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Teachable Moment | Less Is More

When Do Not Resuscitate Is a Nonchoice Choice A Teachable Moment

Michael J. Nabozny, MD1; Nicole M. Steffens, MPH1; Margaret L. Schwarze, MD, MPP1,2
[+] Author Affiliations
1Department of Surgery, University of Wisconsin, Madison
2Department of Medical History and Bioethics, University of Wisconsin, Madison
JAMA Intern Med. 2015;175(9):1444-1445. doi:10.1001/jamainternmed.2015.2326.
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This Teachable Moment describes the experience of a spouse who was asked to make the decision regarding withholding cardipulmonary resuscitation for a patient whose death from surgical complications was judged by the surgeon to be imminent.

Article InformationCorresponding Author: Michael J. Nabozny, MD, Department of Surgery, University of Wisconsin, 600 Highland Ave, H4/785, Madison, WI 53792 (mnabozny@uwhealth.org).

Published Online: June 15, 2015. doi:10.1001/jamainternmed.2015.2326.

Conflict of Interest Disclosures: None reported.

Funding/Support: Dr Schwarze is supported by a training award (KL2TR000428) from the Clinical and Translational Science Award program, through the National Institutes of Health National Center for Advancing Translational Sciences, grant (UL1 TR000427), and the Greenwall Foundation (Greenwall Faculty Scholars Program.)

Role of the Funder/Sponsor: These funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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How to have a better end of life care discussion
Posted on September 23, 2015
Madhusree Singh
Veteran's Hospital, San Diego
Conflict of Interest: None Declared
I work as an Academic Hospitalist at the Veteran's Hospital at San Diego where I help train UCSD Internal Medicine trainees. When we admit a patient to the Medical Service, at the very end of our conversation, the junior or senior medical resident often starts by saying- \"I don't think this is going to happen, but if your heart stops or you stop breathing do you want CPR, intubation?\" This way of finishing a medical interview is much like ordering a sandwich, a smorgasbord of choices are offered and one takes a pick. Medicine does not work this way, this is a way of wasting the privileges inherent in the practice of Medicine.

I recommend to our trainees that that end of life care discussions can be challenging and though there is no one way of doing it right, the following can be helpful-
1. Speak of Death- do not use euphemisms like passing away.
2. Make some time for this conversation- this is almost never one shot- and- you are done sort of procedure.
3. Ask them about their Advanced Directive and who will make decisions for them if they were incapacitated and write down their name, relationship, telephone number.
4. Educate them about their medical condition especially their prognoses, if you are aware of them or after speaking to their other doctors. Do not lecture, though. And never use jargon.
5. Have an on going conversation with the patient, and in a perfect world, their primary care doctor and other specialist providing care.

This is not a comprehensive list and should be finessed often but in my opinion a good place to start to have better conversations.
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