Rob Orman steers a conversation on skillful ways to discuss code status, comfort care, intubation, and whether or not dying debilitated patients should go to the ICU.

For more of the amazing Rob Orman, check out the Stimulus Podcast.

Pearls:

* When family members have to make decisions for their loved ones, you can minimize their guilt by being clear what you think is medically inappropriate.

* In an ideal world, a DNR order would only affect what you do when a patient’s heart stops.

* When having a comfort care conversation, Scott uses the dichotomy of two goals:  curative care vs. dignity.

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Tips and tricks for having a conversation with a patient and/or their family about plan of care:

* If you don’t have time for the conversation, then reconsider having it.

* You still must make the initial foray to find out if they have preexisting wishes and if the pt's condition is dire, then you have no choice.

* Deferring the conversation to the ICU is an option.

* A slapdash conversation is worse than no conversation at all.

* Create a space where everyone feels comfortable.

* Provide chairs so people can be seated.

* Reassure the family that this is a discussion you have with EVERYBODY who enters the hospital system.

* Feel out the situation and try to understand one another. 

* Your job is to translate the medical realities in a way the family can understand.

* The family’s job is to translate their wishes, desires, and belief structure to us in a way we can understand.

* 5-10% of people are “vitalists”. They want anything done to bring back whatever form of life possible, no matter the predicted quality of that life. You’re not going to get what you feel is medically appropriate in those cases.

* Pick your own philosophy that fits with your strategy and psyche in medicine.

* Weingart has learned to be medically paternalistic and socially completely open.

* Inquire:  has the family had prior end-of-life conversations with their loved one?

* It makes everything easier if they have.

* If they haven’t, ask them to put themselves in the mindset of their loved one. By asking the family to be a channeler of what their loved one would want, you minimize their guilt.

* If you feel something is medically inappropriate, state it clearly.

* This transfers guilt to yourself.

* In many countries (ie. Canada, Australia, New Zealand), CPR is not offered if it’s felt to be medically unacceptable.

* Avoid being manipulative when describing CPR.

* Don’t tell them chest compressions might break ribs or cause organ damage.

* Instead, concentrate on the end game and what you could get out of CPR.

There are 3 tiers of care:  DNR (do not resuscitate), DNI (do not intubate), and comfort care.

* DNR

* In an ideal world, DNR would only apply when a patient’s heart is about to stop.

* While DNR is not supposed to affect the rest of the care we provide, it often does.

* Being DNR may have significant effects on the willingness of physicians to provide aggressive care,