In this national database of Medicare patients >age 65, from 1992 to 2005, the incidence of in-hospital CPR remained steady, but the proportion of hospital deaths preceded by CPR increased from 3.8% to 5.2%. This indicates that CPR is increasingly being performed in patients unlikely to survive, escalating the need for discussions about futility
I could have told you that. Just the other day I took care of a patient with 10 chronic medical illnesses, immobilized in a nursing home.
Full code, despite me spending 15 minutes of uncompensated time describing why the last thing in the world they want to be is full code. I asked him what he knew about CPR. "Just what I see on television" was the response.
We physicians are in for an uphill battle on this one. You won't get physician directed discussions about allowing natural death until somebody pays for it. And pays for it well.
Here's an idea. Perhaps the Medicare National Bank could pay on commission. For every appropriate patient you convince to allow natural death, they send you a $100 check in the mail. And for every 9 patients that sign up, you get your 10th check for free. $100 to save the eventual death of a patient that should be allowed to die naturally while saving $50,000 for that two week stay in the ICU two years from now.
Now that's a market solution to a growing problem. WIN-WIN.
16 Outbursts:
It sounds like Happy was saying he was trying to convince the patient to go DNR, not the family, which makes this suck even more.
Don't know age of pt., sounds like they value their life enough to fight to come back, for reasons you don't need to understand.
Families that want to crack Grandma's chest, etc making her exit as torturous as possible, different ball of wax entirely.
More Dead Patients Are Getting CPR
I hope every patient that you do CPR on is dead at the time you start CPR. That happens to be the main criteria for starting CPR if you weren't aware.
Death is not "criteria" for CPR. Being pulseless is.
I'm sure you knew that though, Nurse Triage.
I have another couple of ideas: How about every physician who takes Meidcare gets a personal limit on how many procedures they can do that year on Medicare patients. The best example of PEG tubes. I propose that every surgeon only gets to do 5 PEG tubes a year. After five, Medicare bills the surgeon for excessive PEG's. There could even be s secondary market so that surgeons could buy and sell procedures (hmmm... just like cap and trade with carbon credits).
I have another great idea. Once Grandma gets in the hospital all the social security money she collects goes directly to the hospital to pay for care unless they are DNR.
Cost saving ideas are endless ... we just need the political will.
anon 349. Your attitutude is part of the problem. When I tell a patient, in my experience, that getting CPR will be futile, that their medical conditions will lead to an extremely painful rather than natural death if CPR is performed, I have nothing to personally gain. In fact, I am doing it on my own uncompensated time that nobody pays for.
In fact, I have every financial incentive to do CPR on patients. Medicare pays the equivalent of about 75 minutes of critical care time or over $200 for me to be present at a code, bark out some orders while the RT's the critical care nurses and the rest of the code team do their thing. The average code lasts less than 15 minutes. And all I have to do is document a quick note and sign the code sheet. For over $200.
How about I tell all my patients I want them to be full code so when I have to run a code I can bill $200 for their 15 minutes of delayed death.
Maybe I should just convince everyone to be full code, including the 89 pound 92 year old in a wheelchair since Carter.
When I tell a patient that doing CPR on this is the wrong decision, I am tellling them they are losing their opportunity to die peacefully as opposed to brutally. Your assumption of fighting back indicates your lack of medical training. It doesn't happen in patients I recommend to be DNR.
Fighting to come back. I quiver at those words. That's how bed bound 90 year olds end up in the ICU on a ventilator for two weeks before succombing to their delayed but natural death.
Better yet, we recognize that healthcare isn't a right and unless you have the funds to pay for your care you won't get it. This stops the uncompensated care issue. This also eliminates the issue of every one avoiding end of life care. If you want the full press, speak up, and back it up with benjamins.
Nick,
Absolutely it is up to the patient and/or family to determine what quality of life consists of...my hope is that these conversations would have happened before a serious medical event occurs. This is why Advance Directives can valuable. Now, my point of reference in my original comment applies to the elderly demographic-that's my area of expertise and I can't really speak outside of that. Living on a ventilator for someone in their 80's, 90's, etc. and whose quality of life was already low--that's where I have an issue. No blanket statement there; I have a specific population I'm referring to.
Letting nature take its course sometimes is not such a bad thing.
I think Happy's main point is, by performing CPR on patient's with poor quality of life to begin with, more problems are created in the long run... that is,*if* they even survive the code in the 1st place. Elderly, frail individuals who survive CPR are more than likely going to need even more interventions to stay alive...possibly even needing a respirator to aid in breathing thereafter. Not to mention a whole slew of potentially new medical issues created by enduring CPR. That's going to cost our health care institutions a good chunk of change. But beyond the financial implications, who wants to live the rest of their life hooked up to a machine?
I actually like what Happy says here. I'm a social worker in long term/subacute care and I have had tons of conversations with elderly patients and their families regarding Full Code Vs DNR. There are a lot of misconceptions about this directive. Sure, its a moral issue for some and no one wants to think that the doctors and nurses are "giving up on them" if they sign that DNR consent. But what we need to consider even *before* a patient codes is, what would the quality of life be *if* they were resuscitated and were "brought back"? What are they being brought back to? Life in a nursing home depending on others to maintain their daily routine and care needs? No one lives for that day, I can assure you.
Point taken.
Full code, despite me spending 15 minutes of uncompensated time describing why the last thing in the world they want to be is full code.
Enough with the "uncompensated" doing your job nonsense already. This is why everyone thinks you're a jackass. Next thing, you'll want to bill Medicare for giving an uncompensated hug to the widow of someone who died.
Happy:
In past posts, you've often implied that being put on life support (whether ventilator, PEG, whatever) is a terrible fate that is worse than death.
Because I'm on life support, some have told me my life is not worth living. They're wrong.
I respect your legitimate concerns about "just delaying the inevitable" and prolonging suffering, and obviously the calculation is different with a brain dead patient, but life on life support should never be ruled out as horrible, as a blanket statement across the board. Please never go to the extreme of thinking that just because someone will never be like they once were, their life is not worth living (e.g. The Onion | Gymnast Shawn Johnson Put To Sleep After Breaking Leg).
:-P
You spent 15 minutes talkin to a patients Family???? What? you think you're a Nurse or something???... And how do you do CPR on 0.2% of a patient??? Gotta learn to triage your time a little better... I can tell in 1/2 a second if a patient wants General or Spinal...and all the fancy talk in the world won't change Aunt Flo's mind...
I knew using a phrase like "fighting to come back" would make all those decimal points in your brain go clackity-clack and probably earn me a special Happy you're-too-ignorant-to-get-it award, but f-me I did it anyway.
My frame of reference was patients like Nick, above.Younger people kept alive for long periods periods of time, with good quality of life, through improving technology. Not old, end-stage chronically ill people in whom the code would only buy back s small amt of miserable "Life" But you would have known that if you weren't so eager to bite back the dummy and read the last sentence.
Oh, and your assertion that physicians will not initiate end-of-life discussions unless "paid for it and paid for it well"? Der, I think you must have some kinda brain syndrome or somethin'.Love, anon 3:49
Stephen Hawking isn`t the p50 but you obviously got a point, but I guess if US got the money to do an MRI, when isn’t needed or to do a catch when isn’t needed, 10 min of coding won’t harm anyone.
If you look, in retrospective 200 years ago people usually die at their 5xs 4xs, how much can we trick death?, I don’t know but... 20 years ago HIV was incurable, right now is considered by OMS as chronic disease, well soon have a cure for cancer, as science progress we are meant to live longer, look at the protocols, certain uses or medications are indicating at older ages, than we did previously.
Someone with 10 medical conditions, is someone that got almost zero probability to survive, how can you explain that to a family, human are attached to life, as every other species on the earth, we got reason yes.... but instincts prevails.....
there is no such thing as a protocol, that forbid you doing a CPR, to someone with 10 medical conditions and almost 0% of chances of getting back, on the first 10 minutes…… there nothing written on medical standard not legal, that can make you act differently, your point is valid, but that’s it.
"I think Happy's main point is, by performing CPR on patient's with poor quality of life to begin with"
Who decides what's "poor" quality of life, Ivy? This can be very tricky. MANY would say that my life (and Stephen Hawking's) aren't worth living. They're wrong.
"But beyond the financial implications, who wants to live the rest of their life hooked up to a machine?"
Ivy: I've had a trach and 24//7 ventilator for 14 years. I went to college on a ventilator, got published on a ventilator, had my first kiss on a ventilator. Obviously the calculation is different with an elderly, terminal patient, but life on a ventilator should never be ruled out as horrible, as a blanket statement across the board.
Nick
"For every appropriate patient you convince"??
Who decides who's appropriate and who is convincing difficult patients they don't want to deal with to die? Would someone assume it's more appropriate for Stephen Hawking to die? This is tricky and very subjective territory. Why wouldn't doctors abuse that for more bonuses?
And the smallest violin in the world for a doctor in the top tax bracket went *gasp* 15 WHOLE MINUTES UNCOMPENSATED! please...
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