Thứ Hai, 31 tháng 8, 2015
Revisiting CPR Survival Rates Depicted on Popular TV Shows
Jaclyn Portanova and colleagues at the USC Davis School of Gerontology have just published "It Isn’t Like This on TV: Revisiting CPR Survival Rates Depicted on Popular TV Shows" in Resuscitation. Compared to Diem & Lantos' similar 1996 study, accuracy rates of television CPR depictions appear to not be improving.
The authors found that Grey's Anatomy and House portrayed CPR as more effective than actual rates. Overall, the shows portrayed an immediate survival rate nearly twice that of actual survival rates. Inaccurate TV portrayal of CPR survival rates may misinform viewers and influence care decisions made during serious illness and at end of life.
"Public perceptions of cardiopulmonary resuscitation (CPR) can be influenced by the media. Nearly two decades ago, a study found that the rates of survival following CPR were far higher in popular TV shows than actual rates."
"In recent years, major strides toward enhanced education and communication around life sustaining interventions have been made. This study aimed to reassess the accuracy of CPR portrayed by popular medical TV shows."
"Three trained research assistants independently coded two leading medical dramas airing between 2010 and 2011, Grey's Anatomy and House. CPR was depicted 46 times in the 91 episodes, with a survival rate of 69.6%. Among those immediately surviving following CPR, the majority (71.9%) survived to hospital discharge and 15.6% died before discharge. Advance directive discussions only occurred for two patients, and preferences regarding code status (8.7%), intubation (6.5%) and feeding (4.3%) rarely occurred."
Here is one nice counterexample:
The authors found that Grey's Anatomy and House portrayed CPR as more effective than actual rates. Overall, the shows portrayed an immediate survival rate nearly twice that of actual survival rates. Inaccurate TV portrayal of CPR survival rates may misinform viewers and influence care decisions made during serious illness and at end of life.
"Public perceptions of cardiopulmonary resuscitation (CPR) can be influenced by the media. Nearly two decades ago, a study found that the rates of survival following CPR were far higher in popular TV shows than actual rates."
"In recent years, major strides toward enhanced education and communication around life sustaining interventions have been made. This study aimed to reassess the accuracy of CPR portrayed by popular medical TV shows."
"Three trained research assistants independently coded two leading medical dramas airing between 2010 and 2011, Grey's Anatomy and House. CPR was depicted 46 times in the 91 episodes, with a survival rate of 69.6%. Among those immediately surviving following CPR, the majority (71.9%) survived to hospital discharge and 15.6% died before discharge. Advance directive discussions only occurred for two patients, and preferences regarding code status (8.7%), intubation (6.5%) and feeding (4.3%) rarely occurred."
Here is one nice counterexample:
Chủ Nhật, 30 tháng 8, 2015
Neysi Perez Buried Alive, Wakes Screaming Inside Coffin
Pregnant teenager Neysi Perez was buried alive. She was removed from her tomb and coffin after family members heard her screaming.
Her mother said she was still warm. “We were all so happy. After being declared dead for such a long time, everybody was saying that she had come back to life. We were all so happy." (Independent)
Her mother said she was still warm. “We were all so happy. After being declared dead for such a long time, everybody was saying that she had come back to life. We were all so happy." (Independent)
Kevorkian "Coma" [EOL in Art 111]
In "Coma" Jack Kevorkian depicts an unconscious patient being slowly pulled into the mouth of a macabre death mask. Helpless. The death's head resembles the opening of a CAT scan machine, a symbol of modern medical technology.
New Futility Case: Siner v. Kindred Hospital Indianapolis
The Court of Appeals of Indiana issued a decision that allows a family to proceed with its medical malpractice action alleging that a hospital's unilateral DNR order caused the patient's death. Facts
"October 26, 2007, eighty-six-year old Geraldine Siner became a patient at Kindred Hospital. Geraldine suffered from advanced dementia caused by Alzheimer’s disease and as a result could no longer care for herself. Geraldine’s son, John Siner, was designated as her health care representative and had power of attorney."
"Upon Geraldine’s admission to Kindred, and several times thereafter, John informed . . . Geraldine’s attending physician, that Geraldine was to be a ‘full code’ patient. On November 16, 2007, Kindred’s Ethics Committee decided to make Geraldine a No Code/Do Not Resuscitate (“DNR”) patient, meaning that Kindred staff would not attempt to resuscitate her in the event that she went into respiratory or cardiac arrest (otherwise known as “coding”)."
"The Ethics Committee did not receive approval from John or any other family member to change Geraldine’s status in this manner. Geraldine’s health continued to decline over the following two weeks and Kindred declined to keep Geraldine on ‘full code’ status despite her family’s protests."
Expert Testimony
Plaintiff's expert Timothy Pohlman opined both that the hospital was negligent and that this negligence caused Siner's death.
"Kindred’s Ethics Committee recommended over-riding the wishes of the family and instructions of the patient’s medical representative for full treatment, and instituted Do Not Resuscitate (DNR) order, which ruled out such alternative treatments."
"Gerri Siner was also suffering from over-whelming infection, and septic shock at the time of intake. There is no documentation produced for me that indicate SCCM Surviving Sepsis Guidelines, . . . were followed . . . . These guidelines were not followed apparently because the patient was under a DNR order."
"Full damages and suffering that more likely than not resulted from re-prioritization of treatment modalities for Gerri Siner based on her existing ‘DNR’ order that was left in place without full agreement and consent of her Surrogate decision makers . . . ."
Appellate Ruling
The trial court granted summary judgment in favor of Kindred Hospital, finding the family had failed to introduce any evidence on causation. The appellate court reversed, because Pohlman's testimony does create a disputed fact as to causation.
Thứ Bảy, 29 tháng 8, 2015
Kevorkian "Very Still Life" [EOL in Art 110]
In "Very Still Life," Jack Kevorkian's message, "though somewhat capricious, nebulous and indefinable, is clearly underscored by intense feeling. Brilliant colors highlight the melancholoy age-old balance between the warmth of life and the iciness of death, spiced with the sardonic humor of irony."
"The disquieting mood portends inescapable doom for the frail symbol of individual life and seemingly callous extinction of its evanescent aura. The age-old balance is certainly skewed."
"The disquieting mood portends inescapable doom for the frail symbol of individual life and seemingly callous extinction of its evanescent aura. The age-old balance is certainly skewed."
Supreme Court of Nevada Asked to Determine Brain Death Standards
Earlier this month, the Supreme Court of Nevada ordered a hospital to continue physiological support for a dead woman pending briefing, argument, and adjudication. (I summarize the lower court proceedings here.)
Today, the family filed its opening brief. Basically, they make two arguments.
First: "The District Court incorrectly interpreted Nevada's Uniform Determination of Death Act (NRS 451.007(1)(b). The plain language of the Act specifically requires that if there is any functions of a person's brain, including his or her brain stem, then there is no 'death.'"
Second: "The District Court failed to apply and construe the Act in a manner that makes Nevada's criteria uniform among the states which have enacted the law regarding the determination of death. NRS 451.007(3). For what appears to be the first time, a District Court has concluded that the medical standards and protocols to determine ''brain death" are set by the American Academy of Neurology. Indeed, Nevada will be the first state to make a determination of death when the person was first determined to be alive, as confirmed by an electroencephalogram (EEG), without confirmatory evidence of a subsequent flat EEG."
This is not the most eloquent or comprehensive brief. But the core argument is not crazy. The UDDA articulates a standard: "irreversible cessation of all functions of the entire brain." But it is deliberately silent on the specific criteria used to measure "cessation of all functions."
In shot, the law punts the question to the medical profession. But there is significant variability in medical practice across the country in terms of the criteria used to ascertain brain death.
Today, the family filed its opening brief. Basically, they make two arguments.
First: "The District Court incorrectly interpreted Nevada's Uniform Determination of Death Act (NRS 451.007(1)(b). The plain language of the Act specifically requires that if there is any functions of a person's brain, including his or her brain stem, then there is no 'death.'"
Second: "The District Court failed to apply and construe the Act in a manner that makes Nevada's criteria uniform among the states which have enacted the law regarding the determination of death. NRS 451.007(3). For what appears to be the first time, a District Court has concluded that the medical standards and protocols to determine ''brain death" are set by the American Academy of Neurology. Indeed, Nevada will be the first state to make a determination of death when the person was first determined to be alive, as confirmed by an electroencephalogram (EEG), without confirmatory evidence of a subsequent flat EEG."
This is not the most eloquent or comprehensive brief. But the core argument is not crazy. The UDDA articulates a standard: "irreversible cessation of all functions of the entire brain." But it is deliberately silent on the specific criteria used to measure "cessation of all functions."
In shot, the law punts the question to the medical profession. But there is significant variability in medical practice across the country in terms of the criteria used to ascertain brain death.
Thứ Sáu, 28 tháng 8, 2015
Minnesota Board of Medical Practice at Hamline
Join the Minnesota Board of Medical Practice at Hamline on September 12 for some educational sessions on health law.
The Changing Definition of What Is ‘Brain Dead’
Healthline News has just posted a nice new review of the debate over brain death. It is not 100% accurate. But it is a lucid, comprehensive, lay presentation of the issues.
I love this quote from the distinguished critical care specialist and ethicist John Luce: " The brain dead people are not as dead as we once thought they were, in the overall biological sense."
The article also notes that Calixto Machado is working on a paper, to be published before the end of the year, which will propose a new category of consciousness to describe Jahi McMath’s as-yet-unseen circumstances.
I love this quote from the distinguished critical care specialist and ethicist John Luce: " The brain dead people are not as dead as we once thought they were, in the overall biological sense."
The article also notes that Calixto Machado is working on a paper, to be published before the end of the year, which will propose a new category of consciousness to describe Jahi McMath’s as-yet-unseen circumstances.
Medicine Holding Back Death [EOL in Art 109]
The buff man of medicine holding back death itself at Fulton County Health Services in Atlanta. Are we still so confident?
Thứ Năm, 27 tháng 8, 2015
Is ICU Treatment Inappropriate? Clinicians Now Have Guidelines
Medical Ethics Advisor has just posted an article on the new "Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units." There are comments from me, Gabe Bosslet, Larry Schneiderman, and Nancy Jecker.
Child's Garden for the ICU [EOL in Art 108]
Lisa Austin, Child's Garden for the ICU, 2001 (casters, steel, pine, plastic laminate, electric light, 6 x 10 x 10 ft).
Thứ Tư, 26 tháng 8, 2015
Original Art in the ICU Waiting Room [EOL in Art 107]
Ulla Darno donated this piece for the new ICU Waiting Room at Columbia Memorial Hospital in Hudson, NY with hopes of providing a more peaceful and soothing environment to others during times of stress.
Thứ Ba, 25 tháng 8, 2015
Original Art in the ICU [EOL in Art 106]
Judith Margolis created these "Panels" for Faraway Places, a project that placed original art made specifically for the Intensive Care Units of Hadassah Ein Kerem Hospital in Jerusalem.
Canadian Medical Protective Association - End-of-Life Panel
The Canadian Medical Protective Association works to protect the professional integrity of physicians and promote safe medical care in Canada. Its annual meeting starts tomorrow in Halifax.
The meeting includes a session on "End-of-Life Care: Medical Legal Issues."
Moderator:
Panelists:
The meeting includes a session on "End-of-Life Care: Medical Legal Issues."
Moderator:
- Mr. André Picard, Health reporter and columnist, The Globe and Mail
Panelists:
- Dr. Douglas Grant, Registrar, College of Physicians and Surgeons of Nova Scotia
- Dr. James Downar, Palliative care physician and intensivist, University Health Network
- Mr. Eric van Wijlick, Senior policy advisor, Royal Dutch Medical Association
- Mr. Domenic Crolla, Gowling Lafleur Henderson, CMPA General Counsel
Thứ Hai, 24 tháng 8, 2015
Do Not Leave Definition of Death Just to Doctors
Andy Ho lucidly explains how the definition of death is value-laden, synthesizing a lot of recent philosophical and medical literature. The issue is more acute in Singapore, because organ donation is presumed and opt-out. "They make a value judgment when they say that the loss of personhood in brain death makes it really death. . . . So what is a moral issue involving life and death has been surreptitiously changed into one about a biological fact to be discovered medically."
"[T]he current public policy permitting organ harvesting from the brain dead may be resting on shaky moral grounds. . . . It deserves being reopened for debate by all. It should not be left to doctors who have no particular expertise in philosophical endeavours."
Chủ Nhật, 23 tháng 8, 2015
Prescription for Medical Students: A Day at the Art Museum? [EOL in Art 104]
A study just published in NEUROLOGY (abstract here) shows a new way to help medical students learn about dementia - at the art museum.
"A day at the museum might be a wise prescription for helping students become compassionate doctors and giving them a better understanding of how patients and caregivers continue their relationships and quality of life despite their diagnosis."
"This research adds to a growing consensus about the value of museum-based arts activities in medical education. . . . A day at the museum may well be a wise prescription, for persons with dementia and their caregivers, to be sure, but also for apprentice physicians."
"A day at the museum might be a wise prescription for helping students become compassionate doctors and giving them a better understanding of how patients and caregivers continue their relationships and quality of life despite their diagnosis.""This research adds to a growing consensus about the value of museum-based arts activities in medical education. . . . A day at the museum may well be a wise prescription, for persons with dementia and their caregivers, to be sure, but also for apprentice physicians."
Futility Dispute - Mary Jane Pierce v. B.C. Women's Hospital
In April, Mary Jane Pierce was born prematurely at 25 weeks with serious health problems. She has cerebral palsy and has suffered multiple hemorrhages that damaged her brain. Next month, a BC court will decide whether B.C. Women's Hospital in Vancouver must maintain life-sustaining treatment.
The Hospital
At some point, NICU clinicians determined that interventions to maintain Mary Jane's condition were burdensome on her body and that she has multiple seizures every day. On August 10, the physician caring for Mary Jane planned to remove the ventilator and transfer the infant to palliative care.
But on August 11, shortly before the ventilator was to be removed, a B.C. Supreme Court judge granted a temporary injunction to stop doctors from removing the life-support.
The Parents
Mary Jane's parents, Michelle Arnold and Justin Pierce of Chilliwack, B.C., say they were pressured on August 7 into signing temporary custody of their daughter over to the care of an agency under the province's Ministry of Children and Family Development.
600 Days of Death - Jahi McMath
DocBastard posts some good thoughts on brain death and the Jahi McMath case by Cory Franklin, a retired ICU physician from Cook County Hospital in Chicago. Franklin had a shorter version of his remarks in the San Francisco Chronicle.
"Any time you have a diagnosis with an outlier, it’s a good idea to review your original assumptions. In this case our assumptions about what brain death actually is."
"Any time you have a diagnosis with an outlier, it’s a good idea to review your original assumptions. In this case our assumptions about what brain death actually is."
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