H E A L T H L A W Continue CPR! or How to Save the Patient and Screw the Pooch 1 ■ JOHN SHUFELDT, MD, JD, MBA, FACEP S o there I was (all good stories start this way), having just participated in saving a 58-year-old guy who collapsed while playing golf with his buddies. It was a classic v-fib arrest—dropped after hitting a great drive right down the middle of the fairway. The man’s friends started CPR, para- medics arrived and shocked him out of VF into a sinus rhythm and intubated him. While in the emergency department (ED), the man started waking up; he was reaching for the tube and seemed to be following commands. I had already arranged an ICU bed for him when a woman claiming to be his wife ran into the ED and screamed, “Take that tube out immediately; he has a DNR” at the top of her lungs. Although the patient was waking up, it was still way too early to extubate him. In my very gentle, Marcus Welby-like voice I said, “Ma’am, your husband is alive and, considering what happened to him, doing great. We expect him to wake up and have minimal or no cognitive impairments. However, if we remove that tube now, we may completely wreck his chances for a complete recovery.” Her response was less than encouraging: “If you don’t pull that tube immediately, I’ll have your a** and your medical license.” How nice, she wants me for my mind too! I’ll spare you the details, but the story actually gets worse from here. We actually did extubate him about 10 hours later. His first words? “I want a cheeseburger!” His wife? An RN; this was her fifth marriage and her first four husbands all died. Can you say Black Widow? She filed a complaint with the med- ical board about me saving her husband. The reason I did not simply yank the patient’s tube when she shoved the DNR papers into my face was my belief that John Shufeldt is principal of Shufeldt Consulting and sits on the Editorial Board of JUCM. He may be contacted at Jshufeldt@Shufeldtconsulting.com. w w w. j u c m . c o m I could get sued if I killed him but no one would successfully sue me for saving him. Until recently, that belief held true. (More on that later.) Why does this matter in to an urgent care provider? Every day, 7,000 people–yes, 7,000—enroll in Medicare. Odds are great that with all of us “baby-boomers” hitting retirement age, some of us will decide to spice up your day and die in your urgent care center. So, listen up, because unless you have a pediatric urgent care practice, this is relevant to you. First, some background. A number of legal or quasi-legal documents fall under the term “advanced directive.” Gener- ally speaking, advanced directives are written to provide some direction regarding end-of-life care for a patient who may not be able to give medical consent or direction. They fall into the following categories: DNR Order Controversy exists surrounding the interpretation and exe- cution of do not resuscitate (DNR) orders. For example, does “DNR” mean do not treat up to the point the patient requires resuscitation? Or does it mean once the patient codes, everything stops? Some newer forms are more spe- cific, using check boxes to delineate the level of care accept- able to the patient. On the surface, that makes sense, but practically speaking, these forms are still challenging to use. If a person checks no intubation and suffers a short-term event (seizure) and needs to be intubated, do you let him/her die? If “no defibrillation” is checked, does that mean no AED in the case of sudden death? What if the pa- tient is still conscious and can make decisions and wants “everything done”? Do you quit when he/she becomes un- responsive? Because of all these common potential pitfalls, many institutions now use a “limitation of treatment form.” Take-home point: When faced with one of these situations, misery loves company. Get the family involved at the outset and document the decision made together. JUCM T h e J o u r n a l o f U r g e n t C a r e M e d i c i n e | Fe b r u a r y 2 0 1 3 31