Goals of Care
Preference Stability
In a retrospective cohort study of nonsurgical patients from the California patient discharge database from 2016 to 2018, the authors found that DNR reversals at the time of readmission are common (45.1% of patients readmitted within 30 d following a first DNR hospitalization experienced DNR reversal upon readmission) and patients readmitted to a different hospital versus the same hospital were at higher risk of DNR reversal (p < 0.001). They also found that patients readmitted to low versus high DNR rate hospitals were more likely to have DNR reversals, and patients readmitted to a different hospital and with DNR reversal had higher rates of mechanical ventilation and hospital death. They also observed a strong hospital effect associated with DNR reversal rates. It is unlikely that patients would choose a hospital based on DNR preferences, as hospital-level DNR practices are neither reported nor in the public domain. This raises the important issue of the effect of hospital characteristics. As the authors state, “the primary and most striking implication of this work is the possibility that DNR reversal is not patient driven…and leads to care inconsistent with patient goals.”
Surrogate Decision-makers
Paternalism vs SDM vs Menu
Consider how you (as someone without a great understanding in auto maintenance... or finance) would like your mechanic to interact with you. Menu of options = clearly problematic without sufficient information to
identifying a patient who is acutely dying
Three questions. Is this potentially survivable By anyone? would the outcome be acceptable? For this patient would the treatments be tolerable?
https://twitter.com/iwashyna/status/1311746137251024899?s=21
Resource allocation
Utilitarianism (e.g. distribution of resources to achieve the most good) is actually used in a minority of cases, while "Rule of Rescue" (attempting to save the life in front of you at all costs) is the method of reasoning in the ICU.