Monday, November 19, 2012


   We as physician are asked about the prognosis . This is not a question when we diagnose things like high blood pressure or diabetes or asthma . But when we tell patients about cancer or poor heart function etc , then the question always arises as to what is the prognosis . This goes farther when the condition progresses and when the patient and the family realizes that the things are not going well or not getting better and are not likely to get better. This is the time when patients make decision on DNR. If the END is near then sometimes they decide to go with the Hospice . But as I mentioned in last blog , when these decisions are not made in advanced or they are made but we as doctors are not made aware of it , we end up having a mess . Once is patient is put on 'life support ' , taking him off is little difficult . There are state laws and regulations and there are hospital rule and regulations .When we have to take patient off the life support , it is called 'withdrawal of life support ' . In this process there must be an agreement between patient or his representative , and two doctors about the prognosis and to stop the futile efforts . If patient can not make decision (which is the case most of the time as he is on respirator and sedated ), then we have to get OK from his relatives . If patients have made decision about their representative it is easier .If there is no written representative , then there is rule as to who can make decision . The spouse is first in line , then children , then the parents and lastly siblings.The problem is when there are more than one child . The law needs 50% plus one to agree on the decision  to withdraw.So if there are 3 children then all must agree .(one and a half plus one ).
    I face this situation frequently in Intensive Care Unit . It is easier to make decision when we know patient or there is really terminal condition or condition is terminal . e.g. brain bleeding . But then there are times when it is not that clear . When a physician signs a form stating that the " condition is terminal and recovery is unlikely " he is acting as God . In my life time there may have been two or three cases when I have postponed the withdrawal for 24 hrs just to get a chance to wean down or get more evidence that with or without treatment patient will die . This has sometimes caused some friction with the family or other physician . I have weaned off some patients of the life support and avoided making decision as God .

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