Monday, October 17, 2005

Your Truth: Confusion and Code Status - Part 2

I will admit, that while all identifying information has been changed, the scenario for Confusion & Code Status is based on a true situation with one of my patients.

That said, it was very interesting to read your comments with what information I provided and what additional information I have that I did not share.

To share the remainder of the story:

Mr. Garcia's mind cleared on and off the next day, so I was able to follow up and clarify his wishes. I did not think to inquire as to if he is truly on a sports team or a coach, though that would have been interesting.

As for Catherine's concern, part of the problem was that Mr. Garcia had not written an Advanced Directive stating his wishes, so there was no Advanced Directive for us to be disrespecting. In order for a DNR/DNI to be continuous through multiple hospitalizations, one must fill out an "community" DNR/DNI, which many states offer. A DNR/DNI written by one doctor during one hospitalization is only effective for that one hospitalization.

This is probably not a bad policy, as upon his mind clearing, Mr. Garcia decided that he wanted to be a full-code. I encouraged him to write an Advanced Directive so that we would know what to do should he become acutely confused again, because like most of you, the doctors were leaning towards DNR/DNI and apparently that was not in tune with where Mr. Garcia's thoughts were.

The fact that people change their minds about their goals of care is a continuous point of debate with code statuses as well as with advanced directives. What if you write out what you think you'd want knowing what you know today, but then when you're later in need of making those critical decisions, you change your mind? It's not only important to write down what your wishes are for today, but to also keep open communication with all of your loved ones as to what your goals are. For example, "If I can't do A or B, then I don't think life would be worth living; THEREFORE if I was diagnosed as being in a persistent vegetative state, then I would NOT want to be kept on a respirator." The first part of that sentence is almost more important than the last.

I never found out why Mr Garcia's family wasn't present at the bedside those first 48 hours, but they became a strong presence after. Before that, the daughter was called, as Carrie had suggested, but she was not in a mental state to be of much assistance and only answered the most basic questions. Mr. Garcia's confusion may have been too distressing for his family to witness. Even as a professional, watching Mr. Garcia come in and out of awareness was distressing and brought me near tears at times.

Perhaps Mr. Garcia decided to be a full-code to buy himself time to help his daughter accept the fact that he is dying. And that is a respectable decision. And regardless what we would want or think he should do, it's a decision only Mr. Garcia can make. Fortunately, Mr. Garcia did not code during this hospitalization.

This job is not easy. Ethical dilemmas almost never have a clearly right answer. And yes, sometimes I struggle with finding compassion towards family members. Sometimes I struggle with finding compassion towards my patients. And often, as in the case of my absence at my grandmother's death, I struggle with finding compassion for myself on this journey. But every day I pray that compassion wins.

No comments: