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Hospitals considering universal DNR for covid patients.

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  • #16
    Originally posted by Sparko View Post
    This is terrible.

    If you have a heart attack or something in the hospital, they are now talking about just letting you die, no matter what you or your family want.

    Sounds like another taste of what socialized medicine would be like.

    -------
    Hospitals consider do-not-resuscitate order for all COVID-19 patients

    Some hospitals are considering do-not-resuscitate orders for all COVID-19 patients, citing the high exposure risk for staff as protective equipment supplies run low, The Washington Post reports.

    Chicago-based Northwestern Memorial Hospital is currently discussing a universal DNR policy for COVID-19 patients, regardless of patient or family wishes. Hospital administrators have asked Illinois Gov. J.B. Pritzker to clarify if state law would allow such policy changes.
    https://www.beckershospitalreview.co...-patients.html
    ---------
    I doubt that medical professionals would comply with such an order which goes against their oath.

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    • #17
      Originally posted by JimL View Post
      I doubt that medical professionals would comply with such an order which goes against their oath.
      It'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).
      ...because every forum needs a Jimbo

      Comment


      • #18
        Originally posted by JimboJSR View Post
        It'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).
        I 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. Harmful, brutal or undignified have nothing to do with whether or not to perform CPR.
        Last edited by JimL; 03-29-2020, 07:45 PM.

        Comment


        • #19
          Originally posted by JimL View Post
          I doubt that medical professionals would comply with such an order which goes against their oath.
          I would hope so, but read the article.

          Comment


          • #20
            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 Post
            I 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.
            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:

            "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."
            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.
            ...because every forum needs a Jimbo

            Comment


            • #21
              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.

              Comment


              • #22
                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, 05:04 PM.

                Comment


                • #23
                  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!

                  Comment


                  • #24
                    Originally posted by Christianbookworm View Post
                    You don't shock a flatline.
                    That's true, but cardiac arrest doesn't necessarily mean flatlining.

                    Comment


                    • #25
                      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.

                      Comment


                      • #26
                        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; 04-01-2020, 01:51 AM.

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