Download Three Patients: International Perspective on Intensive Care at the End of Life djvu

From Dr. Hoyt's chapter "Globalization of Critical Care"
"There is only one way to explain the birth of this book. That is CCM-L..., an electronic bulletin board that is devoted to critical care medicine), and Dr. David Crippen, one of the book's editors. An avowed nonconformist and refugee from the 1960's, Dr. Crippen has connected intensive care unit (ICU) physicians from around the world by means of the Internet. He has singlehandedly, without commercial sponsorship, woven a network of international intensivists. Nothing like this has ever occurred before. All readers of this book are being treated to a unique experience."
I might add a historical irony. One of Dr. Crippen's ancestors was Dr. Hawley Harvey Crippen. This man was the first criminal to be arrested in 1910 via the use of wireless technology. The earlier Dr. Crippen had murdered and disposed of his wife, then sought escape by going on an ocean liner with his mistress (disguised as his 12 yr. old son). The Captain grew suspicious (he saw the "father and son" holding hands and appearing amorous) and wired back to shore. This then led to a spectacular arrest as a member of Scotland Yard traveled on a faster ship and arrived in time to board and arrest Dr. Hawley Crippen. The papers at the time had a field day and this case was part of the "inspiration" for the Alfred Hitchcock film "Rear Window" starring James Stewart, Gene Kelly, and Raymond Burr. Now at the turn of another century we have yet another Dr. Crippen again making history via the use of a new "wireless" technology-- the internet. And the issue of death is involved. But instead of the sensational and criminal death of one person, we have the issue of death and dying in ICU's all over the world.
The four issues interwoven and discussed throughout the book are 1) patient autonomy, 2) beneficence (providing benefit), 3) nonmaleficence (doing no harm), and 4) distributive justice. Does patient autonomy imply not only the right to refuse treatment, but also to insist upon whatever aggressive therapies they may desire (and may have looked up on the internet)? Could we provide more benefit by trying to ease suffering during the end of life as opposed to prolonging life by a matter of days to weeks? To what extent do patients, on the surface appearing calm and sedated, actually suffer as we apply futile resuscitation efforts in their last days? If we are to formally apply some legal formula for the just distribution of critical care resources, is this a decision best left for medical professionals? Or is it a political and ethical decision for the public at large? Those looking for easy and short answers to these questions will be disappointed with this book. Many of the chapter's authors take divergent viewpoints.
What I found interesting was how several authors pointed to a historical trend in the USA. In the old fee-for-service era, when all provided technology and service was very lucractively billed, it was the families whom were going to court to have futile life support terminated. Now, in the new era DRG's, capitation & shrinking reimbursement, it is the hospitals and MD's whom are seeking to legally no longer provide futile care. This seems to imply that there has always been an economic foundation as to the determination of what constitutes "futile care". If we are discussing the compassionate and just application of medical technology and service then "futile care" may be seen as one thing. If we are talking about the provision of billable medical services then "futile care" may be seen as quite something else.
If this book has any one failing in my opinion it is that the issue of Palliative Care isn't addressed adequately. I feel this issue warranted a full chapter at least. While "palliative care" was mentioned in passing by several contributors, a more in depth look at the international differences would have been quite revealing. In many countries Palliative Care is it's own specialty. "Doing everything" is usually meant to do everything in regards to prolonging life, not doing everything to ensure a good death-per many of our default biases. Indeed a recent SCCM pamphlet I received in the mail, titled "ICU, Issues and Answers" and meant for family members of ICU patients, answers the question ""What is meant by `doing everything' with the following.
"'Doing everything' implies tht any and all appropriate therapies will be utilized in order to preserve life." The pamphlet goes on to describe how MD's aren't required to offer therapies that would be medically ineffective. But what if we expanded our definition of "doing everything" to include effective and compassionate end of life care. That care may not be "critical" in the technological sense, but certainly it is "intensive" from the standpoint of patient need and clinician time, energy, and professionalism.
One chapter is by an RT and is titled "Advanced Medical Technology and End of Life, A Respiratory Care Practitioner's Perspective by David Walker, MA RRT. Mr. Walker eloquently describes a "day in the life" of a Respiratory Therapist.
Another chapter is titled "End of Life Care in the Intensive Care Unit" by Gabriele Ford CCRN. Ms Ford paints a rather disturbing picture of what it is like to oversee the provision of futile care.
This is one of the most interesting and riveting books I've read in a while. It is a book which deserves to be both read over again as well as passed around. No ready-made solutions pop out of the book, but I assure you that your cerebral matter will be quite stimulated.

An interesting book, probably unique in its kind. Dr Crippen is an intensive care specialist from Pittsburgh, Pennsylvania who in 1996 started an international internet discussion group (CCM-L) to deal with many issues involving critically ill patients. More than 1,000 members have enrolled. This is exceptional in the sense that for the first time health care professionals and providers from all over the world were able to interact and exchange information and opinions in such a direct, facile, almost immediate way.
A fundamental problem - As the population ages and life may be "artificially" extended with the use of sophisticated and often expensive technical support, ICU availability and costs have become an issue of growing public importance and concern. Dr Crippen created three hypothetical patients and asked critical care providers from all over the globe to offer their comments on their management. The result is this remarkable book which is surprisingly easy to read despite the use of specialized terminology. Different perspectives based on different cultures and socioeconomic backgrounds emerge as the reader proceeds. A physician from South Africa describes the huge demand for ICU beds and the limited availability. Physicians from India and Russia underline the importance of the patient's social and financial status and what impact this may have on future decisions related to hers/his critical care. A physician from the Netherlands describes the universal coverage health system available in his country and how the decision for further care rests primarily on the physician's medical judgment. A physician from Israel tries to achieve a balance between religious constraints and futile care. And at the end of the book, non-physician critical care providers contribute with vivid descriptions of pertinent cases and with their perception of futility. Among them, a hospital chaplain describes how she helps her patients deal with the fear of the incoming inevitable death by bringing them closer to a picture of a God who is love, mercy and compassion instead of fear, punishment and revenge.
It is evident throughout the book that one of the major issues shaping critical care costs and distribution in the USA is unlimited patient autonomy and overzealous litigation. Increased physician mistrust on behalf of the patients is stated as a major cause of this phenomenon. Whereas many physicians outside USA would assume a role conceived as paternalistic for the USA standards, patients in the USA are often offered a menu of available option regarding their future critical care treatment ("Mr. Jones, in case your breathing worsens do you want us to proceed with mechanical ventilation? In the event your heart stops, do you want us to start chest compressions?" and so on... )
Under the editing of Dr's Crippen, Kilcullen and Kelly a balance and an answer is sought. It is not an easy task but the team involved is one of the best international teams available. I highly recommend this book. It underlines once again the concept that a good question is often more important than the answer.