Friday, July 17, 2009

Living wills and DNRs are not enough---patients need a comprehensive advance care plan

This topic was nicely addressed in a recent article in CCJM. It’s an important reference for the hospitalist’s library because it contains many algorithms and assessment tools. Here are a few key points:

Planning is best done as a series of discussions and should therefore take place in the ambulatory setting. As a hospitalist your job will be a lot easier if that has already taken place. All too often it has not. In such cases you as the admitting physician have to ask unprepared family members, caught in the overwhelming stress of the moment, what their preferences are. The chances of you getting an informed and rational decision are somewhere between slim and none.

Discussions need to go beyond the usual DNR check list. Would dialysis be appropriate? What about PCI as opposed to non-invasive symptomatic treatment of acute coronary syndrome? Next time the patient deteriorates at the nursing home should s/he be transported to the hospital again?

Discussions need to address the big picture. Patients and families may be clueless about big picture issues despite superficial familiarity with all the medspeak of gramma’s disease processes. Big picture questions include: What are the expectations of treatment? Can we really “fix” anything? Is it really important to make precise etiologic diagnoses if we can otherwise maintain comfort and quality of life? What’s the prognosis?

An accompanying editorial disagrees with the authors on several points, including the degree to which algorithms are useful.

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