, who really does need their help and has a much higher chance of benefitting from it.

    3) Going against patient's / relatives' wishes. I'm not sure what the legal situation is in the USA. Here, CPR is a medical procedure. As doctors, we are not obligated to offer a medical procedure simply because the patient wants it. My day job is in rheumatology. Recently a patient with osteoarthritis (wear and tear) in their joints came into my clinic. They had heard about a famous drug called Humira (it's an anti-arthritis drug - in fact, the biggst-grossing drug in history) and watned to try it. I said no, because Humira works by suppressing the immune system in inflammatory arthritis; OA isn't an inflammatory condition, and we have plenty of scientific rational and clinical experience to tell us that Humira doesn't work in OA. If I think a medication is not going to provide benefit, I'm not obliged to prescribe it - in fact, it would be highly unethical of me to do so. The same principle holds for CPR - if it's gonna work, then let's talk about it; if the evidence shows that it's very unlikely to help, then it's pointless and unethical, no matter how much a patient might ask. Of course these decisions can be hard, and we should discuss and inform the patient - but that's different to asking their permission.
    I am assuming these deathly ill covid patients would be in an ICU isolation ward with constant monitoring by ICU nurses, who would already be all geared up with PPE if they don't want to catch the virus themselves. So the excuse "they have to get dressed up in PPE before giving CPR" doesn't work. And the patients in their room are already "aerosoling" the air in their room with their coughs.

  2. #22
    tWebber
    Join Date
    Jan 2014
    Faith
    Agnostic
    Gender
    Male
    Posts
    17,276
    Amen (Given)
    2146
    Amen (Received)
    1685
    Quote Originally Posted by JimboJSR View Post
    I read the article. There are a few separate issues here. Please note I'm a conservative (by british standards) christian, pro-life and anti-euthanasia or assisted-suicide. However I've also looked after a lot of criticially ill people, participated in many CPR scenarios, and seen many successful and unsuccessful outcomes.



    Er... we kinda do.

    1) We have decades of experience with CPR, and we have good predictors of success or failure. From the beginning, CPR has a low level of success.
    Additionally, the evidence so far seems to be that, if your Covid infection is severe enough to cause cardiac arrest, your chances of leaving hospital alive are smaller still. Finally, one of the strongest influences on the success of CPR is the speed and quality of chest compressions - any delay in starting CPR following cardiac arrest, and survival rates drop precipitously. Put all three together, and I can completely understand the hospital's reasoning. Rolling out this policy to EVERY patient I think is too much - for example, even in this scenario, a 30 year old would have some chance of survival, abeit a small one, whilst a 70 year old is likely beyond our help - but the decision making process is basically sound. That's why the article quotes medical staff:



    We've seen this. Lots and lots of times. We have a decent idea of what work and what doesn't, and medical / nursing staff tend to be much more realistic in the odds of CPR success than the public.

    2) Another factor is the safety of hospital staff. CPR is a aerosol-generating procedure and carries a high risk of infecting medical staff, unless full PPE is worn. Commencement of CPR will inevitably be delayed as staff done PPE. If full PPE is not available, are your eally going to ask docs and nurses to risk their own life by not protecting themselves? This brings the hospital to consider what would happen if they are running low on PPE - do they use up precious equipment to do something with is almost certainly not going to get a heartbeat back and even less likely to result in the patient acually leaving hospital alive? Because if they run out of kit smashing up the ribs of a 70-year old corpse, they then have nothing to use when the 30-year old comes in, who really does need their help and has a much higher chance of benefitting from it.

    3) Going against patient's / relatives' wishes. I'm not sure what the legal situation is in the USA. Here, CPR is a medical procedure. As doctors, we are not obligated to offer a medical procedure simply because the patient wants it. My day job is in rheumatology. Recently a patient with osteoarthritis (wear and tear) in their joints came into my clinic. They had heard about a famous drug called Humira (it's an anti-arthritis drug - in fact, the biggst-grossing drug in history) and watned to try it. I said no, because Humira works by suppressing the immune system in inflammatory arthritis; OA isn't an inflammatory condition, and we have plenty of scientific rational and clinical experience to tell us that Humira doesn't work in OA. If I think a medication is not going to provide benefit, I'm not obliged to prescribe it - in fact, it would be highly unethical of me to do so. The same principle holds for CPR - if it's gonna work, then let's talk about it; if the evidence shows that it's very unlikely to help, then it's pointless and unethical, no matter how much a patient might ask. Of course these decisions can be hard, and we should discuss and inform the patient - but that's different to asking their permission.
    The odds of manual CPR alone are never good anyway, but we don't just allow someone to die because we think the odds may not be good. Besides, hospitals are equiped with AED defribulators.
    Last edited by JimL; 03-31-2020 at 02:04 PM.

  3. #23
    tWebber Christianbookworm's Avatar
    Join Date
    Jan 2014
    Location
    Northern Hemisphere
    Faith
    Christian
    Gender
    Female
    Posts
    9,659
    Amen (Given)
    5733
    Amen (Received)
    1875
    Quote Originally Posted by JimL View Post
    The odds of manual CPR alone are never good anyway, but we don't just allow someone to die because we think the odds may not be good. Besides, hospitals are equiped with AED defribulators.
    You don't shock a flatline.
    If it weren't for the Resurrection of Jesus, we'd all be in DEEP TROUBLE!

  4. #24
    tWebber
    Join Date
    Jan 2014
    Faith
    Agnostic
    Gender
    Male
    Posts
    17,276
    Amen (Given)
    2146
    Amen (Received)
    1685
    Quote Originally Posted by Christianbookworm View Post
    You don't shock a flatline.
    That's true, but cardiac arrest doesn't necessarily mean flatlining.

  5. #25
    tWebber demi-conservative's Avatar
    Join Date
    Dec 2015
    Faith
    Christian
    Gender
    Male
    Posts
    4,273
    Amen (Given)
    172
    Amen (Received)
    585
    Quote Originally Posted by JimL View Post
    The odds of manual CPR alone are never good anyway, but we don't just allow someone to die because we think the odds may not be good]
    Is Jimbo going to invite you to his hospital?
    Remember that you are dust and to dust you shall return.

  6. #26
    tWebber
    Join Date
    Jan 2014
    Faith
    Agnostic
    Gender
    Male
    Posts
    17,276
    Amen (Given)
    2146
    Amen (Received)
    1685
    Quote Originally Posted by demi-conservative View Post
    Is Jimbo going to invite you to his hospital?
    I doubt it. But I know what he's talking about, hospitals aren't going to have a choice, they're not going to have the personell, they're not going to have the equipment, or the time to be able to care for everyone. and that's why they may have to make those decisions that they would otherwise not make. They would never consider the odds under normal circumstances. At some point, they just aren't going to have a choice any longer! Pretty sad situation for everyone involved!
    Last edited by JimL; 03-31-2020 at 10:51 PM.

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •