[HSF] Futility?
Nasser F Abou'Seada
nfaabouseada at gmail.com
Mon Dec 7 23:23:24 EST 2009
Could not agree more
NFA
-----Original Message-----
From: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of Tea Acuff
Sent: Monday, December 07, 2009 10:54 PM
To: OpenHeart-L at lists.hsforum.com
Subject: Re: [HSF] Futility?
I will drop this as the thread is too robust for for a couple of paragraphs.
Certainly the easiest critique of my comment is that I am a sophist who just
changes the meaning of a word or two and argues in circles. I wonder myself
who i am.
Perspective is everything. That Ani asks "Who is on first?" might be due to
my sophism or perhaps to the problem of which level or microscopic focus are
we using to get our orientation. Just as Bob reminds us that the anatomy
and physiology of each patient is unique, we can assess medical systems from
different prespectives: payer, patient, surgeon, political, scientific, etc.
While all perspectives can color the view and provide insight, it makes no
sense to seek answers along a single dimenison whether financial, anatomic,
etc. Like Einsteins curved universe the unified field theory of patient care
must curve back to the patient-doctor relationship. This is particularly
true for surgical therapies.
This is why the present state of "patient advocacy" is spinning out of
orbit. Whether legal, academic, business, governmental, or nonprofit
nongevernmental, eg STS, AMA, they all bring so much baggage, conditions,
and protections to their role as providers that they can not be trusted. We
are best practicing, regulating, and pretorting ourselves out of the very
center of our universe. We have lost our way.
In the letters of Mother Theresa of Calcutta she meets the poor in their own
slums with nothing that we would consider substantial. She gave a dying man
a cigarette (a gift from someone) to satisfy his wish and notice his
condition as a one who needed. More than medicine he needed care. I don't
have her compassion, and we as doctors always wonder if more could be done.
If we don't treat patients where ever they are including treating them as
they pass to death, who are we?
We have, perhaps for some, more than a cigarette to give. But are we selling
or giving?
In the end, end of life or end of arguement, all we can control is our
perspective. Let's pick a good one.
tea
________________________________
From: "hgrmd at aol.com" <hgrmd at aol.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Sun, December 6, 2009 11:26:09 PM
Subject: Re: [HSF] Futility?
Ani,
Don't spend too much time cogitating what Tea speaks. I will say he's
pretty cool to hang with.
Hal
-----Original Message-----
From: Edward Bender <ebender001 at me.com>
To: HSF List <OpenHeart-L at lists.hsforum.com>
Sent: Sun, Dec 6, 2009 10:57 pm
Subject: Re: [HSF] Futility?
Ani:
've operated with Tea, and he seemed much more cogent in the OR. But that
as years ago.
d Bender, MD
n 12/6/09 9:41 PM, "Ani Anyanwu" <anianyanwu at hotmail.com> wrote:
>
Tea
I really do not understand much of what you say. Maybe I need to come and
observe you practice for a week then maybe I can paraphrase in my brain what
it is you say or believe - assuming that you do believe anything. Some
general
things you said I understand and agree such as the lack of definition or
truth
in most we may say or do (including whatever you or me or anyone is saying
about life); but still have no clue of the us or them, dont understand
meanining of "life as it comes", "particular", "where we meet life" etc.
Most
importantly I do not see how any of this answers michael's question. I am
sure
you will expand - maybe then I will begin to understand.
ani
> Date: Sun, 6 Dec 2009 17:47:41 -0800
> From: tacuff at swbell.net
> Subject: Re: [HSF] Futility?
> To: OpenHeart-L at lists.hsforum.com
> CC:
>
> We doctors should, if we are able, serve for preservation of life as it
> comes. We should not set limits or definitions for life as it always comes
in
> the particular.
> We must judge and act in the particular for that is where we meet life and
> where we see it lost. And for that judgement we are accountable.
>
> Whatever our ideas, visions, generalizations as doctors, they should not
be
> decrees or laws but evidence offered with our best persuations stopping to
> listen to those whose life we seek to effect. Time will change our ideas,
our
> particulars and if long enough factors we associate with and against
> preservation of life. Life is ambiguous in that it may not conform to the
> prior or "expected" state. Thus our "best" or definitions or rules are
either
> trivial or only part true.
> You may or may not agree or wish to refine, but this is the us and them to
> which I refer.
> Tea
> Sent from my iPhone
>
> On Dec 6, 2009, at 3:53 PM, Ani Anyanwu <anianyanwu at hotmail.com> wrote:
>
>
> Like the trauma surgeon in Afganistan we should not be defined by the
ideas
> of others, or the political force in power, but by life itself. Not
blindly
> without consideration, but with a discipline that allows others to see our
> vision for life.
>
>
>
> tea
>
>
>
> Tea
>
>
>
> I really am lost now...
>
>
>
> 1) When you say "life itself" what actually do you mean by "life"? You
> already referred to life as ambiguous yet it seems central to your thesis
-
> what meaning are *you* applying to it?
>
>
>
> 2) WHen you say our "allows others to see our vision for life" - who are
the
> "others" and who does "our" refer to?
>
>
> Ani
>
>
> Date: Sun, 6 Dec 2009 11:26:18 -0800
> From: tacuff at swbell.net
> Subject: Re: [HSF] Futility?
> To: OpenHeart-L at lists.hsforum.com
> CC:
>
> One more layer to this thread as we study the fresh edges.
>
> Cardiac surgeons, yes even life itself, are the offspring of 1%ers. Heart
> surgery was considered impossible until we changed our assumptions, and
> transplantation not so much discovered as created a new science for us to
> push into a field of suffering. Whether it is the best way is not the
point.
> In fact it is the opposite. It was a way. Life is ambiguous.
>
> Like the trauma surgeon in Afganistan we should not be defined by the
ideas
> of others, or the political force in power, but by life itself. Not
blindly
> without consideration, but with a discipline that allows others to see our
> vision for life.
>
> It will take a miracle. May we live in a culture where we are free to do
> that.
>
> tea
>
>
>
> ________________________________
> From: "Rwmfglycar at aol.com" <Rwmfglycar at aol.com>
> To: OpenHeart-L at lists.hsforum.com
> Sent: Sat, December 5, 2009 9:36:32 PM
> Subject: Re: [HSF] Futility?
>
> Very good analyses in this thread. You all touch on an issue that will
> eventually catch up with us in the USA. If you are the Minister/Secretary
of
> Health or the Budget Director you will have one answer to the ultrahigh
risk
> case question. If you are the doctor interacting one on one the answer is
> reached differently. Here I would say only "To thine own self be true and
> add to that "To thine own patient be true".
> The fools in Congress think they can fiddle with a bad system and control
> its costs. They will fail badly and unless we do it, it will eventually be
> done for us after complete meltdown has occurred.. Although we do not have
> the ability to pick the 1/100 survivor, if we know that is a correct
> survival chance a future Budget Director will commission a "Best Practice
"
> study and state that patients with these features will not be done (we
might
> use the saved money on alcoholIc pregnant mothers councelling ) .
> In these posts there is also a theme of horrible communication. This will
> not go away until we abolish or pool fee for service and group experts by
> disease rather than by ownership of machines or skills.
> Bob
>
>
>
> In a message dated 12/6/2009 4:31:17 A.M. South Africa Standard Time,
> ebender001 at me.com writes:
>
> Here's a "flipside case" I was asked to do surgery ont
> A 33 year old comes to the hospital after being awoken with pain at night.
> He had several weeks of chest pain on exertion, but he really doesn't
exert
> too much. He had no ST elevation, and very small troponin bump. He got a
> cath, having a totaled mid RCA, normal everything else with rich
> collaterals
> from left to right. The intervention cardiologist tried unsuccessfully to
> pass a wire thru the obstruction, prompting a consult for CABG.
> I said I would talk to the patient outside the cath lab, leaving the
> impression he would be going to the OR.
> Looking at the chart and doing H & P, the patient was on no meds
whatsoever
> and was pain free. I suggested that he be placed on the usual (beta-block,
> ACEI, statin, ASA, etc), and, if he did not have symptoms, stress him a
few
> weeks. This was apparently misunderstood by the cardiologists, who did a
> stress echo the next day. I looked at it myself, and, in spite of
achieving
> max heart rate, it was stone cold normal (I hope mine looks like this).
> Prior to this, I was receiving phone calls and emails from the patient's
> friends and relatives, asking why I refused to operate on this patient,
and
> was he so bad off that surgery could not be done. Even some of the
surgical
> personnel were wondering if he should go to the mecca a couple of hours
> away
> for surgery or a different interventionalist.
>
> Ed Bender, MD
>
>
> On 12/5/09 6:25 PM, "Ani Anyanwu" <anianyanwu at hotmail.com> wrote:
>
>
> I used the word allegedly to describe my patient's non-compliance to
> emphasize
> how even untruths can make us decide not to help a patient - hence how
> risky
> it is to leave life or death decisions in the hands of one single person
> who
> can be easily swayed by his (wrong) information, convinction or
> judgement. My
> patient was said to me as they are doing CPR to be a smoker,
> non-compliant,
> doesn't keep appointments, stuffs himself with mcdonalds etc. He had been
> transferred from far away 5 days early in our CCU and was intubated so
> no one
> could ask him but this story got passed from person to person and
> everyone
> labelled him. As it turned out I learnt days later this was largely
> untrue -
> he had not smoked in over 2 years, and reason he was 'non-compliant' was
> because he didnt have insurance. In last few months he has been insured
> he did
> all doctors say and had lost 40 lbs weight in last 6 months.
>
>
>
> To get back on track - you did not though add option 5) patient does
> okay and
> returns home to a reasonable quality and duration of life. If this is
> not a
> realistic outcome then that is certainly a scenario where every physician
> should say no. As for everything else, it is up to debate.
>
>
>
> It is certainly okay to die without an incision with a 'fixable' defect
> but
> unfortunately many, if not majority, (lay) Americans feel otherwise and
> that
> drives a lot of these exercises in futility. I have seen everything
> including
> a surgeon walking into a cardiac arrest which had not responded to an
> hour
> resuscitation, few minutes after death had been called and resucitation
> stopped and surgeons asks to resume compressions and next patient is in
> an OR
> having emeergency 'surgery'.
>
>
>
> An exercise cannot though be judged based on the outcome of a try. In the
> examples we give it really does not matter if the patient lived or died
> (your
> recent 18 hour tour de force being a typical example - something for
> rest of
> us not to try at home as will be almost always met with uniform
> failure). That
> one wins does not make it a 'right' decision. Decision analysis is based
> on
> prior probabilities and convictions not on final result. i.e. that you
> buy a
> one dollar lottery ticket and win 1 million USD does not mean the
> decsion to
> buy a lottery ticket is the right one. Similarly, if you give a child a
> vaccination against measles and he gets encephalitis and dies does not
> mean
> the decision to vaccinate was a wrong one. We can though judge exercises
> on
> the basis of repeateed tries, so if 1 million people all bought 1 dollar
> lottery tickets, and all won 1 million USD, or 10,000 kids received
> measles
> vaccines and 5,000 got enchepalitis then our conclusions would differ.
>
>
>
> Also to clarify on your prior email, the access to ECMO, LVAD, long-stay
> ICU,
> long term rehab facilities or whatever does not mean you or I or anyone
> has
> access to unlimited resource. All resources are limited and anything we
> do is
> at the expense of something or somebody else. It is irresponsible as
> physicians if we feel we can just use or spend because we have 'access'
> to
> whatecer drug, technology or other resource. As an example I visited a
> surgeon
> who uses inhaled nitric oxide on every, lvad, transplant or high risk
> cardiac
> surgery case and also places them all on sidenafil for 6 months. I asked
> how
> do you afford or justify that (iNO he says is 5,000 USD per day) and
> answer is
> well it comes out of another cost center (budget) so not my problem. And
> the
> viagra? How do you justify 1000 USD per month of viagra? Well I dont
> care,
> insurance pay for it or if they dont patient somehow has to buy it. We
> certainly shouldnt have that attitude and have to spend and use resources
> responsibly. Of course your next question is what is responsible use of
> resources...
>
>
>
> Ani
>
> Date: Sat, 5 Dec 2009 18:45:40 -0500
> Subject: Re: [HSF] Futility?
> From: msfirst at gmail.com
> To: OpenHeart-L at lists.hsforum.com
> CC:
>
> OK -
> To build on your recent case - as we all guide our decisions based upon
> the
> 1/100 save. What's happens if what you did - didnt work..... picture if
> you
> will:
> taking him to the OR, doing some huge operation (defined as spending
> enough
> money on valves, grafts, blood products, pericardium, nitric oxide,
> factor
> VII, etc) and you get the patient to the ICU where -
> 1) codes immediately and you open his chest and he dies or
> 2) spends a month in the ICU and has a fatal arrhythmia on the floor a
> few
> days later or
> 3) never wakes up, gets PEGed and Trach (toss in a dialysis catheter for
> good luck) and you park him in a nursing home and never hear about him
> again
> (but assume he does well since you never hear to the contrary)
> 4) He does as you describe, goes home, resumes his ways - diabetes and
> smoking out of control and pusses out his sternum, comes back in DKA,
> intubated from not taking his CHF meds, stops coumadin and thrombosis a
> mechanical valves, ro some other common disaster.
>
> Did we still do the right thing since we did our part - we fixed
> (palliated?) a technical problem and everything else is someone elses'
> job
> or responsibility?
>
> Is it OK to die of a "fixable" cardiac problem in the hospital - i.e.
> without an incision?
>
> -michael
>
>
>
> On Sat, Dec 5, 2009 at 6:23 PM, Ani Anyanwu <anianyanwu at hotmail.com>
> wrote:
>
>
> It always comes down to the surgeon's own decision, based on his/her
> own
> philosophy of life, within the constrains of the system within that
> person
> works.
>
> Victor
>
>
>
>
>
> But why? Who made you (surgeon) judge and executioner over others? What
> gives the surgeon that right?
>
>
>
> I admittedly have one such exercise in futility that I had to take
> care of
> on thanksgiving day, who I very reluctantly took to the operating room
> and
> almost didnt because he remains in ventricular fibrillation for 10
> minutes
> just as being got ready for OR, and had had at least 15 cardiac
> arrests and,
> CPR etc in the hour plus it took to assemble and OR team. Of course
> patient
> is also morbidly obese (allegedly) non-complaint and a reoperation with
> patent bypass grafts, and of course I am supposed to be elsewhere with
> my
> family. Same patient is sitting in a chair and on way home next week.
>
>
>
> We have to be careful in suggesting we as surgeons have a right - or
> should
> be assigned the right -to play God in deciding that patients do not
> have a
> right to an attempt to life. In the example I gave, many a surgeon
> would
> have gone home and ate their turkey - I almost did. It is such
> arrogance (in
> the cockpit) that has lead to some notable air disasters such that (and
> rightly so) many 'decisions' have been taken out of the hands of the
> airline
> pilot and strictly covered or regulated by others or by protocol. I
> have
> certainly seen many patients in my training who were far from dead or
> futile
> being denying access to surgery (and going on to die) because of such
> surgical arrogance where the surgeon takes the decision to refuse to
> give a
> patient an attempt at survival.
>
>
>
> Ani
>
> Subject: Re: [HSF] Futility?
> From: valdretemd at shaw.ca
> Date: Sat, 5 Dec 2009 15:00:11 -0800
> To: OpenHeart-L at lists.hsforum.com
> CC:
>
> It always comes down to the surgeon's own decision, based on his/her
> own
> philosophy of life, within the constrains of the system within that
> person
> works. The remainder of the questions are irrelevant, for at the end
> of the
> day you are the one that has to live with yourself. Did you do it for
> the
> money, for the excitement, for "the glory" or just because that was
> the best
> thing you could do for another human being? If the answer to the
> question is
> the last one, then again the other questions are irrelevant, even if
> you
> have to fight against the system within which you practice, with all
> of its
> associated consequences.
>
> May you sleep soundly at night
>
> Victor
>
> On 2009-12-05, at 1:32 PM, Michael Firstenberg wrote:
>
> When are are asked to evaluate a patient for surgery, how is it that
> we
> define the benefit?
> When do we say "no"?
> or when should we say "no"
>
> I and others have been criticized for taking people to the OR with no
> hope - but about if that was their only hope?
> What are examples of 100.00% certain death?
> If we have 1 survive, is that justification for doing another 100
> until
> you get another survivor?
> What about if you never had a survivor?
> (probably the same questions were being asked when the arterial
> switch
> operation was being sorted out)
>
> or should we ever say no as long as we have resources to spend and no
> one is keeping score?
>
> what criteria would you use to offer someone an operation even if you
> knew (or assuming you where truthful with yourself) that they would not
> survive (sure just about anyone can survive an operation, but making
> it out
> of the ICU/hospital/nursing home/etc is another question)......
>
> When can we claim "victory" or pat ourselves in the shoulder for a
> job
> well done?
> Is getting an 80 year/old PEG/trached/dialysis to a nursing home
> after
> an AVR a job well done (if they survive 30 days and until discharge?)
> or have we won when they survive past the average and are living at
> home independently?
>
>
> I know we usually save these questions for Sunday mornings, but I am
> getting an early start......
>
>
> -michael
>
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