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Teachable Moment
Less Is More
September 2015

When Do Not Resuscitate Is a Nonchoice Choice: A Teachable Moment

Author Affiliations
  • 1Department of Surgery, University of Wisconsin, Madison
  • 2Department of Medical History and Bioethics, University of Wisconsin, Madison
JAMA Intern Med. 2015;175(9):1444-1445. doi:10.1001/jamainternmed.2015.2326

A 70-year-old man presented to our hospital for elective descending thoracic aortic aneurysm repair. Four years earlier, the patient had experienced acute aortic dissection of the descending aorta and was effectively treated with tight blood pressure control. This dissection was followed with serial imaging and his aorta slowly expanded to 6.5 cm. The patient reported intermittent back pain, fatigue, and weakness progressing over several months. After extensive discussion with the vascular surgeon and routine cardiopulmonary testing, the patient was brought to the operating room for replacement of his arch and thoracic aorta.

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How to have a better end of life care discussion
Madhusree Singh | Veteran's Hospital, San Diego
I work as an Academic Hospitalist at the Veteran's Hospital at San Diego where I help train UCSD Internal Medicine trainees. When we admit a patient to the Medical Service, at the very end of our conversation, the junior or senior medical resident often starts by saying- \"I don't think this is going to happen, but if your heart stops or you stop breathing do you want CPR, intubation?\" This way of finishing a medical interview is much like ordering a sandwich, a smorgasbord of choices are offered and one takes a pick. Medicine does not work this way, this is a way of wasting the privileges inherent in the practice of Medicine.

I recommend to our trainees that that end of life care discussions can be challenging and though there is no one way of doing it right, the following can be helpful-
1. Speak of Death- do not use euphemisms like passing away.
2. Make some time for this conversation- this is almost never one shot- and- you are done sort of procedure.
3. Ask them about their Advanced Directive and who will make decisions for them if they were incapacitated and write down their name, relationship, telephone number.
4. Educate them about their medical condition especially their prognoses, if you are aware of them or after speaking to their other doctors. Do not lecture, though. And never use jargon.
5. Have an on going conversation with the patient, and in a perfect world, their primary care doctor and other specialist providing care.

This is not a comprehensive list and should be finessed often but in my opinion a good place to start to have better conversations.
CONFLICT OF INTEREST: None Reported
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