In praise of death panels

[Elok]

So, I work at a hospital. We see a lot of cases where they're putting in way, way, way too much work to save the patient. Like, if your eighty-year-old patient codes four times in one day, by the fourth time you bring them back, you have definitely crossed over the hard-to-define line that divides white magic from necromancy. You're not saving a life at that point, you're just temporarily resuscitating an increasingly battered corpse. That happened today, and the last code announced came as I was near a nurse on another unit. I asked her, "am I crazy, or are all of those for the same patient?" She shrugged and said some families just won't let go, and they can keep using up crash carts until either the family gives up or the doctor gets POed enough to say no. Then you get into things like quad-strength Levophed, which is basically an intravenous defibrillator. If you need that much norepinephrine, it's not that your heart is slow, it's just not working at all. Nor is your dead heart going to somehow figure out how to work on its own again if you keep chucking Levophed at it. It's a Frankenstein dose.

Running into all these--and billing for the unholy chunks of crash cart material they use up--has somewhat modified my perspective on things. With crash carts, it's not so bad, because they use mostly common things we have a plentiful supply of. It's just a PITA being in pharmacy and supplying all these meds for Weekend at Bernie's. And I can get what drives a family to hold on to hope well past the point of sanity. But healthcare resources are finite. Sometimes doing everything you can is just not the optimal approach, and it might be better if somebody could say, "look, we've given it a game try, it's time to let go." The question is, who gets to say no?

[SlowwHand]

No DNR, you're obliged.

[Berzerker]

[Lorizael]

I think moving in the direction of who gets to decide takes us to dangerous territory, but...

No DNR, you're obliged.

...medical professionals can certainly do a better job of counseling patients and family about end-of-life options. Which, of course, was all death panels were really about--letting doctors include such discussions in their billable hours for Medicare patients.

[Elok]

How about if, after the second attempt in X hours, the obligation becomes that the family has to specifically opt to continue resuscitating, and incurs some of the costs for quixotic medicine?

EDIT as a counterpoint to my own argument, there was that case in Britain lately where the kid was brain-dead, and the government of Italy said, "hey, we'll accept this kid as a citizen while we try ludicrous hail-mary medicine to revive him, in Italy, at no cost to the British taxpayer." The parents were all for it, but the British government ruled that it was not in the brain-dead child's best interests--I'm still not sure how a brain-dead child has interests any more, without Her Majesty's government delving into metaphysics--and put a wall of cops or something in front of the hospital to keep anyone from interfering while the kid went off life support and died.

[Kidlicious]

People are too stupid and ****ed to say who should die.

[The Mad Monk]

Noreprinephrine 0.1 mcg/kg/min
Fentanyl 25 mcg/hr
Propofol 25/mcg/kg/min

That's what was in my mother's IV drip the night she died.

It was twenty hours after she went through exploratory surgery, and it was determined that nothing could be done. She was awake and alert before the surgery, and Dad expected her to wake up after, even with the bad news. Even after liver failure and low oxygen, in the last hour, he was still calling to her.

It was rhe damned propofol, wasn't it.

[Dinner]

Wiki says Propofol can cause people to become extremely sleepy.

[Elok]

Uh, yeah, you could say that. Propofol is the go-to knockout drug.if you need somebody conked out now. I'm told it takes you out in seconds, but also wears off quickly. They go through tons of it in surgical. One of the nurses got in trouble for using it to power-nap through lunch; she snitched some, went out to her car, dispensed an appropriate dose for twenty minutes, and woke up ready to kick some ass. Until the day she took slightly too much, didn't come back from lunch, and they went out and found her still snoring in her car. Oops. Supposedly it gives extraordinarily refreshing sleep. Now, it's used quite routinely, and it's quite safe if you know what you're doing, but yes, it can kill you if you're a moron. Like Michael Jackson. "More milk, please."

[Elok]

Okay, I asked one of the pharmacists today. He said fentanyl and propofol together sounded pretty dangerous, and we don't run those two together at our hospital. As a rule of thumb, it's a bad idea to mix two drugs with the same general effect but a different method of action. The classic example would be benzos and alcohol. You can pop Xanax pretty aggressively, and as long as you don't deliberately down the whole bottle you'll simply fall asleep before it will hurt you. Likewise it takes some doing to really drink yourself to death; your body tends to barf it back up once BAC gets too high. But mixing the two is a pretty reliable suicide method. Likewise fentanyl and propofol; both are powerful sedatives, but they work quite differently. My pharmacist couldn't guess whether the norepi would do anything to counteract it, especially since I didn't give him exact quantities and rates, but he certainly wouldn't dispense that.

Of course, I don't know your mother's condition, weight, medical history, etc. Make of that what you will.

[-Jrabbit]

This is the most interesting and civil thread on Poly in months. Maybe this year.
Even Kid's inevitable over-generalization was on topic and worth consideration.

Well done, Elok.

[COckney]

gday maight

[Sava]

get well soon

[Elok]

Well, it was bound to be civil, seeing as most of the posts are mine. I'm not going to be rude to myself, am I? But thank you.

For a second opinion, I asked another pharmacist about fentanyl and propofol together, and he says he's heard of using both together. However, I gather it's not really what you'd call good practice, and the typical rationale (one for pain, one for sedation) is kind of moronic. If you're unconscious, by definition you're not feeling pain. They also work in different ways; fentanyl is more of a long-term sedative, while propofol is what you whip out for controlled intervals. Or when the patient is just going bat**** crazy. We have 100 mL bottles of propofol they put on continuous drip, but I can't recall anyone ever putting it in an IV bag. Propofol's one of those funny drugs that requires an emulsion; it's premixed with fats, and looks like milk, hence MJ's asinine last words.

NB that some doctors just have weird drug preferences you can't budge them from; they've found a combo that works for them, and they will get thoroughly peeved if anyone suggests it's not a good idea. One surgeon we've got requires "analgesic cocktails," enormous PCA syringes filled with fentanyl, lidocaine, an antibiotic and methylprednisolone, for all his knee replacements. Now, the combo doesn't last too long; although all the ingredients are shelf-stable; after thirty hours or so the antibiotic reacts somehow and forms a precipitate that looks like the bottom of a poorly-cleaned urinal. Unusable. So we make two big syringes every day he's got cases, and sometimes he doesn't need them so we take them out and throw them away the very next day. But God help us if we try to deny this man his magic mix. Doctors can be like that. Possibly some docs swear by fentanyl and propofol, IDK.

EDIT holy crap it's C0ckney good to see you!

[rah]

Well, it was bound to be civil, seeing as most of the posts are mine. I'm not going to be rude to myself, am I? But thank you.

Post of the year, for Poly.