Thursday, September 21, 2006

Full Code

Mr. Grainger is going to die.

Not now, but the time for him is more imminently on the horizon that it is for me or you. He has cancer throughout his body, spreading into his brain. And as with any seriously ill patient, when we brought him into the hospital, we talked with his family about his "code status."

Code status refers to how aggressive the patient wants his caretakers to be in resuscitation. "Full Code" means that if his heart stops, we'll do CPR, and defibrillation as necessary, if his breathing stops we'll put a tube down his throat, etc. A "full code" on a patient is a violent occasion. CPR, if done properly, can break ribs, especially 80 year-old osteoporotic ones. A 30 year old might survive a code. An 80 year old almost certainly won't.

Which is what we tried to convey to Mr Grainger's family. But they were incensed that we would even ask about this and insisted he be "Full Code." So that was entered into the chart, though we didn't agree with the decision.

So this morning, my attending gave us a long talk about the ethics involved, insisting that in a patient like this, where a code has zero apparent chance of success, it is within our power as physicians to simply refuse to perform the code. His exact words were "if they want to sue, let them. There is no way a court can hold you liable for not performing a procedure that is against your medical judgment."

Leaving aside for the moment the fact that he turned, without thinking, an ethical debate into a legal one, the point is that we are to do the best for our patients, and sometimes that means doing nothing. I think I'm on board with that.

What bothered me about the way he defended it was by turning the discussion into a legal one. I'm concerned that so many derive their morality, at least in ambiguous situations, from the law. The reverse should be true, no?


I've also noticed, throughout my time at this hospital, that my concern for my patients has been somewhat lower than previously. My team, and indeed, most of the residents at this place seem to hate their jobs, hate the program, and hate their patients. I know that's not true completely, but the contrast with other hospitals, including my Number One Choice, is stark. I'll be ranking this one pretty far down my list when it comes to the match.

What this means for my blog is that I've realized my tiredness more, I've had a harder time finding touching stories and fun patients to write about, though I've been reluctant to join in the cynicism of my team. So I'm going to try to swim against this tide of negativism.


medstudentitis said...

Swim Nathan, Swim (maybe watching forrest gump last night instead of studying neuro wasn't such a good idea).

Thainamu said...

What makes one hospital different (that is, more cynical or having less concern) than another? Why would that be?

You have a hope within you to help you remain positive.

tinea said...

This post should be called Embrace the Big Picture. And that's a wonderful thing. Your question about whether law should instead by dependent on ethics is very much a 'big picture' question. Even if the level we operate on doesn't always look to a grander scale (and thus turns legalism into morality), when we do take a step back it seems to put things into focus better. Applying that outlook to your time left in this rotation - 'swimming against the tide of negativism' because you believe there is something more important than the attitude of your team - that's one of the best ideas I've heard in a while. Somehow life seems happier when we don't get caught up in the day-to-day difficulties and instead remember that the gift of having a day to live at all makes it worth it.

And if that's cliched, oh well.

zhoen said...

The only attitude you can adjust is your own. But it is so hard when no one else is positive. It is worth it, but so much work.

Good luck finding a better environment. Just do what you can, you may have more effect than you will ever realize.

Families so often do not realize how bad codes are, and we hide it from them, excluding them from the brutality of it. It's messed up.

thebeloved said...

Wow, I have always been fairly healthy and avoided anything medical at all so your posts have been opening up a whole new arena for me. Thanks... although I think I will try to still stear clear of medicine.

Steve Hayes said...

It is sad that some people don't seem to be able to distinguish between law and ethics.

I was just reading a comment on a book about "ethical sensitivity" put as a requirement for a job. Not ethics, but "ethical sensitivity". That's scary!

Nathan said...

medstudentitis - thanks :)

thainamu - hospitals are just collections of people, and that is especially true of a residency program. If a program director is not liked, or is capricious (or both, as is the case here) the residents are grumbling, and more likely to be cynical.

tinea - quite true.

zhoen - thanks.

thebeloved - if you don't smoke, don't drink to excess, don't eat to excess, and excercise occasionally, I very much doubt you'll wind up a patient on an internal medicine service.

Steve - That is indeed scary. It is actually ironic, but one of the writing prompts on my MCAT (the test university students take to apply to medical school) was this: "laws affect the moral convictions of society." I had to write thesis, antithesis, synthesis for that, though I didn't think about it on any deeper level at the time.

Barbados Butterfly said...

It's always darkest before the dawn, as they say.