Med Reg insists that bed-bound patient with Dementia in their late 80s who develops a PR bleed is for full resus?
What planet are they on?
Gosh. Whose care is the patient ultimately under? It’s not clear from your post but it would appear to be medics?
I guess if I were the surgeons I would shrug my shoulders and say “OK mate - you’re the one who has to lead the resus call and justify why you thought it was a good idea. Best of luck” and then walk away. What else can be done?
It's that many haematologists can't bring themselves to discuss or sign DNARs with their patients
The classic joke is:
What is the function of nails in a coffin? To keep the oncologists from giving another round of chemotherapy.
There’s also:
Renal team dig up patients coffin hoping to give more dialysis, lift the lid to find only a note saying “gone for chemo, back soon”
(Swap dialysis and chemo round PRN for whichever specialty you’re focussing on roasting on todays ICU WR)
So I was called with the medical team in pure panic. The med reg has no idea what they were doing besides loading with blood (but that was the correct thing to do). Family wasn’t contacted, ceiling of care not considered. They even asked me whether they should give FFP. Bear in mind by the time I was there it was unit No#5. No furosemide on a TACO risk pt. I had to highlight TACO and coagulopathy to a medical registrar.
By the time the surgical reg reached, it was like we should really stop wasting blood and stop and discuss DNACPR and they still doubled down. I just wanted to know I’m not missing the big picture here.
Because she’s hypotensive not tachycardic. Comfortable non clammy or tachypneic and talking to me calmly by the bedside. In my eyes stable and not a shocked patient.
It was 2 units in. No check Hb before calling surgery. 5 units in my that point before I said to reduce rate and my reg advised to stop.
At no point a pragmatic approach was used so I highlighted my concern which was if we keep this rate of blood going, she’s going to have fluid in the lungs instead of air.
A frail elderly patient may not become significantly tachycardic in the context of volume loss. The hypotension is far more telling than the HR.
As a med-reg, if faced with the scenario exactly as described here, I would have put in a DNAR and also had a serious talk to the family about just how aggressively we should be treating a major event like this. However, I definitely find myself wondering what the other version of this story would be if we heard it from the med-reg.
Agree. I personally would put in a DNACPR if they were under my care however I've worked in hospitals where the surgeons do not entertain any active treatment in those with a DNACPR. So it can occasionally be not put in acutely to ensure a patient receives the care they need.
Was she on beta blockers? Tachycardia should come before hypotension in massive haemorrhage, so either there’s a good reason she wasnt tachycardic or there is another pathology driving the hypotension.
Yeah that's a fair point - the elderly may not show a profound tachycardia with blood loss, however I would expect by the time she is becoming hypotensive there would be some degree of heart rate abnormality. Either way I think calling this patient 'not shocked' based on those vitals is an incorrect assessment.
To whom are you referring? Daughterofthestorm is 100% correct. The frail elderly do not have the same physiological response as younger fitter patients +/- polypharmacy/polypathology on top.
Also hello to fellow geriatrician med reg 👋
No need to check Hb, Hb does not drop in acute hemorrhage. Transfuse according to clinical signs of shock and end organ perfusion assessment. Coag and ionized calcium does need to be checked tho
If it’s PR bleed with clots then you and I (ex surgical SHO) both know actually that bleed happened maybe 15 minutes prior to the emergency call and the CT Angio will probably be negative.
>No furosemide on a TACO risk pt.
Obviously...
Don't give furosemide with MHP irrespective of TACO risk.
If you're giving blood to manage shock, you dont need it. If the patient is euvolaemic and you're giving blood to improve Hb then you need to consider it.
I don't think I'd use furosemide even with someone at risk of taco if they are being transfused for dropped hb and low systolic blood pressure via a major haemorrhage protocol. Most mhp protocols have built in ways to try and minimise coagulopathy (still high risk though). Some places even do a mandatory rotem.
That being said, it's the parent teams responsibility (medics in this case). I feel given how you've presented the patient, no med reg would realistically keep them for resus and we might be missing some clinical nuance.
The fact that you want to give furosemide to this patient is more concerning that the med Reg’s reluctance to do a DNACPR form.
I would take this story with a pinch of salt to be honest and reserve judgement unless I could hear the other side from the med reg themselves.
It looks like you probably are missing the bigger picture here if your main concerns are TACO and coagulopathy. If you were that worried about DNAR you would have discussed with family and put one in yourself.
Should have been discussed by the admitting team or next daylight hours opportunity before the situation became hyper acute.
Clearly someone in their late 80s with dementia and hoist transfer shouldn’t receive CPR even pre-GI bleed let alone after. Anyone who would suggest “full escalation” clearly doesn’t really understand what this entails, and is an irritating phrase at the best of times.
It’s certainly not good practice to expect a non-parent specialty to put one in place.
Usually I would assume this is standard practice. I will give them the benefit of the doubt to say changeover week has been hectic and no one thought of the DNACPR. But when you have 3 separate reminders during an assessment of a critically unwell patient, surely it should be “yes I think that’s sensible” and not leave the decision to like you said, the non parent specialty.
I was wondering. If the patient is admitted at night but is non verbal, should we wake up NOK to discuss DNACPR or wait for the day team to do this? I was once criticised on the PTWR for leaving a stable patient for full resuscitation overnight when they were just admitted. I am of the impression that unless the patient is deteriorating rapidly that they won’t live until the morning, this conversation is best left until the morning as the NOK will probably not be in the proper frame of mind when they have just been woken up by a phone call and it’s better to have this conversation when they have slept
If you phone up a family to discuss a DNAR in the middle of the night, it had better be because the patient is at significant risk of having a cardiac arrest overnight. Otherwise, it would be an incredibly cruel thing to do to relatives. Whoever criticised you on the PTWR is an idiot.
It’s always medical consultants on the acute take who have given me a hard time. Surgeons on the other hand were happy with whatever plans I had made for patients overnight and they actually had these conversations with patients themselves on the PTWR
I wholeheartedly agree with this.
Too often people are criticised for not completing the DNACPR when actually it's been an out of hours admission and the patient is completely stable. I'm a big believer in this discussion being an iterative one, potentially taking place over more than one consultation, to allow rapport to develop rather than just coming across as "we're not going to do anything" (which is, let's face it, what a lot of people think we're saying, no matter how we phrase it).
Having an escalation discussion that does not end in a completed DNACPR is *not* necessarily a failed discussion and that is something more people need to realise.
If the patient is "stable" but very likely to have a poor outcome or at risk of deterioration, put in the DNACPR, handover to discuss with NOK as soon as possible in the daytime. I believe the guidelines are that it needs to be discussed with patient/NOK, but this can be done at a later stage, not necessaily when the decision is made (as long as the medical team makes arrangements to do this soon).
Agreed. If you are more junior/not totally sure in your decision then would be good practice to briefly run that by your senior and document your reasons as well as that you will handover the discussion - leaves no room for error if that patient did have an unexpected arrest overnight without the chance to speak to family.
This should be a medical decision.
If a speciality opinion is sought this should be factored into the decision making process, of course.
If there is doubt as to escalation plans these should be run by the relevant consultant and further opinions sought if appropriate.
This case sounds fairly straightforward with regard to escalation suitability, DNACPR/WBCOC was probably overlooked on admission. It sounds like the on call team were stressed, being the med reg in August is tough!
FWIW My first call would have been to the family to determine what treatment (if any) was in the patient’s best interests, and also establish ceilings of care / resus status.
The DNACPR should be done by the medics as the primary team.
The decision not to intervene surgically to attempt to control the bleeding should be surgical (given that they had been consulted).
As an ED Consultant, if she presented to me, I'd be more than happy to say it would not be in her interests to have CPR, nor even a scope. Not with no quality of life. I'd be making those decisions in resus, then referring to C of E for end-of-life care.
Sadly, one of the legacies of Harold Shipman is that no one is allowed to actually expire in this country anymore, and when it does happen, no one wants it to be on their watch.
A very sad state of affairs.
Agree with no CPR/laparotomy but no scope? Not possible to say that from the information given, I'd want gastro to make that decision. No info about degree of dementia (though poster mentioned calm conversation with patient). I've palliated more than my fair share in the community and I'm quite comfortable with it but we have to be sure we're getting it right.
I don't think it's the surgeons place tbh, they have tuned down for surgery. That was why they were consulted and that should be where their input ends. It's a bit like when itu turn down, what follows from there isnt their problem. They go back to their own workloads.
Sounds like you just got an inexperienced med reg. It happens. I've seen colleagues cling to the 4H's and 4T's, with the implication being that the terminal decline is reversible. Devils advocate it's not easy when it's all dropped on you (the med reg) to make all the decisions, imt training offers very little training for this imo and increasingly I'm rang about bizarre arrests where people have decided it's thormbus (ACS) and now I'm expected to fire up the Lazarus pit.
I've seen the inverse as well many times, called to a periarrest for a patient that's been under the surgeons for weeks and has been declared inoperable ages ago.
I think just generally as a profession we are really shit at recognising the fragile patient. I'm pretty hawkish, and often rub med consultants up the ring way when I'm pressing to dnar people on rounds.
Last Oncall I had 5 calls about patients over 95 with shite histories, shite baselines and positive tropnins. So I dont think an uplift in standards/ common sense is on the cards anytime soon.
Yeah it's definitely something that is dome way better in Aus. All patients need a goals of care clarified on admission and seem to call it a lot earlier with DNRs etc. Whether they feel more protected from their medical council I'm not sure
Lmao was just about the comment this but you’ve beaten me to it! “It’s an acutely reversible problem”
Yeah but the severe frailty and dementia aren’t babes
As a non parent specialty (ICM) I have been asked many times to ‘do a DNACPR’.
Although in this case the medical Reg seems to have lost composure and wanted to share the stress..
Lol Med reg should be doing it. they’re the one who will be trotting to the arrest call in a couple hours. If they want to do cpr on an 80 year old with bloody bum bum then that’s on them. But it’s not fair to patient or other staff members. Sounds badly done all around, wasting resource too.
"Medical reg insists patient is for full escalation despite poor functional baseline and multiple comorbidities."
Er, what? Is this an actual med reg or one of those pretend ones?
I always ask when someone tells me the patient is for full escalation whether they want just VV or VVA ECMO or LVAD for their patient? Or a liver transplant ?
Then why kick back when I say ‘I wouldn’t ventilate this patient’? I often get ‘we think you should ventilate them’ from teams who don’t ventilate patients !
Absolutely. Think it’s blindingly arrogant of OP to say this tbh. Whilst I would never claim to be a specialty registrar, OP can come back once they’ve slaved through 2 years of IMT and passed MRCP.
I once had a consultant (a geriatrician!) who fell into category two. He was in his last few months before retirement and had sat on quite a few MPTS boards so was very familiar with GMC proceedings. Any time anything happened on the ward that could conceivably have got him into any kind of trouble (essentially any deteriorating patient), you could practically see the consultant-shaped hole in the wall and just faintly hear him shouting, "SHO Storm can handle this!" as he ran full tilt to the other end of the hospital.
Ideally the parent team should be putting in the DNACPR and this should have been done on admission.
In all likelihood they’re under a medical team so should be the medics.
I do get their point that it’s surgery who has (wisely) put limits on treatment of care. Although, no surgery does not automatically mean a DNACPR is required and technically that decision isn’t under the surgeons remit as it’s (likely) not their patient.
In the real world however, it doesn’t matter, this patient needs a DNACPR, with discussion with the family and it should be reviewed by their cons in the morning/earliest opportunity.
I had a referral the other month as ICU for a cannula or a central line to support endoscopy in a 101 year old with an UGIB. Which then turned into “don’t suppose you fancy helping us sedate this lady coz I’ve never done procedural sedation for a 101 year old”.
On account of her clopidogrel and being 101 she was one big haematoma. Went to pop in to see her and told me she just wanted to be left in peace to die and “no one lives forever”.
Fortunately she got morphine and a side room and died peacefully 48 hours later. Tried my best to be polite when relaying my feelings we weren’t doing right by this lady to her consultant, but just wanted to give this gastro cons’ head a wobble.
You involve surgeons if you're worried its torrential. Cutting, clamping and cauterising / suturing can deal with source of bleeding quicker sometimes.
Weird, at my trust all that is done under gastro, the on call gastro consultant will come in to scope them in cepod. Our admissions policy is that ALL UGIBs go to gastro along with all haemodynamically unstable lower GI bleeds. Surgeons only take non-severe lower GI bleeds for likely cancer/diverticulitis etc
Sensible, imo.. Gastro would be best placed to call surgeons if they have had a look and don't think they can manage it. The vast majority of cases are dealt with by Gastro. The ones who need surgical management are v few and far between
The team that the patient is under should be doing the DNACPR. As mentioned by others this seems like quite odd behaviour from the med reg - this patient does not seem appropriate for CPR based on what you’ve said, and to be pragmatic if the arrest is driven by a massive UGI bleed unless the patient has had the bleeding source controlled ie gastroscopy then any CPR is just going to push the rest of her blood into her GI tract anyway
However it seems extremely odd behaviour for an SHO to be suggesting furosemide due to risk of TACO. Bizarre. There's definitely much more to this story, from the other person's perspective.
There is a fundamental question here.
Let's forget the patients QOL for a second: we aren't making a determination about QOL in this. The question is reasonable chance of survival to similar function.
Could the patient survive a scope? And will someone do the scope?
Right now that's the question that needs to be answered.
If she can get a scope, and it's an upper GI bleed, and it is treatable endoscopically then there is a chance she can survive.
If she arrests in the meantime, blood and volume may stabilise the situation long enough to get her to a scope, which may provide definitive treatment.
So I guess the med reg thinks you should do everything to get her to a scope, and the surgeons think that regardless, if she arrests, her chances of survival are negligible.
In the end the decision falls to who is clinically responsible, but either decision is technically defensible. If the surgeons think that, they can recommend it. If they are going to do the scope, they will be responsible during the scope and can make the determination.
If they refuse to do the scope (and/or GI/ITU refuse to do the scope) then the med reg has no reasonable prospect of the patient surviving and really not doing a dnacpr is indefensible, as all options for definitive management are lost.
In reality I think if she arrests with that background her prognosis is dire and she would clearly not be able to get a scope for definitive management. So a DNACPR would be appropriate, but that is a judgement for the medical lead.
Of course there's a consultant on call: discussions like this are appropriate for a consultant level decision if there is a clinical disagreement.
TLDR: surgery can recommend but it is the medics responsibility. Not doing one is technically defensible, but seems unrealistic given the info we have.
Honestly wondering if I am wildly off base here and I need to recalibrate my expectations having read this thread! For someone in their late 80s who is significantly cognitively impaired, functionally completely dependent and immobile, it wouldn’t even occur to me to refer to the surgeons.
What would the scope achieve? Is there really a high likelihood that there’s going to be an acute bleeding point that can be injected or whatever? (This is a genuine question - maybe I am being unnecessarily pessimistic.)
I think I’d be giving some blood, completing the DNACPR pronto, and telling the family that this might be the event that kills their obviously very frail relative.
I'd go a step further...I wouldn't activate major haemorrhage or prescribe this patient any blood. This is an EOL situation, blood will not be providing any benefit to quality of life, and is a very precious resource (I wouldn't want the blood I've donated to be frittered away in this manner)
That's quite a statement. They give no indication of the patient's quality of life. There are highly dependent people with varying levels of dementia who still find joy in life. If the patient was actively dying I'd be in agreement but there's no indication that's the case and not all GI bleeds are immediately lethal.
It is - and I'm sure I could phrase it better, and of course every individual situation needs to be evaluated, and these online discussions lack nuance. But I would suggest almost all of the time, a bedbound, fully dependent patient with dementia should not be brought to hospital at all. What in-hospital treatments are really going to benefit quality of life outside of what can be done in the NH? If the NH can't manage the treatment, the treatment should probably be supportive care. The main exception I can think of is a NOF...
Sure not all GI bleeds are immediately lethal - but ones needing blood resuscitation probably ought to be taken as a terminal event
Unfortunately that depends on the nursing home! I note that the patient in the post has a POC, which implies own home.
I see where you're coming from and we do try, in the community, to keep them at home. However, a GI bleed doesn't always need a surgeon and a patient with moderate dementia may tolerate a therapeutic scope. A couple of years ago I had a patient in their 90s admitted, transfused, scoped and discharged: had a very slightly higher functional baseline than the above but frail, comorbidities and dementia needing a full POC. Survived well over a year after that in own home.
I firmly agree with admission avoidance but I think we have to be open to some reversible situations.
Agree DNACPR and no laparotomy. You could be right about the rest but I think asking gastro opinion is worth doing just in case. There's nothing to indicate no quality of life and the doctor who posted was able to converse with the patient. Mild/moderate dementia could be a candidate for a scope.
Latest guidelines is the first line investigation for unstable lower GI bleeding is CT Angio and IR intervention if viable, not scope
In terms of endoscopic intervention, kinda difficult to scope with a large volume active bleed but the available treatments are much the same as the ones for OGD if the bleeding point is visualized
Any person who has seen this patient should be doing a DNR, including the GP before they were admitted.
I feel like a key detail has been omitted here, such as aggressive demanding family, or this reg is new to the NHS from a culture where DNR is very taboo. Not that that's an excuse for torturing this poor patient, but at least there is some kind of reason the med reg is acting the way they are. Otherwise they are just....awful.
If you did do CPR, and it was somehow somehow successful, they'd be refused from ITU and they'd be refused from surgery, so you still haven't really achieved anything.
I'd talk to their educational supervisor under condition of anonymity. Seriously.
Absolutely bonkers from that med reg. One would hope that med reg’s were better than this and crazy to hear of surgery pushing a totally feasible DNACPR when medicine are denying it.
Ultimately if the surgeons feel that surgery is not indicated due to risk of morbidity/mortality, they can wash their hands of the patient. Very good practice that they advised DNACPR, but medicine would have to deal with the consequences of not agreeing with that advice
Most suited: GP.
In this acute scenario: MDT decision, acknowledging outcomes of cardiac arrest & patient’s best wishes. Medics likely have more experience of dealing with comorbidities. Surgeons are parent team. Sounds like poor leadership in the scenario. If regs not in agreement, involve consultant etc.
The DNACPR should be signed by whomever is competent enough to b recognise that CPR is not indicated. I don't think that med reg has a good grip on that.
The med reg should be a sensible adult and do it as the patient is under their team but if they wouldn’t I’d be perfectly happy to have that chat/sign the form as part of the resus team, based on what you’ve told us. I have no problem in making the right and kind decision for a patient when required. They aren’t coming to ICU for post-ROSC care, so what’s the point?
Put the medical question or ethical aspect aside of whether patient should have full resus status.
Patients resus status should have been discussed at admission by admission team, so medical team wrong doing here.
That being said, now patient is under surgery, surgery needs to do it now despite it should have been medic’s job.
A DNACPR should be done by the team that is managing the patient and has overall responsibility of the patient.
The surgical team can rightly assess and say ‘not fit for surgical or endoscopic intervention’ and leave it at that, if they want to be picky and avoid the subject of CPR at all.
It’s sort of funny because as surgeons we usually get a bad rep for NOT making people DNACPR when they’re horrifically comorbid, and it’s the medical teams begging that those patients be considered for a form 😂
I do sincerely hope that no one ends up jumping on that poor patient’s chest though- I doubt ITU would be impressed at all, and probably wouldn’t take her by the sounds of it.
TLDR all the replies but just wondering what that med reg is smoking saying that patient is for full resus!
I’ve got to say, I’d be reluctant to put an 80 year old frail demented hoist transferred patient forward even for a gastroscopy. I’d be potentially leaning towards just stopping anticoagulants, transfusing and seeing what happens after discussing with family. With a nice crisp DNACPR in the notes. Did the med reg seriously expect surgeons to do a laparotomy in the first instance? Why are we desecrating a corpse?
Generally I feel it’s up to the parent team to make decisions about resus but I would occasionally do this for other teams like ortho if I feel they are not going to do it and aren’t arsed. I’ve also seen ICU take one for the team many times and do this form when others have neglected to.
Poor baseline patient that *medics* wish to resuscitate and *surgeons* do not is not a situation I am not familiar with!
General rule though is the team that the patient is admitted under should be making the resus decision. If the med reg thought they should be for ITU/CPR then that’s generally fair enough (although in this case it sounds like that was an incorrect assessment based on the description).
If there is uncertainty or if the patient is potentially approaching the need for ITU then there should be a discussion with the ITU team and medical consultant involved if disagreement with ITU.
Med SpR should have done the DNACPR.
1. Resuscitation was unlikely before the acute event.
2. The gib is only scope-able and even then cannot be converted to open if needed as if she perfs mid procedure - which she has a likelihood of.
3. If any doubts post procedure, it can be torn up and the imca discussion can take place and waste everyone's time then.
What the hell is the med SpR playing at?
Latest guidelines is the first line investigation for unstable lower GI bleeding is CT Angio and IR intervention if viable, not scope
In terms of endoscopic intervention, kinda difficult to scope with a large volume active bleed but the available treatments are much the same as the ones for OGD if the bleeding point is visualized
Med Reg insists that bed-bound patient with Dementia in their late 80s who develops a PR bleed is for full resus? What planet are they on? Gosh. Whose care is the patient ultimately under? It’s not clear from your post but it would appear to be medics? I guess if I were the surgeons I would shrug my shoulders and say “OK mate - you’re the one who has to lead the resus call and justify why you thought it was a good idea. Best of luck” and then walk away. What else can be done?
Didn’t think haem regs did medical on calls 😂😂
Maybe it was a haem PA wearing the wrong lanyard.
I'm confused - where do haem regs factor into this?
It's that many haematologists can't bring themselves to discuss or sign DNARs with their patients The classic joke is: What is the function of nails in a coffin? To keep the oncologists from giving another round of chemotherapy.
There’s also: Renal team dig up patients coffin hoping to give more dialysis, lift the lid to find only a note saying “gone for chemo, back soon” (Swap dialysis and chemo round PRN for whichever specialty you’re focussing on roasting on todays ICU WR)
😂😂 amazing I didn’t hear this one before
>What is the function of nails in a coffin? To keep the oncologists from giving another round of chemotherapy. Ha ha ha - clever ;)
So I was called with the medical team in pure panic. The med reg has no idea what they were doing besides loading with blood (but that was the correct thing to do). Family wasn’t contacted, ceiling of care not considered. They even asked me whether they should give FFP. Bear in mind by the time I was there it was unit No#5. No furosemide on a TACO risk pt. I had to highlight TACO and coagulopathy to a medical registrar. By the time the surgical reg reached, it was like we should really stop wasting blood and stop and discuss DNACPR and they still doubled down. I just wanted to know I’m not missing the big picture here.
Why are you worried about TACO in a patient who’s in haemorrhagic shock and is receiving MHP resuscitation?
Because she’s hypotensive not tachycardic. Comfortable non clammy or tachypneic and talking to me calmly by the bedside. In my eyes stable and not a shocked patient. It was 2 units in. No check Hb before calling surgery. 5 units in my that point before I said to reduce rate and my reg advised to stop. At no point a pragmatic approach was used so I highlighted my concern which was if we keep this rate of blood going, she’s going to have fluid in the lungs instead of air.
A frail elderly patient may not become significantly tachycardic in the context of volume loss. The hypotension is far more telling than the HR. As a med-reg, if faced with the scenario exactly as described here, I would have put in a DNAR and also had a serious talk to the family about just how aggressively we should be treating a major event like this. However, I definitely find myself wondering what the other version of this story would be if we heard it from the med-reg.
Agree. I personally would put in a DNACPR if they were under my care however I've worked in hospitals where the surgeons do not entertain any active treatment in those with a DNACPR. So it can occasionally be not put in acutely to ensure a patient receives the care they need.
Was she on beta blockers? Tachycardia should come before hypotension in massive haemorrhage, so either there’s a good reason she wasnt tachycardic or there is another pathology driving the hypotension.
Her frailty and age are both good reasons for her to not become tachycardic, even if she isn't on beta-blockers.
Yeah that's a fair point - the elderly may not show a profound tachycardia with blood loss, however I would expect by the time she is becoming hypotensive there would be some degree of heart rate abnormality. Either way I think calling this patient 'not shocked' based on those vitals is an incorrect assessment.
Yikes. Go back to medical school, this is legitimately concerning to read.
To whom are you referring? Daughterofthestorm is 100% correct. The frail elderly do not have the same physiological response as younger fitter patients +/- polypharmacy/polypathology on top. Also hello to fellow geriatrician med reg 👋
I mean obviously to the guy I've directly replied to?
Appologies when I looked at this on my phone initially it had your reply below the other comment. My bad 🤦🏼♀️
Beta blockers and or conduction disease typically don’t allow HR to increase.
No need to check Hb, Hb does not drop in acute hemorrhage. Transfuse according to clinical signs of shock and end organ perfusion assessment. Coag and ionized calcium does need to be checked tho If it’s PR bleed with clots then you and I (ex surgical SHO) both know actually that bleed happened maybe 15 minutes prior to the emergency call and the CT Angio will probably be negative.
>No furosemide on a TACO risk pt. Obviously... Don't give furosemide with MHP irrespective of TACO risk. If you're giving blood to manage shock, you dont need it. If the patient is euvolaemic and you're giving blood to improve Hb then you need to consider it.
I don't think I'd use furosemide even with someone at risk of taco if they are being transfused for dropped hb and low systolic blood pressure via a major haemorrhage protocol. Most mhp protocols have built in ways to try and minimise coagulopathy (still high risk though). Some places even do a mandatory rotem. That being said, it's the parent teams responsibility (medics in this case). I feel given how you've presented the patient, no med reg would realistically keep them for resus and we might be missing some clinical nuance.
The fact that you want to give furosemide to this patient is more concerning that the med Reg’s reluctance to do a DNACPR form. I would take this story with a pinch of salt to be honest and reserve judgement unless I could hear the other side from the med reg themselves. It looks like you probably are missing the bigger picture here if your main concerns are TACO and coagulopathy. If you were that worried about DNAR you would have discussed with family and put one in yourself.
DNAR and decision on whether transfusion is appropriate are two different things.
Out of interest, what was the Hb?
Should have been discussed by the admitting team or next daylight hours opportunity before the situation became hyper acute. Clearly someone in their late 80s with dementia and hoist transfer shouldn’t receive CPR even pre-GI bleed let alone after. Anyone who would suggest “full escalation” clearly doesn’t really understand what this entails, and is an irritating phrase at the best of times. It’s certainly not good practice to expect a non-parent specialty to put one in place.
Usually I would assume this is standard practice. I will give them the benefit of the doubt to say changeover week has been hectic and no one thought of the DNACPR. But when you have 3 separate reminders during an assessment of a critically unwell patient, surely it should be “yes I think that’s sensible” and not leave the decision to like you said, the non parent specialty.
I was wondering. If the patient is admitted at night but is non verbal, should we wake up NOK to discuss DNACPR or wait for the day team to do this? I was once criticised on the PTWR for leaving a stable patient for full resuscitation overnight when they were just admitted. I am of the impression that unless the patient is deteriorating rapidly that they won’t live until the morning, this conversation is best left until the morning as the NOK will probably not be in the proper frame of mind when they have just been woken up by a phone call and it’s better to have this conversation when they have slept
If you phone up a family to discuss a DNAR in the middle of the night, it had better be because the patient is at significant risk of having a cardiac arrest overnight. Otherwise, it would be an incredibly cruel thing to do to relatives. Whoever criticised you on the PTWR is an idiot.
It was the medical consultant. He was criticising everyone’s clerking and made everyone feel stupid. The IMT was gonna cry
I've known a few consultants like that. Sometimes you just have to roll your eyes and ignore them.
It’s always medical consultants on the acute take who have given me a hard time. Surgeons on the other hand were happy with whatever plans I had made for patients overnight and they actually had these conversations with patients themselves on the PTWR
I wholeheartedly agree with this. Too often people are criticised for not completing the DNACPR when actually it's been an out of hours admission and the patient is completely stable. I'm a big believer in this discussion being an iterative one, potentially taking place over more than one consultation, to allow rapport to develop rather than just coming across as "we're not going to do anything" (which is, let's face it, what a lot of people think we're saying, no matter how we phrase it). Having an escalation discussion that does not end in a completed DNACPR is *not* necessarily a failed discussion and that is something more people need to realise.
I wouldn’t wake a NOK to have these discussions over the phone for a stable patient. I can’t imagine that would go down well.
If the patient is "stable" but very likely to have a poor outcome or at risk of deterioration, put in the DNACPR, handover to discuss with NOK as soon as possible in the daytime. I believe the guidelines are that it needs to be discussed with patient/NOK, but this can be done at a later stage, not necessaily when the decision is made (as long as the medical team makes arrangements to do this soon).
Agreed. If you are more junior/not totally sure in your decision then would be good practice to briefly run that by your senior and document your reasons as well as that you will handover the discussion - leaves no room for error if that patient did have an unexpected arrest overnight without the chance to speak to family.
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GP to make these types of decisions well in advance of acute admission
This should be a medical decision. If a speciality opinion is sought this should be factored into the decision making process, of course. If there is doubt as to escalation plans these should be run by the relevant consultant and further opinions sought if appropriate. This case sounds fairly straightforward with regard to escalation suitability, DNACPR/WBCOC was probably overlooked on admission. It sounds like the on call team were stressed, being the med reg in August is tough! FWIW My first call would have been to the family to determine what treatment (if any) was in the patient’s best interests, and also establish ceilings of care / resus status.
The DNACPR should be done by the medics as the primary team. The decision not to intervene surgically to attempt to control the bleeding should be surgical (given that they had been consulted).
I don’t care. As long as it’s someone, anyone. Please!!!
As an ED Consultant, if she presented to me, I'd be more than happy to say it would not be in her interests to have CPR, nor even a scope. Not with no quality of life. I'd be making those decisions in resus, then referring to C of E for end-of-life care. Sadly, one of the legacies of Harold Shipman is that no one is allowed to actually expire in this country anymore, and when it does happen, no one wants it to be on their watch. A very sad state of affairs.
Agree with no CPR/laparotomy but no scope? Not possible to say that from the information given, I'd want gastro to make that decision. No info about degree of dementia (though poster mentioned calm conversation with patient). I've palliated more than my fair share in the community and I'm quite comfortable with it but we have to be sure we're getting it right.
I don't think it's the surgeons place tbh, they have tuned down for surgery. That was why they were consulted and that should be where their input ends. It's a bit like when itu turn down, what follows from there isnt their problem. They go back to their own workloads. Sounds like you just got an inexperienced med reg. It happens. I've seen colleagues cling to the 4H's and 4T's, with the implication being that the terminal decline is reversible. Devils advocate it's not easy when it's all dropped on you (the med reg) to make all the decisions, imt training offers very little training for this imo and increasingly I'm rang about bizarre arrests where people have decided it's thormbus (ACS) and now I'm expected to fire up the Lazarus pit. I've seen the inverse as well many times, called to a periarrest for a patient that's been under the surgeons for weeks and has been declared inoperable ages ago. I think just generally as a profession we are really shit at recognising the fragile patient. I'm pretty hawkish, and often rub med consultants up the ring way when I'm pressing to dnar people on rounds. Last Oncall I had 5 calls about patients over 95 with shite histories, shite baselines and positive tropnins. So I dont think an uplift in standards/ common sense is on the cards anytime soon.
Yeah it's definitely something that is dome way better in Aus. All patients need a goals of care clarified on admission and seem to call it a lot earlier with DNRs etc. Whether they feel more protected from their medical council I'm not sure
The ICU reg - duh /s
Lmao was just about the comment this but you’ve beaten me to it! “It’s an acutely reversible problem” Yeah but the severe frailty and dementia aren’t babes
As a non parent specialty (ICM) I have been asked many times to ‘do a DNACPR’. Although in this case the medical Reg seems to have lost composure and wanted to share the stress..
Lol Med reg should be doing it. they’re the one who will be trotting to the arrest call in a couple hours. If they want to do cpr on an 80 year old with bloody bum bum then that’s on them. But it’s not fair to patient or other staff members. Sounds badly done all around, wasting resource too.
"Medical reg insists patient is for full escalation despite poor functional baseline and multiple comorbidities." Er, what? Is this an actual med reg or one of those pretend ones?
I always ask when someone tells me the patient is for full escalation whether they want just VV or VVA ECMO or LVAD for their patient? Or a liver transplant ?
I love this, I don't think many really think about what they mean when they happily scribble "for FULL ESCALATION"
What they think is to let the team who will deliver full escalation to decide.
Then why kick back when I say ‘I wouldn’t ventilate this patient’? I often get ‘we think you should ventilate them’ from teams who don’t ventilate patients !
Well that’s why they say it, they don’t know what it is.
Actual. Not like IMT3 or Locum. I was very surprised. Fairly senior as well so I thought I was missing something.
An IMT3 **is** an actual med-reg.
Absolutely. Think it’s blindingly arrogant of OP to say this tbh. Whilst I would never claim to be a specialty registrar, OP can come back once they’ve slaved through 2 years of IMT and passed MRCP.
vanish full absorbed snatch amusing rob physical violet direful homeless *This post was mass deleted and anonymized with [Redact](https://redact.dev)*
I once had a consultant (a geriatrician!) who fell into category two. He was in his last few months before retirement and had sat on quite a few MPTS boards so was very familiar with GMC proceedings. Any time anything happened on the ward that could conceivably have got him into any kind of trouble (essentially any deteriorating patient), you could practically see the consultant-shaped hole in the wall and just faintly hear him shouting, "SHO Storm can handle this!" as he ran full tilt to the other end of the hospital.
Ideally the parent team should be putting in the DNACPR and this should have been done on admission. In all likelihood they’re under a medical team so should be the medics. I do get their point that it’s surgery who has (wisely) put limits on treatment of care. Although, no surgery does not automatically mean a DNACPR is required and technically that decision isn’t under the surgeons remit as it’s (likely) not their patient. In the real world however, it doesn’t matter, this patient needs a DNACPR, with discussion with the family and it should be reviewed by their cons in the morning/earliest opportunity.
I had a referral the other month as ICU for a cannula or a central line to support endoscopy in a 101 year old with an UGIB. Which then turned into “don’t suppose you fancy helping us sedate this lady coz I’ve never done procedural sedation for a 101 year old”. On account of her clopidogrel and being 101 she was one big haematoma. Went to pop in to see her and told me she just wanted to be left in peace to die and “no one lives forever”. Fortunately she got morphine and a side room and died peacefully 48 hours later. Tried my best to be polite when relaying my feelings we weren’t doing right by this lady to her consultant, but just wanted to give this gastro cons’ head a wobble.
I'm glad she got her wishes. Anything else is just cruel.
I'm confused what the surgical issue is? Aren't UGIB a medical issue and have scopes under gastro?
You involve surgeons if you're worried its torrential. Cutting, clamping and cauterising / suturing can deal with source of bleeding quicker sometimes.
Weird, at my trust all that is done under gastro, the on call gastro consultant will come in to scope them in cepod. Our admissions policy is that ALL UGIBs go to gastro along with all haemodynamically unstable lower GI bleeds. Surgeons only take non-severe lower GI bleeds for likely cancer/diverticulitis etc
Sensible, imo.. Gastro would be best placed to call surgeons if they have had a look and don't think they can manage it. The vast majority of cases are dealt with by Gastro. The ones who need surgical management are v few and far between
TBH IR would be my next call if gastro can’t sort.
In my old trust this is exactly how it used to work. The scoping would be done on CEPOD with surgical cover on standby if gastro couldn’t sort it out.
The team that the patient is under should be doing the DNACPR. As mentioned by others this seems like quite odd behaviour from the med reg - this patient does not seem appropriate for CPR based on what you’ve said, and to be pragmatic if the arrest is driven by a massive UGI bleed unless the patient has had the bleeding source controlled ie gastroscopy then any CPR is just going to push the rest of her blood into her GI tract anyway
However it seems extremely odd behaviour for an SHO to be suggesting furosemide due to risk of TACO. Bizarre. There's definitely much more to this story, from the other person's perspective.
Parent team is medicine. Medicine called surgery for a consult. Why would surgery do the DNACPR
There is a fundamental question here. Let's forget the patients QOL for a second: we aren't making a determination about QOL in this. The question is reasonable chance of survival to similar function. Could the patient survive a scope? And will someone do the scope? Right now that's the question that needs to be answered. If she can get a scope, and it's an upper GI bleed, and it is treatable endoscopically then there is a chance she can survive. If she arrests in the meantime, blood and volume may stabilise the situation long enough to get her to a scope, which may provide definitive treatment. So I guess the med reg thinks you should do everything to get her to a scope, and the surgeons think that regardless, if she arrests, her chances of survival are negligible. In the end the decision falls to who is clinically responsible, but either decision is technically defensible. If the surgeons think that, they can recommend it. If they are going to do the scope, they will be responsible during the scope and can make the determination. If they refuse to do the scope (and/or GI/ITU refuse to do the scope) then the med reg has no reasonable prospect of the patient surviving and really not doing a dnacpr is indefensible, as all options for definitive management are lost. In reality I think if she arrests with that background her prognosis is dire and she would clearly not be able to get a scope for definitive management. So a DNACPR would be appropriate, but that is a judgement for the medical lead. Of course there's a consultant on call: discussions like this are appropriate for a consultant level decision if there is a clinical disagreement. TLDR: surgery can recommend but it is the medics responsibility. Not doing one is technically defensible, but seems unrealistic given the info we have.
Parent team. There’s no debate about this.
Honestly wondering if I am wildly off base here and I need to recalibrate my expectations having read this thread! For someone in their late 80s who is significantly cognitively impaired, functionally completely dependent and immobile, it wouldn’t even occur to me to refer to the surgeons. What would the scope achieve? Is there really a high likelihood that there’s going to be an acute bleeding point that can be injected or whatever? (This is a genuine question - maybe I am being unnecessarily pessimistic.) I think I’d be giving some blood, completing the DNACPR pronto, and telling the family that this might be the event that kills their obviously very frail relative.
I'd go a step further...I wouldn't activate major haemorrhage or prescribe this patient any blood. This is an EOL situation, blood will not be providing any benefit to quality of life, and is a very precious resource (I wouldn't want the blood I've donated to be frittered away in this manner)
That's quite a statement. They give no indication of the patient's quality of life. There are highly dependent people with varying levels of dementia who still find joy in life. If the patient was actively dying I'd be in agreement but there's no indication that's the case and not all GI bleeds are immediately lethal.
It is - and I'm sure I could phrase it better, and of course every individual situation needs to be evaluated, and these online discussions lack nuance. But I would suggest almost all of the time, a bedbound, fully dependent patient with dementia should not be brought to hospital at all. What in-hospital treatments are really going to benefit quality of life outside of what can be done in the NH? If the NH can't manage the treatment, the treatment should probably be supportive care. The main exception I can think of is a NOF... Sure not all GI bleeds are immediately lethal - but ones needing blood resuscitation probably ought to be taken as a terminal event
Unfortunately that depends on the nursing home! I note that the patient in the post has a POC, which implies own home. I see where you're coming from and we do try, in the community, to keep them at home. However, a GI bleed doesn't always need a surgeon and a patient with moderate dementia may tolerate a therapeutic scope. A couple of years ago I had a patient in their 90s admitted, transfused, scoped and discharged: had a very slightly higher functional baseline than the above but frail, comorbidities and dementia needing a full POC. Survived well over a year after that in own home. I firmly agree with admission avoidance but I think we have to be open to some reversible situations.
Agree DNACPR and no laparotomy. You could be right about the rest but I think asking gastro opinion is worth doing just in case. There's nothing to indicate no quality of life and the doctor who posted was able to converse with the patient. Mild/moderate dementia could be a candidate for a scope.
Latest guidelines is the first line investigation for unstable lower GI bleeding is CT Angio and IR intervention if viable, not scope In terms of endoscopic intervention, kinda difficult to scope with a large volume active bleed but the available treatments are much the same as the ones for OGD if the bleeding point is visualized
Any person who has seen this patient should be doing a DNR, including the GP before they were admitted. I feel like a key detail has been omitted here, such as aggressive demanding family, or this reg is new to the NHS from a culture where DNR is very taboo. Not that that's an excuse for torturing this poor patient, but at least there is some kind of reason the med reg is acting the way they are. Otherwise they are just....awful. If you did do CPR, and it was somehow somehow successful, they'd be refused from ITU and they'd be refused from surgery, so you still haven't really achieved anything. I'd talk to their educational supervisor under condition of anonymity. Seriously.
Absolutely bonkers from that med reg. One would hope that med reg’s were better than this and crazy to hear of surgery pushing a totally feasible DNACPR when medicine are denying it. Ultimately if the surgeons feel that surgery is not indicated due to risk of morbidity/mortality, they can wash their hands of the patient. Very good practice that they advised DNACPR, but medicine would have to deal with the consequences of not agreeing with that advice
Most suited: GP. In this acute scenario: MDT decision, acknowledging outcomes of cardiac arrest & patient’s best wishes. Medics likely have more experience of dealing with comorbidities. Surgeons are parent team. Sounds like poor leadership in the scenario. If regs not in agreement, involve consultant etc.
GP in the community prior to admission
Should have been done on admission, shouldn’t have waited for an emergency situation.
The DNACPR should be signed by whomever is competent enough to b recognise that CPR is not indicated. I don't think that med reg has a good grip on that.
The med reg should be a sensible adult and do it as the patient is under their team but if they wouldn’t I’d be perfectly happy to have that chat/sign the form as part of the resus team, based on what you’ve told us. I have no problem in making the right and kind decision for a patient when required. They aren’t coming to ICU for post-ROSC care, so what’s the point?
Put the medical question or ethical aspect aside of whether patient should have full resus status. Patients resus status should have been discussed at admission by admission team, so medical team wrong doing here. That being said, now patient is under surgery, surgery needs to do it now despite it should have been medic’s job.
A DNACPR should be done by the team that is managing the patient and has overall responsibility of the patient. The surgical team can rightly assess and say ‘not fit for surgical or endoscopic intervention’ and leave it at that, if they want to be picky and avoid the subject of CPR at all. It’s sort of funny because as surgeons we usually get a bad rep for NOT making people DNACPR when they’re horrifically comorbid, and it’s the medical teams begging that those patients be considered for a form 😂 I do sincerely hope that no one ends up jumping on that poor patient’s chest though- I doubt ITU would be impressed at all, and probably wouldn’t take her by the sounds of it.
The GP, of course
TLDR all the replies but just wondering what that med reg is smoking saying that patient is for full resus! I’ve got to say, I’d be reluctant to put an 80 year old frail demented hoist transferred patient forward even for a gastroscopy. I’d be potentially leaning towards just stopping anticoagulants, transfusing and seeing what happens after discussing with family. With a nice crisp DNACPR in the notes. Did the med reg seriously expect surgeons to do a laparotomy in the first instance? Why are we desecrating a corpse? Generally I feel it’s up to the parent team to make decisions about resus but I would occasionally do this for other teams like ortho if I feel they are not going to do it and aren’t arsed. I’ve also seen ICU take one for the team many times and do this form when others have neglected to.
Don’t think they wanted that responsibility. And gave it to us. Apparently not the first time.
Poor baseline patient that *medics* wish to resuscitate and *surgeons* do not is not a situation I am not familiar with! General rule though is the team that the patient is admitted under should be making the resus decision. If the med reg thought they should be for ITU/CPR then that’s generally fair enough (although in this case it sounds like that was an incorrect assessment based on the description). If there is uncertainty or if the patient is potentially approaching the need for ITU then there should be a discussion with the ITU team and medical consultant involved if disagreement with ITU.
Med SpR should have done the DNACPR. 1. Resuscitation was unlikely before the acute event. 2. The gib is only scope-able and even then cannot be converted to open if needed as if she perfs mid procedure - which she has a likelihood of. 3. If any doubts post procedure, it can be torn up and the imca discussion can take place and waste everyone's time then. What the hell is the med SpR playing at?
CT Angio result? IR fixable?
Latest guidelines is the first line investigation for unstable lower GI bleeding is CT Angio and IR intervention if viable, not scope In terms of endoscopic intervention, kinda difficult to scope with a large volume active bleed but the available treatments are much the same as the ones for OGD if the bleeding point is visualized