Thursday, May 2, 2013

Videos of CPR Aid Informed Consent

When my Dad was 94 years old and in a nursing home in western Pennsylvania, I got a call from my sister, "Jim, Dad's losing weight and seems to be withdrawing.  I'm worried about him.  The doctor's doing some tests today."

Well, one of the many tests turned out to be a chest and abdominal CT scan.  His heart was enlarged (we knew that from his history) and everything else was normal except for a 1cm spot on his left kidney.  Whether this was benign or malignant was clinically irrelevant but my sister was worried.  "Shouldn't it be biopsied or removed?"

I replied, "I don't recommend that.  It couldn't be causing his lack of appetite or general dwindles.  Even if it is a small cancer, it's very unlikely to ever cause him a problem.  A medical intervention may well harm him."

I had to pull some strings to set the direction toward comfort care, which is what he always said he wanted.  But what if I hadn't intervened?  Often, we almost mindlessly opt for more intervention, a diagnosis, a new drug, or a "life saving" treatment - even in a 94 year old trying to approach the end of his life in a dignified way.

There are a variety of attempts in our country to figure out the most effective way to have "the conversation" with patients and families about end of life values, options, and choices.  It's pretty clear that pamphlets, words, and discussions aren't enough by themselves.  Harvard physician Angelo Volandes has found that videos of things like dementia care and CPR may profoundly alter the choices that patients make.

In a calm manner Volandes' physician spouse, Aretha Delight Davis, presents factual data during the videos.  This visual learning appears to be much more powerful than verbal descriptions and may affect our choices on intervention.

It's nearly universally felt among physicians, that we're overusing the "technologic imperative" at the end of life - often depriving the patient the opportunity to die at home surrounded by loved ones and receiving support from hospice and palliative care.  As one patient told me, "If I wake up in the next life attached to tubes, I'll know where I've gone."

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