Wednesday, May 31, 2006

Tired II

There were so many interesting comments on my previous "Tired" post, and enough controversy generated by it, that I thought I'd go over some of the issues again - and defend myself, although most commenters were remarkably polite.

The consensus opinion seems to be that sleep should not have a role in our decision whether or not to stop life support. As smartblkwoman said, "it is very cruel to weigh someone's death by how much sleep you can get." I absolutely agree, and that is why I try my hardest to not let my desire for sleep affect my decision about termination of life support. Most of the time I'm successful. As Dianne said, my hope is that I'm "able to make better decisions knowing that that motivation is there."

But it brings up the more general problem of a physician's personal needs or desires affecting his or her medical decisions. For example, an obstetrician has tickets to a concert in two hours. Does that affect his decision whether to do a caesarean section in a woman who's poking along in labor, versus letting her labor longer? Or a pediatrician wants to be home in time for her son's birthday party, and she has two more patients to see. Does that make her rush through those patients faster than she normally would? A good physician doesn't let his or her personal life affect medical decision making, but we're kidding ourselves if we think there isn't at least a potential problem there.

Commenters also opined that a physician should not be able to unilaterally decide to stop life support and needs to discuss it with the parents. I agree with that, too. My paragraph addressing that issue said "sometimes" I wish we could stop the ventilator on our own. Most of the time I realize that would not be a good thing, that there would be too much potential for abuse by some physicians. Having parents agree is a check and balance in the system. (Sometimes, too, before withdrawing the ventilator I'll ask the nursing staff if they agree with stopping support.) I think, though, that the worry about causing the parents guilt by making them say it's okay to stop the ventilator is a legitimate concern.

These end of life issues are tough. If they're not tough for you, maybe you shouldn't be making them.


Anonymous Exutero said...

Hi NeoDoc,

One of the the abstracts at this year's SPR meeting was an analysis demonstrating that there was significantly more death in NICUs at night and on weekends then during week days. I can't remember which westernized continent it was on for sure but I believe it was over here. This is consistent with data from adult ICUs where the off hours increase in morbidity and mortality phenomenon have already been well documented.

I guess my point is that you're right in saying it's not something we can sweep under the rug and say it's not an issue. There are a lot of forces at work that may be making this trend even more likely (shortened resident work hours and decreased house staff competency in academic NICUs, increasing nursing turnover due to micropremie burnout and a national nursing shortage, an administrative tendency to have a leaner night crew ("hospital at night" as Dr John Crippen might call it) and an ever increasing sentiment amongst physicians that the job simply isn't what it used to be and it's not worth the personal sacrifices it once was). These things are adding up and now we can actually detect their cumulative effect statistically.

Every Physician disagrees with a parent's decision once in awhile (Hell I probably disagree with at least one every day) but the problem isn't that parents sometimes make decisions that might be "wrong", the problem is that when physicians are sleep deprived they are not necessarily objective decision makers. I think the Texas Law is resonable because it takes a while to get permission to withdraw and it takes multiple physicians and multiple institutions, but I would have real problems with legalization of unilateral decisions made by healthcare staff in the acute phase of disease. The Texas Law seems ideal for patients in a persistent vegitative state and severe, chronic, complicating health conditions (short bowel requiring continuous IV nutrition for example).

I once had a 23 week gestation case exactly as you described checked out to me at the 5 pm hand off with a potassium of 10 and no central access, with the parents distraught and demanding that every thing be done. I was up all night doing essentially futile therapy but at the same time I was talking them through the dying process, explaining how each time we coded the child for torsades, it was another step closer to the end. Eventually they did allow us to take the child off at about 4 a.m. That's how long it took them to make the journey and accept that death was inevitable. It's part of the job, teaching parents what dying looks and feels like in a micropremie.

In most cases, they have no idea and that educational part of the process is never futile, because they have to live with those memories for the rest of their lives. They need to know that everything that could be done was done.

10:52 PM  
Anonymous Ged said...

Several units I've worked at (PICU's, not NICU's, but same issue really) specifically say to the family, "you are not choosing to turn the machines off. There is nothing further that can be done. However, we can keep him going long enough for you to get family members in to say goodbye and to support you."

I've never really thought of it as the parents' decision at all, to be honest. The child is going to die, and flogging them with technology won't change that at all. Leaving the parents with the guilt of thinking they might have killed their son or daughter is not a path I wish to take.

11:09 PM  
Blogger neon88 said...

Being tired is bad. I can sympathize with you. I have been exhausted to the point of falling asleep while writing notes or waiting on the phone. I have been up for 72 hours straight. I don't think most people have any comprehension what it's like to be that tired. I have worked between 60 and up to 110 hrs a week. When you're that tired sometimes there is a very dark place in the back of your mind that hopes that the very premature infant dies before the transport team can get there to save the baby. It would be great if Neonatologists didn't have to work more than a 14 hour shift and a 60 hour work week. But that would require more Neonatolgists than there are and hospitals and society are not willing to absorb the cost.

12:14 AM  
Blogger That Girl said...

I had nothing to say to this post because I agreed with it all.

But I wanted to say to Neon 88 that those of us who work 2 full time jobs to support our family know exactly what it's like to be that tired. And we get to work in places that consider talking to other employees, or even sitting down during our shift "stealing" money from the company.

10:17 AM  
Anonymous Shamhat said...

I wish that the doctor with personal needs would just admit them to the patient, and let the patient decide whether to speed things up before the concert or let someone else take over.

Recently a doc who had a plane to catch induced a 39-week primip on a Saturday despite a car accident on the way to the hospital for which protocol would have been observation (ruptured her while the nurse was in the bathroom). The woman labored beautifully without medication, but as soon as she was fully dilated the doc told her she needed an epidural for a vacuum extraction, started Pit at 2mu/min increasing by 2 every 10 minutes, and then turned it up herself at about 5 minute intervals.

The doc pulled 4 times to bring the baby down but then let the woman push the baby out (with an epis), then asked the resident to stitch her and ran out the door without charting a word.

I suspect that if the patient had been told that the doctor had travel plans, she would have consented to letting the resident catch.

10:35 AM  
Anonymous Dianne said...

thatgirl: I was going to say something similar but you beat me to it. Oh, well, I've got an anecdotal example to give anyway: When I was a resident a woman came to my clinic for advice on loosing weight. Since she weighed well over 300 lb, it seemed a good idea. I talked to her a bit about her daily schedule and eating habits and was shocked to find that she was working longer hours than I was. She held 3 jobs, all of them sedentary, with a total work time of about 110 hours/week between one full time and two part time jobs (no health insurance from any of them, naturally).

There are 168 hours in a week. If you work 110 of them that leaves 58 for everything else, including sleep. A typical person needs about 8 hours of sleep per night, ie 56 hours a week, leaving 2 hours for all other activities including eating, commuting, etc...Is it any wonder that her diet was less than optimal and she rarely got any exercise? I know, this is a digression, but this forced work ethic has gotten out of hand. And not just for doctors. It is possible to survive the 100+ hour work weeks of residency for two reasons: 1. they're time limited and 2. the work is interesting. So it is probably actually easier to be a resident than to be an underpaid worker in the "service industry" working 2-3 jobs to try to survive: at least in residency the work is fun.

I recently read an article stating that many health problems, including diabetes, hypertension, and heart disease were much higher in the US than in Britain. Obesity could account for some of it, but does not seem to account for all of the difference. Could the overwork encouraged by sub-living wage level minimum wage and lack of benefits contribute to this problem?

3:57 PM  
Blogger Cathy said...

This comment has been removed by a blog administrator.

8:19 AM  
Blogger neonataldoc said...

Thanks, everyone. Ex utero, you hit the mail on the head. It's part of the job dealing with death and dealing with parents dealing with death. Shamhat, it's an interesting concept, telling the patient the doc's personal needs.

1:45 PM  
Anonymous Kim said...

You ask the nurses their thoughts on some of the cases.

You are a gem!!!! : )

11:33 PM  
Anonymous Anonymous said...

Just like the rest of us have to plan our family life around our work schedule, so should doctors. The doctor with the birthday party could have planned the pary for a Saturday or Sunday when she's not on call. The doctor should have ordered concert tickets for a night he's not on call.

Working long hours at odd times - that's part of the job. And anyway, who works only 40 hours? Even my husband who makes a fraction of what a doctor makes has to work late without additional compensation (becauase he's salaried, they don't have to pay overtime). Legal holidays? They make him come in on other days to make up the work, or stay late the rest of the week to do that. 9 to 5? He doesn't come home until 8:30 most evenings.

Everyone works hard, everyone makes sacrifices, regardless of salary. At least in my husband's case, people's lives and health are not on the line. /soapbox

shamhat, your story is appalling. I'm very lucky that my Maternal-Fetal Specialist was the exact opposite of what you described. I had my almost 41 week appointment late one afternoon and the doctor felt I should be delivered immediately because my blood pressure had risen again. He would deliver me himself even though he was not on call that evening. The doctor who WAS on call had an some problems I (both with attitude and competence) and I previously discussed him with the head of the practice, who had heard complaints before and agreed I did not have to be delivered by him. All the other doctors in the practice agreed to cover in the event that he was the one on call.

So, I realized that being delivered meant my doctor would lose his free evening at home with his family. I offered to come in the next morning and be delivered by whoever was on call then, but he was adamant, saying that any number of things could go wrong overnight. So I offered to be admitted and have the nurses watch me overnight, but he still insisted, saying he doesn't want me to abrupt again as I could have a stillborn. (In my previous pregnancy, I had a placental abruption and was unable to make it in to be delivered, but was delivered in the closest hospital the ambulance took me to, by the on-call OB.)

In the end, not only did my doctor stay until 1 or 2 in the morning to deliver me, but another doctor in the practice assisted him and lost his evening as well! And my doctor had to be at work at 7 the next morning - and he's not a young man.

I was so overwhelmed with awe and gratitude for the sacrifices they made, saying they had to "take responsibility" for their colleague, with only the health of me and my baby in mind. When I gave them a gift later, I made sure to include their families in my thank-you letter, as they had sacrified their husband/father for an entire evening.

I love that practice, and I know you don't find care like that every day. By the way, these amazing doctors left to establish their own practice, leaving the idiot behind.

11:49 AM  
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