BLACK E4
HEALTH 03-09-10 DM EE E4 BLACK
E4
KLMNO TUESDAY, MARCH 9, 2010
SCENES FROM THE
cause their sedation was done
21ST-CENTURY DOCTOR’S OFFICE
correctly. So here are my educated
instructions.
I refuse to have a DNR or DNI
Life or death?
order for myself. Go ahead, doctor
and family, give me some comfort
meds, then shock me, tube me
and line me.
Life is precious and irreplace-
The easy choice
able. Even severe incurable illness
can often be temporarily fixed,
moderated or controlled, and
most discomfort can be made tol-
may not be best.
erable or even pleasant with sim-
ple drugs. In chess, to resign is to
give up the game with pieces and
options remaining. My version of
DNR is “Do Not Resign.” Don’t
dnr continued from E1 to contract. While the pads are be- give up on me if I can still think,
ing adjusted, I glance at the mon- communicate, create and enjoy
technique, but even harder chest itor. life. When taking care of me, take
compressions would be better. “He’s got a rhythm!” Slow wide care of yourself as well, to make
“Allow me,” I say as I take over blips on the monitor with a barely sure you don’t burn out by the
the chest compressions. This is palpable pulse. “Dial up the pac- time I need your optimism the
unusual for an attending physi- er,” I order. Potent electric shocks most.
cian to do because it’s hard to at 80 beats per minute begin to My DNI? It means “Do Not Ig-
think during manual labor. But stimulate his heart, causing the nore” early signs of trouble when
correct CPR, faster and more muscles of his chest and neck to my failing body and mind need
forceful than most people think, spasm as well. The pacer is work- support so I can continue to func-
is of paramount importance for ing. Now there is a strong pulse, tion in ways that matter. And Do
this patient. I’m moving his blood great blood pressure of 150/80, Now, he’s stabilizing. Then I get potassium: He’s in acute kidney chance, however, we must go all- Not Ignore my needs for compan-
and feeding his brain with glu- and his pupils are beginning to the story: several failed rounds of failure. Because of his failing kid- out and ‘do everything’ for the ionship, stimulation and purpose,
cose and oxygen, keeping the neu- constrict, suggesting decent blood chemo; several weeks of weak- ney, it’s likely that high levels of next several days.” I pause and as these, too, make life worth liv-
rons from dying. I synchronize flow to the brain. The EKG’s nor- ness, decreased appetite and de- potassium in his blood (hyperka- add, “You can always change your ing. To leave me in the hospital
my words with compressions and mal. He has a heart that works. He pression; many days of feeling un- lemia) caused cardiac asystolic ar- mind,” addressing a family’s fear. bed alone staring at the TV is tor-
call out for a pacemaker. It’s not gags, coughs and starts to reach well. I hear that his meds don’t in- rest. Every other system appears The family members spend the ture. Surround me with people:
here; someone’s going to get it. for the breathing tube in his clude appetite stimulants, intact. A full-body CT scan shows next two hours in discussion with Bring the kids so I can teach and
Okay, hurry up. Pumping . . . throat. He has a brain that works. antidepressants or narcotics; why only mild evidence of metastatic the primary oncologist, nephrol- talk to them. Discuss the news
thinking .... I order narcotics and sedatives. not? The family wants me to cancer. But without dialysis, he is ogists and the ICU team. They de- with me. Let me use my e-mail.
“You want epi? Atropine”? the “Good job, everyone,” I say, “make him comfortable.” doomed by tomorrow. cide on comfort care only and no Treat my depression, dehydra-
nurse asks. Yes, everyone knows knowing the pride they have in “Right now he’s comfortable,” I The members of the intensive dialysis. tion, malnutrition, muscle wast-
the standard protocol: If there’s their skills. I’d customized the respond, and they appear sur- care unit team, having heard I see the burnout in their eyes. ing and pain with potent pills, in-
pulseless flat-lining, it means therapy on the basis of intuition prised. They thought comfortable about the DNR, are reluctant to Their will to fight quit weeks ago, fusions, tubes and hormones.
asystole — the heart’s ventricles and experience. And the interven- was going to be complicated, ex- treat aggressively. Talking with after this patient’s minor symp- Recall the great people of our
aren’t contracting — so start CPR the family, they are painting a toms from the chemo and cancer time who thrived with disability
and inject the drugs epinephrine bleak and — to their credit — of- were left unaddressed, leaving the and my willingness to savor life
and atropine to stimulate the
No amount of hope in my heart can
ten realistic picture of what it’s impression that his life wasn’t just like them. Give me a motor-
heart. I decline the usual drugs, like for someone dying over weeks worth living. No amount of hope ized wheelchair and a feeding
expecting they’ll do more harm
rekindle what has died in theirs.
as organ systems shut down one in my heart can rekindle what has tube if I need them, along with a
than good. This resuscitation isn’t after another. They’ve seen it so died in theirs. tracheostomy to help me breathe
by the book. The nurse looks con- many times. Why make the pa- He is taken off the ventilator and dialysis to filter out toxins.
fused, “Asystole, epi, atropine. It’s tions were optimized and per- clusive of everything else. I ex- tient suffer? Meanwhile, the pa- and placed on the time-honored Those do nothing to stop a good
what we always do.” formed without delay by skilled plain about the euphoric pain re- tient maintains excellent vital morphine drip. He expires peace- mind and a strong spirit, while
“Unless the asystole is from too hands. But we’re not done. lief of the fentanyl infusion and signs, and when sedation wears fully several hours later. The best permitting both to overcome ob-
much potassium,” I reply. That “Where’s the family?” I ask. “I the deep sleep and amnesia in- off he’s able to follow simple com- resuscitation of my career turned stacles of blood and flesh.
would explain it. “Get two amps of need some history.” They’re wait- duced by the propofol drip that mands. into my most memorable profes- It’s so easy to let someone die,
bicarbonate. Take over compres- ing outside. I wipe the smile of accompany his life support. He I’ve resuscitated many patients sional disappointment. It also re- but it takes effort, determination
sions,” I say to the intern. “Central success off my face and walk out feels no pain; he’s sleeping. I also who died hours later. This case minded me that the concept of and stamina to help someone stay
line kit, please.” The jugular line slowly. I introduce myself, and be- tell them that his heart appears to feels different to me. Hopeful. I re- DNR, however ethically sound and feel alive. Only after you
takes seconds, and I flush it with fore I can go further, a woman in- be working and, on the basis of port my findings to the family. and well conceived, can be com- made every effort to let me be
sodium bicarbonate. This prob- terrupts and hands me papers. his purposeful hand movements, There are times when giving hope plex and contentious. happy and human, ask me again if
ably will correct the blood’s ex- “He has DNR and DNI orders,” his mind might still be intact. I is morally and professionally Folks who say, “When I get that my life is worth living. Then, lis-
treme acidity, which I suspect is she says. ask the questions still unan- wrong because the hope is false. sick, unplug me, don’t let me suf- ten and comply. At that point, if I
driving up the potassium. The ex- It’s a bit of a shock, and I take a swered. “Is the DNR in effect Today is not that day. fer,” usually watched a depressing wish to die, let me die. But until
ternal pacemaker finally arrives. deep breath. The papers clearly now? In case of heart arrhythmia, “I think there’s a good chance movie or saw someone dying mis- that happens, none of us realizes
Technicians attach the pads to the show that both CPR and intuba- can I give him a shock or more he is fixable in the short term,” I erably on life support. They’ve what I can accomplish with an-
patient’s right shoulder and left tion should have been off-limits. I chest compressions? Given the se- say. “He needs dialysis, but other never been exposed to the other other day, another week, another
ribs. But I want them on front and didn’t know this, and I erroneous- dation, it won’t hurt.” Confusion than that we can address every point of view or learned how the month. So do it all for me. Then
back for “better capture.” By this I ly saved my patient’s life. overcomes the family, and I step other comfort issue. I think he can end of life can be done better. And ask someone to do it all for you.
mean that the electrical stimulus I carefully explain that every- back to let them think it over. wake up and talk, probably even they should hear it from a medical
health-science@washpost.com
will be transferred more effective- thing happened fast. We weren’t The lab reports the blood work, write or use a computer. I think professional before making up
ly and will better induce the heart aware of the DNR and the DNI. and I was right about too much his depression, weakness, appe- their minds about something this Veysman is an assistant professor of
tite, dehydration and malnourish- important. emergency medicine at the Robert
ment can be effectively treated. In my role as a doctor, I’ve met Wood Johnson Medical School,
Whatever his prognosis is from countless disabled, disfigured, University of Medicine and Dentistry
the cancer, I think he can prob- machine-supported people who of New Jersey, in New Brunswick. This
ably get at least a few good weeks, enjoy living and wish to continue essay is excerpted with permission
which is done best by a hospice. doing so as long as possible. I’ve from the Narrative Matters section of
Seniors can live at home,
He might want to do something met intensive-care survivors who the February edition of Health Affairs.
with that time. To finish up. To say lead full, productive lives, often The full essay is available at
goodbye and good luck. I think it’s with few or no memories of their
www.healthaffairs.org.
with the best trained
too early to die. To give him a ordeals and heroic procedures be-
caregivers in America.
LETTERS
WHERE TO WRITE:
health-science@washpost.com
The Washington Post, Health and Science, 1150 15th St. NW, Washington, D.C. 20071
Treating leg cramps
Many possible treatments for
leg cramps are mentioned in the
article “Leg cramps? Quinine is
not the answer” [March 2], in-
cluding quinine, Vitamin B com-
plex and the blood pressure med-
ication Diltiazem. It is odd that
there is little discussion of non-
pharmaceutical treatments.
Dehydration and/or potassi-
um, magnesium or calcium def-
icits can cause an electrolyte im-
balance, and dietary intervention
could correct those deficits. Bal-
ance of these key electrolytes is
“We’ve used other agencies before, but never dealt with such
necessary for healthy blood pH
and nerve and muscle operation;
professional and caring people.”
imbalance can cause muscle
—E.B., Chevy Chase
weakness or severe muscle con-
CHRISTOPHER GEARON
tractions. A geothermal heat pump, right, taps into underground warmth.
Most scuba divers and athletes
“I am writing to express my extreme gratitude with the services that
know that low fluid levels or min-
eral imbalances are the most Taking the heat presence of grain in cat food.
your company has provided. Without your caregivers...and their
common cause of leg-muscle Christopher Gearon indicated SUSAN VAVRICK
thoroughness in understanding difficult situations, my mother had a
cramps for people without a se- that use of the geothermal heat Springfield
vere medical condition, and eat- pump would free a family from
very good chance of not surviving. It was only your caregivers’ critical
ing a banana can be a simple but using fossil fuels [“Looks like a Perils of parity
observations that saved the day.”
effective way to restore potassi- hot deal,” March 2]. Sandra G. Boodman’s article on
—T.F., Bethesda
um levels. Someone suffering However, 60 percent of the federal mental health parity
from leg cramps should certainly electricity generated in Maryland [“Parity law expands mental
rule out diet and water intake be- is coming from coal. Thus, you health access,” March 2] misses
“Jessica went above and beyond any caregiver I’ve ever had.”
fore moving on to medications are still consuming a fossil fuel; the impending new story on uni-
—J.D., McLean
and more extreme measures. its emissions and greenhouse versal mental health parity and
ROBERT M. BIRKENES gases simply are no longer resi- begs questions on the old one.
Silver Spring dentially based, but instead are The new story is that if any of
based at a commercial facility. the national health-care bills
JOHN HUBER passes, mental health parity na-
Alexandria tionwide will be law and will cost
On A Stannah
inestimable billions of dollars; it
Against the grain
Stairlift will be known and understood by
The Green Lantern’s column easily suggestible people who will
about feeding pets took my be motivated to get costly care.
Home Care Assistance is the region’s premiere home care provider
AIRS
Make climbing
stairs easy again breath away [“It’s a dog-eat-meat The old story is that problems
specializing in live-in care. Caregivers are trained in our unique
with the world’s
world out there,” March 2]. in living are not illnesses. Med-
top selling
I cannot ignore advice to add ically authentic cognitive trag-
Balanced Care Method
™
of healthy living and are available 24 hours
stairlift in your
home. Stannah is grains to pet food. Yes, some (al- edies such as dementia and some
simply the best
a day, 7 days a week, or on an hourly basis.
though not all) dogs are omni- other organically based brain dis-
solution for any
vores. But all cats are obligate eases are falsely depicted as men-
straight, curved,
or spiral stair-
carnivores, and grain is probably tal illness prototypes to convince
way. For more
the worst thing you can feed people that all of those who are
301-654-1525 703-356-4333 202-296-2124 information call
them (other than the meat by- unhappy and conflicted are sick
or visit website.
products also mentioned in the and should be covered by health
www.HomeCareAssistance.com
column). Their digestive systems insurance. Cancer and heart dis-
Offices in Maryland, Virginia and Washington, DC
703
MD ~ DC ~ V
998 0178
A
01
are not capable of processing ease are not a matter of direct
301-585-0700
Maryland Residential Services Agency No. R2405
grain properly; kidney stones, choice; substance abuse and in-
Virginia Home Care Organization No. HCO-09558
GLIDE UPST
703-998-0178
struvite (urinary) crystals and terpersonal difficulties are.
bedcomobility.com
diabetes are only a few of the RICHARD E. VATZ
(800) 825-1760
897 380601
many conditions linked to the Towson
BLACK E4
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52