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Here's where we talk about the latest fad diets, the advantages of vegetarianism, the joy of exercise and good health. Like everywhere else at Tweb our decorum rules apply.
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Hospitals considering universal DNR for covid patients.
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Originally posted by JimL View PostI doubt that medical professionals would comply with such an order which goes against their oath....because every forum needs a Jimbo
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Originally posted by JimboJSR View PostIt's more complicated than that. Our first duty is "do no harm", and an inevitably futile attempt at CPR is usually regarded as harmful - its brutal, undignified, anf and usually distressing for family and observers (not to mention the patient, to whatever extent they are aware of what's going on). I can't speak for covid, but there are many instances where we would not perform CPR even if a patient wanted us to - these are when the chances of CPR being successful are extremely low (which, sadly, is very often the case).Last edited by JimL; 03-29-2020, 06:45 PM.
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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.
Originally posted by JimL View PostI understand that CPR is often futile, more often than not it is futile, but one never knows if an attempted resuscitation is futile or not until it is.
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:
"By the time you get all gowned up and double-gloved the patient is going to be dead," Fred Wyese, RN, an ICU nurse in Muskegon, Mich., said. "We are going to be coding dead people."
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....because every forum needs a Jimbo
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Originally posted by JimboJSR View PostI 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.
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Originally posted by JimboJSR View PostI 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.Last edited by JimL; 03-31-2020, 04:04 PM.
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Originally posted by JimL View PostThe 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.If it weren't for the Resurrection of Jesus, we'd all be in DEEP TROUBLE!
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Originally posted by demi-conservative View PostIs Jimbo going to invite you to his hospital?Last edited by JimL; 04-01-2020, 12:51 AM.
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