Posts Tagged geriatrics

The 95 Year-Old Slam Dunk Admission

courtesy cc license by jonrawlinson

courtesy cc license by jonrawlinson

It’s often bragging rights to the doctor who can discharge the 90+ year-old patient to home, because they’re just so likely to have something, and it’s viewed as so risky to send them out. (Similarly for the HIV patient or the renal patient; bonus points for being able to send the 95 year-old HIV+ renal patient home.) And you’re never going to hear someone complain about it being a bogus admission, even if labs are normal. You get to a certain age where you’re just allowed to say whatever you want, and if you say it in triage, you’re coming in.

But ironically, the group with the highest odds of having something seriously wrong with them are probably also the most likely to have something go wrong with them while they’re in the hospital. Benzos in the elderly, for example, have been implicated in cognitive impairment, increased falls, and more side effects than in younger patients (PDF), probably because of changes in CNS receptors and changes in metabolism. Even without benzos, they’re more likely to experience delirium or to sundown. And when they get these side effects, they’re more likely to fall, and when they fall, they’re more likely to break a hip or get a subdural, and when they do those things, they’re less likely to have a good outcome. If you give a mouse a cookie, et cetera.

That’s why, when possible, I think a discussion with the patient and his or her family members is better than a simple “He’s coming in,” dispo, no matter how mentally satisfying an auto-disposition is. There’s the obvious cases, and the few who can obviously go home, but I think there’s probably more patients in the grey area that I don’t even consider. Last week a friend in California was telling me about a chest pain and syncopal patient duo of 90-somethings he had discharged after a conversation with the family — even with an initially elevated troponin in one of them. They didn’t want a cath, or more medications, or heart surgery even if it meant the patient was having a heart attack. I probably wouldn’t want any of those interventions at that age, either. Discharge home.

I’m one of those crazy guys who thinks dying by code in a hospital bed or sedated with tubes in every orifice in an ICU just isn’t what people want, if they have enough experience with the health care system to know what those terms mean. (90% of Americans when surveyed want to die at home, but 80% die in an institution.) I’m also crazy enough to think that often if you’ve made it to 90, you probably don’t want to spend any miniscule percentage of time in the last days, months, or years of your life in a hospital. I certainly admit the vast majority of my elderly patients, but who knows, maybe many of them wouldn’t even want what the inpatient team might be able to offer them in terms of diagnosis or treatment.

Whenever I’m discussing a treatment or procedure with a patient, or getting consent, I often talk about how I believe the benefits of it outweigh the risks; that we in medicine above all try to do no harm (ha!). But this same criteria is often glossed over when deciding to admit a patient, ignoring the potential complications of any hospital admission: falls, nosocomial infections, medication errors, etc. Why do we often minimize these? Perhaps because we don’t know the true risks of a hospital admission? Perhaps because we don’t like the cognitive dissonance that in a profession of healing, in a place of healing, we can actually cause harm. Perhaps because it’s easier not to consider the risks?

In medicine, everything — and I mean everything — comes with a risk and benefit profile. And in considering admission, we need to consider what our patient would want, when feasible and possible.

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The Electronic DNR: Epic Fail

A screenshot from Google Health.

A screenshot from Google Health.

I applaud Google for trying to bring medicine into the 21st century with things like Google Health and Google Scholar; somebody’s gotta try. But their latest addition shows how even a huge organization full of hugely intelligent people can get something wrong in health care, because our world is simply a different beast.

Last week Google announced that it was making it easier to complete, upload, and store your own Advance Directive on Google Health. They even worked with an advance directive organization to have free advance directive forms for all the 50 states. (Warning #1 right there: things are different in all 50 states.)

They then go on to talk about how easy it is to “share your Google Health profile with your doctor, your family, or anyone you like.” And voila, epic fail.

Great, I say, that a patient can share his or her own medical information with loved ones or one’s doctor (more on electronic medical records and personal health records in another post). But these advance directives are not available in a searchable database by, say, name or date of birth. I’d argue that as Emergency Physicians, there are few people who need to know a patient’s code status more; perhaps intensivists, but the vast majority of patients going to an ICU setting who are going to need intubation are already intubated when arrive in the unit, and they’re going to stay that way. It’s a vast minority that get intubated in the ICU.

Our critically ill patients are usually so critically ill they’re not able to be speak, or they’re altered, or too somnolent to be thinking correctly, let alone be able to type and remember their login to Google Health. Or they’re technically DNR/DNI, but they have a family member that says do everything, and another that says “no, don’t,” and no one has any paperwork for anything. Or their DNR form isn’t valid, or they’re from another state, or their health care proxy isn’t available.

Or, say in a perfect world, you get a computer nerd online dweeb (say, me in 60 years) who has everything online and shareable with the world at large. Is the physician going to spend their precious time trying to login to a website to find out if the patient is DNR/DNI if they don’t know already, or is she going to try to review my medications, medical conditions, run through my differential diagnosis, assess my airway, and get oxygen, suction, and intubation supplies ready at the bedside?

We just recently had a case of a woman who was DNR/DNI for many years who was found in respiratory distress by the home health aide at 2am but who didn’t know the patient was DNR/DNI and couldn’t find any of the paperwork. So EMS intubated her. It was a frustrating situation for all of us–EMS, the ED staff, the patient’s family–but what was EMS to do? A perfect illustration of best-made plans falling through when things get stressful. (Luckily she was in flash pulmonary edema, and after a nitro drip we were able to extubate her in the ED.)

Look, I’m just about as techie and computer-friendly and live-your-life-online as anyone out there, but a lot of this stuff isn’t well thought-out, isn’t safe, and has no guarantees. So, Google–and emergency medicine and health care as a whole–we’ve got some work to do if we’re ever going to figure out the advance directive (and even more to take it online):

  • Make a central clearinghouse. Is it going to be Google Health, or the US Living Will Registry, or some government entity? Who knows, but the only people who you really need to know about your code status are your family members and health care providers who may want to code you or intubate you. I’m not going to spend precious minutes searching through multiple websites (or possibly any) to figure out where you’ve stored your online code status.
  • Confirm the patient’s identity. So all I need to know is your Google password, and I can upload a DNR form and forge your signature? (Because really, if you’re altered and septic, I’m not going to be able to verify your signature.) Scary.
  • Guarantee that the online forms that are uploaded are legally binding or accurate. I don’t know how we do this, but we usually want an original copy to initiate an DNR/DNI order, not a copy–and certainly not an uploaded duplicate.
  • Somehow confirm that the DNR order is the most recent. Sure, it’s great to have the information available online, but what if the copy is 3 years out of date and the patient changed their mind 2 years ago and is now full code, yet the only information we have available says “DNR?” That certainly seems suboptimal as well.
  • Decide if we should even have advance directives. Some argue that they’re a waste of time and energy, when they real time should be spent letting your loved ones (and especially your health care proxy) know your wishes. If we’re not legally protected to follow advance directives (a dead patient isn’t going to sue us, but a grieving relative sure can), it’s sure difficult not to listen to that relative telling you to “do everything.”

I’m all about end-of-life care and palliative care and actually believe we don’t do enough of it in the emergency department (but how can we?), but I’m still not sold on the advance directive if it has little-to-no legal weight behind it, and I’m even less impressed by Google’s online attempt.

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