2009-08-28 / Columnists

PHC Health Talk

End Of Life Decisions: Continuity Of Care
Commentary by Dr. Michael Franklin Director, Emergency Medicine Department

Dr. Michael Franklin Dr. Michael Franklin Two of the major issues that frequently cause a problem in today's emergency room setting are end of life decisions and continuity of care.

There is no time like the present to discuss end of life decisions with family members. While no one likes to discuss this issue, a lack of direction can lead to undue hardship with catastrophic consequences.

The emergency room is no place to make this critical determination. But bear this in mind: making no active decision means that the hospital and its staff will be dedicated to administering the entire arsenal of life extending measures at their disposal.

In other words, making "no decision" by default commits you and your loved one to a course of action.

The ideal, most compassionate and advisable course of action, then, is for every individual to make known his or her wishes to loved ones - typically next of kin - via a health care proxy while he or she is still healthy and in the best frame of mind to make those wishes known.

It has been demonstrated time and again that most, but not all of us, would refrain from invasive procedures if the hope for a meaningful survival had ceased. Conversely, many patients and friends have also told their doctors that they cannot know how they would feel in such a situation until they would have to face it.

But the response to that is deceptively simple. Imagine the last time you had Influenza, waking up with a terrible headache, aches and pains, and a fever of 104. What gets us through the agony is knowing that in a few days it will be gone. Now, imagine waking up with that condition or pain that is far worse and knowing that every day would not bring hope but, in fact, would be worse than the day before.

As bad as that scenario sounds, now imagine painful procedures added to the mix.

It must be emphasized, however, that end of life decisions do not mean the end of care. Palliative care is available to alleviate pain and suffering. This type of therapy is available via hospice programs, both as inpatient and outpatient. Both services are available here at Peninsula Hospital Center.

Regardless of how you feel now, talk to your loved ones and decide where you stand on this issue. Your primary care physician will assist you with any of the pertinent paperwork, end of life options, and perhaps just a shoulder to vent your feelings.

Physicians and hospitals are not interchangeable parts in the vast network of medical options. A primary care physician is a necessity in navigating today's complex system. Too often, patients with complicated health issues show up in the Emergency Room with little knowledge or understanding of their conditions. To make matters worse, their physicians are located in their old neighborhoods or near their places of work.

They see their primary physician for checkups when they are well but check into the hospital when they are acutely ill … often without a physician aware of their problems. What is worse is when a post-operative patient shows up at an Emergency Room of a hospital where the surgery was not done. Unless there is a life threatening problem almost all these patients are referred back to the surgeon of record without any definitive treatment. For obvious reasons, most surgeons are hesitant to offer treatment to patients when they are unaware of the details of the original care.

In summary, make end of life decisions when it is comfortable and convenient, not when you are under duress. Try to coordinate care with a primary physician who instills confidence in you.

Do not jump from doctor to doctor and hospital to hospital in hopes of attaining better care. Often it is not better and, in fact, can be quite dangerous.

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