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On Call: The Best Time for a Difficult Question

Thu, 09/03/2020 - 17:55

This week, I had the opportunity to cover as an admitting physician at one of the local hospitals. At one point, my team and I asked a patient we were admitting about his code status, which is doctor-speak for what he wanted to happen if his heart stopped or if he needed help breathing to the point that a ventilator might be necessary. 

Asking this question can be very difficult, for a variety of reasons. For one thing, it brings patients (and their families, if they are involved) face to face with the immediacy of mortality, as you're directly asking someone if they want extraordinary measures to be taken to keep them alive. 

We ask this question because resuscitation in and of itself can be deeply traumatic. CPR often breaks ribs, causes significant bruising, and possibly even damages other internal structures, while the process of coming off a ventilator can be very traumatic in terms of waking up or simply trying to wean from dependence on mechanical ventilation. In addition, when people have significant chronic illnesses or are at an advanced age, the likelihood of successful resuscitation and/or quality of life thereafter is very low, no matter what medical dramas on television might tell you.

Moreover, we tend to ask just about everyone we think could even possibly have some sort of serious event requiring CPR or intubation (the process where a tube is inserted into someone's airway and hooked up to a machine in order to help them breathe) what their wishes are. 

And the reason for that? Why do I ask a stable, 50-year-old mother of three who I am admitting for pneumonia what her wishes are? 

Because experience has taught me, over and over again, to tackle these questions at the beginning. To give someone the opportunity when they are clearheaded and feeling mostly like themselves to grapple with communicating their wishes.

As bizarre as it may seem, this is an infinitely preferable time to consider such questions than in an emergent situation. What if the patient is unconscious, or if he or she hasn't spoken to their next of kin in 10 years? 

These complexities are all the more evident in the current times, when Covid-19 has made it so often impossible to be with a loved one in times of medical crisis. Decision making is hard under the very best of circumstances, but toss in a world coping with isolation and quarantine and everyone's stress levels rightfully skyrocket.

That is not the best time to have to decide about whether or not somebody wants to be resuscitated. 

Granted, there is no best time. But there are better times, and those are the moments when we are awake, able to converse, are clearheaded, and can make whatever decisions are in keeping with our goals and values. 

Particularly in a world ravaged by a pandemic, I urge everyone to have these conversations as far ahead of time as possible. Talk to your husbands and wives, your children and your grandchildren, and let them know what you want to happen if you were to become seriously ill. Ask your family doctor or internist for clarification on anything I've said here, or anything you don't understand. 

Most important, ask yourself: Do you want to be on life support, if it comes to that? If we get a second wave of Covid-19 this fall or winter, we should all know ahead of time how we want to face it. If you want everything done should you become ill, no matter your age or other sicknesses, no matter the severity of your disease, my fellow health care workers will fight ceaselessly for you.

But if you choose to face the dying of the light in a different way, if you want everything up to CPR or intubation but choose to not go down those roads, then we'll do our best to honor those wishes, too, right up to the end.


Joshua Potter, D.O., is a physician with Stony Brook Southampton Hospital's Meeting House Lane Medical Practice who specializes in family and neuromusculoskeletal medicine. He oversees the practice's Shelter Island office. Opinions expressed in this column are his personal and professional views and not necessarily those of his employer.


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