Does our culture dictate recusitation?

downunderwunda

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Let me start by saying I am an Aussie, however I have a large number of friends in the US, Canada & Great Britain.

Death is a very cultural thing, some accept it as a part of life, others as a celebration of passing from one life to the next.

My question is have we, as a society, because those I listed above although cover all parts of the globe, are in essence very similar, become 'deathphobic'?

I saw my GP today & we had this discussion, he has a history of working in ICU & asked the question of me regarding resus of the elderly with multiple comorbidities & how far we go, & how far we should go.

Health systems across our countries cost a fortune. The last figures I got here were estimating an ICU bed at $140K per bed per day. so should we fill these beds up with elderly patients, with inherently poor outcomes, to have them live for a few more weeks, or should we lay it on the line to them & say no interventions, share your time with them. His thoughts were that this should be GP initiated, so they could have everything worked out when they were healthy. This involves discussion with the families.

Have we, as a society seen too many episodes of ER, Grays Anatomy & the like where every Cardiac Arrest is revived & people think it is the normal thing? How can we educate people & change attitudes.

Please try not to make this a legal argument, this is for opinions, not legal speculation. Bear in mind there are countries out there who do this already, sucessfully.
 

Veneficus

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I think it is the culture of a specific generation.

As you mentioned, there are countries al around the world that basically say enough is enough.

In medicine as a whole for years now there has been a shift away from the "combat with death, saves at any price."

I have noticed many in the older genrations are ok with death. They seem to have come to terms that people do not live forever. Most I have encountered though want a dignified death, without pain or suffering.

Children I have noticed are not particularly afraid of death, nor vehement about living at all costs.

I think it stems partially from the last century where scientic advances were happening at such a rapid pace the idea of being able to live forever, seemed reasonable to some.

From the medical standpoint during this time, it was believed that death was an acute event. There was no attention paid to "comorbid" because 1. They thought they could intercede in this acute event. 2. They were and many still are convinced that if you can normalize quantatative assessment parameters, the person will live.

One of the things stressed in the ICUs I am involved with is that they don't take patients who do not have reversible conditions. (I did a rant on it here a few months back)

The ICU is a very expensive and limited resource. The knowledge, ability, and technology there can and does save meaningful lives. It is not the palliative care ward that many physicians like to believe it is though. It is also not magical. Just because a person can be put on a vent doesn't mean they will breath again.

Perhaps one of my pet peeves is pressor support. It has a place, it has benefit, but nobody is going home on multiple IV vasopressors. Which makes in my view, failure to wean a terminal event.

I agree that TV culture does seem to make it seem like everyone is saved or everyone can be saved by medical intervention, but TV is not real. So when families do get to the ICU, education on reality needs to take place. I can tell you it often doesn't.

I have described it many time, intensive medicine is like a game of chess and you are asked to take over the losing side on a game that is already well into play.

I think stragely enough that Pope John Paul II had a profound influence on changing cultural perspecive on death. Prior to his palliation, the view of the church was the continuation of life at all cost, beyond reason.

Now many societies and people are not particularly religious, but there are many common morals and acceptable behaviors. In an educated and pseudobenevolent society, the value of life is high on the list.(note that leaders of society do not usually espouse its collective morals)

People do seem to rally around the ease of choosing everyone should live over who should die. (Rather, who should be permitted to die)

Perhaps the most important person in tha decsion is the actual individual the decision relates to.

Many older people have had very amazing and fulfilling lives. Whether they fought in a decisive battle, raised a family, or changed the world, the glory days are usually well past. That is because of our shift in biology of modern society of death going from sudden event to chronic event.

But having the "death discussion" with my own now deceased family members, I would say some want to live longer to get in a few more experiences or goals. Medical care is directed towards these goals, not towards unlimited life. The most common by statistics I have seen as well as in real life is the desire to die at home and with loved ones. Many would rather die at home in a week than live in a "care" facility for years or decades. While the nursing home lobby might disagree, when people can no longer care for themselves and families cannot reasonably take care of them, it might be time to let them go. I don't know anyone who says "What a really great life I have in the nursing home while I finish out my days waiting to die."

Overall, I thinkn Western society, as postulated here, is shifting back towards acceptance of death. Probably more out of economic necessity, but I would like to think that some are coming back to their senses.
 

mycrofft

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OP, I think the media rides whatever wave will sell ad time, and heroic rescues plus our personal fears about losing loved ones or suffering in the first person (or identifying vicariously with the rescuers) are right up their with sex/skin in their target demographic. The media strongly mold our perceptions and actions and expectations.

We also have the Christian/European "Good Samaritan" social contract, whereby we at least hope we will help those in need, and others will help us. Most cultures have a "golden rule" deal (do unto others, etc.), but their attitude towards curative medical intervention is less about riding to the rescue than knowing when the inevitable is going to come.

I agree with you. Consider though who benefits from an underfilled ICU the hospital has to staff supply and equip anyway. The hospital wants the ICU running at max all the time as long as those patients are generating cash inflow, even if it is a government grant to keep the service regionally available.
 

VFlutter

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Consider though who benefits from an underfilled ICU the hospital has to staff supply and equip anyway. The hospital wants the ICU running at max all the time as long as those patients are generating cash inflow, even if it is a government grant to keep the service regionally available.

I agree that hospitals want full ICUs but they want them full of appropriate patients not terminal futile patients.

A terminal patient that is kept in ICU way past their predicted discharge date suffering from multiple hospital acquired complications (Pressure ulcers, VAPS, CLABSI) is not really a cash cow and will most likely end up costing the hospital money.

The culture in the hospitals I have experience with is to push for DNR or transfer out of critical/acute care. I have never felt any pressure to keep patients to keep the money coming. Case management gets involved very early to ensure this does not happen.
 
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Wheel

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I agree that hospitals want full ICUs but they want them full of appropriate patients not terminal futile patients.

A terminal patient that is kept in ICU way past their predicted discharge date suffering from multiple hospital acquired complications (Pressure ulcers, VAPS, CLABSI) is not really a cash cow and will most likely end up costing the hospital money.

The culture in the hospitals I have experience with is to push for DNR or transfer out of critical/acute care. I have never felt any pressure to keep patients to keep the money coming. Case management gets involved very early to ensure this does not happen.

Buff and turf? ;)
 

mycrofft

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Vene advises if they (ICU's) run over in Europe they make them go sell pencils on the sidewalk.
Actually, when the hospital runs out of money, they shut.

Los Angeles County, take note.
 

Summit

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I agree that hospitals want full ICUs but they want them full of appropriate patients not terminal futile patients.

A terminal patient that is kept in ICU way past their predicted discharge date suffering from multiple hospital acquired complications (Pressure ulcers, VAPS, CLABSI) is not really a cash cow and will most likely end up costing the hospital money.

The culture in the hospitals I have experience with is to push for DNR or transfer out of critical/acute care. I have never felt any pressure to keep patients to keep the money coming. Case management gets involved very early to ensure this does not happen.

I agree. This is my experience as well.
 

the_negro_puppy

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Hopefully society will shift ala stop sending demented, bed-ridden patient's with no concept of their own existence to ED's every week to keep their multitude of chronic co-morbidities at bay for a few more weeks.

Nearly every nursing home patient I see with little to no observable quality of life does not have an Advanced Health Directive or DNR. I've even had palliative care / terminal patients within hours or days of dying with no DNR paperwork.

Families will stand by and demand that you resus their heavily disabled, terminally ill loved ones so that they don't have to say goodbye.

The decision of how much resources to put into health and to whom will always be an ethical one. Hopefully in my lifetime we will see a shift of attitude towards dying, particularly allowing things like voluntary euthanasia etc
 
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mycrofft

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Two shots:
1. My usual rant: put triage ahead of the ED and shunt non-critical cases to an integral primary care, using tact and psychology to make it appear as "important" as the ER section. *
2. There is a part of the social contract where we don't get shunted off to some corner because we are hopeless. As above, if someone isn't going to the ICU because they are moribund, make where they go as psychologically supportive and impressive and make damned sure they don't wind up in the last room on the end because the nurses and etc are "too busy" (see articles on staffing ration and workloads).

* EDIT: actually it IS as important, just not as impressive. You will get plenty of admits from Primary Care.
 
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Veneficus

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Two shots:
1. My usual rant: put triage ahead of the ED and shunt non-critical cases to an integral primary care, using tact and psychology to make it appear as "important" as the ER section. *
2. There is a part of the social contract where we don't get shunted off to some corner because we are hopeless. As above, if someone isn't going to the ICU because they are moribund, make where they go as psychologically supportive and impressive and make damned sure they don't wind up in the last room on the end because the nurses and etc are "too busy" (see articles on staffing ration and workloads).

* EDIT: actually it IS as important, just not as impressive. You will get plenty of admits from Primary Care.

I'd rather just send them home. It is what they want.
 

mycrofft

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I'd rather just send them home. It is what they want.
Having worked transport before, sometimes they want to go home when they are in the ICU (noisy, lots of disturbances, no TV), but once they get there they want to go back (no meals, medication not as effective, housekeeping not done, etc. One guy was going home to roaches and wife who left a "dear john" letter for him and their five kids).
But, yeah, I can see jus going home if there is adequate care.
 
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