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Author: Woolybooger1 Big red star, 1000 posts Top Favorite Fools Feste Award Nominee! Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: of 459821  
Subject: Re: Who Should Pay? Medical Story from the Trenc Date: 7/7/2013 1:37 PM
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Hi Gang,

Just wanted to say "Great post Poz". Proud of you in many ways. Also felt it was a good spot to jump in since ResN also added a good point.

I will keep this relatively short,to the point, but also cut to the quick about how this plays out over and over again.

My point is

*** Just because we can do a thing........ Doesn't mean we should do that thing!!! *****

Several things come into play when events like death come into play.

(1) Guilt
(2) Sadness
(3) Disbelief
(4) Anger
(5) Blame
(6) I am sure there are many more, but I see these the most.

Short story to lay the back ground.

Over this past year we have had a few patients who had to face difficult situations. Notice I didn't say choices. The Choices were already made and now the story would unfold. This young woman was a high rate substance abuser. Many different types and kinds. The reason for putting this in here is there is an association with Cocaine use and Renal anomalies. It became clear during the second trimester that this baby she was growing was severely afflicted with a kidney issue. No amniotic fluid was being generated and this is actually a function of fetal kidneys. The diagnosis of Renal agenesis was made and confirmed. Without amniotic fluid, the long bones of the baby and the skull to some degree will continue to grow. The rib cage and chest muscles however are not strong enough to allow the lungs to grow. The uterine muscle is too much stronger so lungs do not develop. I don't mean they won't mature, but they simply will not be allowed to grow big enough to support the infant at birth. While this very rarely happens to "anyone" even if they don't use drugs, it is exceedingly rare. The story really is not about the drug use, but of course "consequences" come in here somewhere.

Now here is where we are failing as a culture both within the medical field as well as human beings dealing with our own or other's mortality.

My partner and I have told this patient there is a Zero chance of survival for this baby. Zero! Unfortunately one of the specialists in Maternal Fetal Medicine made the comment that less than 1% of these babies survive. He/She must have pulled that out of their A$$ because it simply isn't/wasn't true. The patient's mother also heard that comment and today we transferred this patient to a Neonatal Hospital with preterm labor (also something associated with fetal anomalies) at 32 1/2 weeks. She will undoubtedly deliver today or tomorrow. It won't matter.

What should have happened?

The diagnosis was made. The options were

(1) Induce labor as soon as the diagnosis was certain
(2) Do nothing and allow labor whenever it took place.

Why one or the other you say?

Some folks would feel "guilty" inducing a baby that was pre-viable and feel like they were doing something wrong. Okay, but waiting is not "risk free". Others would want us to stop preterm labor and get the child as far along as possible and then "hope for the best". No matter how many prayers, vigils or fantasy scenarios someone wants to play out, there will be no "best outcome" for this baby. Quite sad, but it is the hand that has already been dealt.

Dangers that we may now encounter because someone (read here well-meaning idiot) did not want to "not give them any hope".

(1) Mom develops severe preeclampsia, seizes and dies as a consequence
(2) Baby has fetal distress in labor because the cord gets compressed since there is no fluid to cushion it during labor. C-section gets done for a non-viable baby and mom dies from complications. Or just gets an infection and then a Hysterectomy or becomes infertile and never gets pregnant again.
(3) Baby hangs on for 5 days on extreme ventilator therapy and then dies since its lungs simply cannot handle the body it has been given. Costs are excessively high due to intensive care, round the clock nursing, x-rays, labs, technology for the vent, the Neonatologist etc......

Or we accept the diagnosis. Grieve appropriately. Look at the choices that got us there. Look at how we can best handle this sad set of circumstances and move on. It we did nothing wrong and were the model patient, then we sadly realize that "bad things sometimes happen to good people". But if we didn't make good choices along the way then hopefully this will be the jolt that makes us search within and change.

As a doctor I have never had a patient stop using drugs or quit smoking or drinking because I told them that may not be the best idea. Rather I have had them come to me months or years later and take me up on the offer to help them get into rehab or start going to meetings.

As a culture we have to step back and see reality for what it is. Get rid of the Vulture ambulance chasers, Learn the dignity can even be found in death, and start taking responsibility for our mistakes. There are plenty of premie babies that can and should be saved. There are plenty of older folks who also will benefit from a Heart Cath with Stents or dialysis. But let's face it............ there is always finally a time to let loved ones go.

Guilt
Sadness
Disbelief
Anger
Blame

are not emotions that need to come into play when we are faced with decisions about death.

Empathy
Compassion
Camaraderie
Friendship
Being engaged

these are the things we need to learn as a culture and as Physicians. No false hope, and no selfish decisions when it comes to allowing someone to pass on with dignity. Our loss simply cannot be turned into their pain and society's financial burden. We are all stardust and to dust we return. Let's help our family, friends, and loved ones learn how to do that better

Wooly.............. bummer topic, but so important to "teach your children well". (2 Crosby,Stills, Nash and Young references in one post)
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