Wednesday, January 13, 2016

Book review: The Conversation

So, I just finished reading this book. This might rehash some of what I said the other day, but I wanted to recommend this book. It is a short, quick read and can be had for less than ten bucks on Kindle through Amazon  

The author of the book describes being a doctor in a hospital and being faced with providing treatment that was not only harmful, but that was also completely useless. He says many things that I felt as an ICU RN, but I appreciated that he took a slightly different angle and mentioned somethings that are frequently not brought up. I think everybody who works in acute care will have some image burned into their brain of a situation where they continued to give life extending care that was not only futile and harmful, but also in direct conflict with the wishes of the patient. My most recent example was when I still worked ICU here in Vegas. In that case, a woman had had a heart attack, and while in the ER, the daughter of the patient arrived and demanded everything be done. The patient had advanced directives that said she didn't want any of this stuff, and the daughter later told me in the ICU that the patient was going to mad if she ever woke up. 30 days later, the patient was discharged, but with a tracheostomy, a feeding tube in her stomach, a very damaged heart, and a slim likely hood that she was ever going to rehab. 

A premise of the book, as shown in the title, centers on the need to have a discussion between individuals, their families, and their doctors. Ideally, this conversation needs to occur before an individual has crashed and needs immediate, intensive care. In my personal experience, I think a lot of people have a deer in the headlights moment here and make an emotional decision based on factors other than what the patient wants. Sometimes it is very self serving and truly unethical, but other times it is because they are just having a hard time letting go. What the author brings up, which is a little unique to this book, is that he doesn't just talk about the potential need for very invasive treatment, he describes what that treatment actually looks like. And I think this is something that is truly missing in many discussions I have seen between doctors and patients. I'll try to wrap this up here. 

As I said on the other thread, advance directives can tell families and doctors that a person does not want to live in a state where they are being kept alive by machines. That part is straightforward. But, many times, a patient has an event occur, goes on a machine temporarily, gets off the machine and goes home. The rub though is that you cannot always tell what will be a short stay of invasive treatment, or what is going to become permanent. Medicine truly involves very many slippery slopes. An uncomfortable thought for many is to consider that a person who is chronically ill may decide after one trip on a ventilator that they never want to do that again, even though they could probably tolerate several more trips without getting stuck on the vent. What if this person doesn't want to quit smoking? What if they don't want to keep eating salty foods? I know for a fact that we typically bring these people to the hospital, do all this stuff, send them home, and then scold them for not adhering to a lifestyle that makes their life miserable. My new job, interestingly enough, will be to see these kinds of people in the hospital and have this conversation. But, as a final thought, I urge everyone to not only have advance directives, but also to name a decision maker who will not get swayed by the emotions of anyone who is not the patient. Additionally, and the author touches on this, it's not enough to tell people what you don't want, it is also crucial that people understand what life means to you. If being alive means that you are able to do what you want, eat what you want and so on, that should guide your health care decision making process.

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