Physicians - maximum of 0.50 AMA PRA Category 1 Credit(s)™
ABIM Diplomates - maximum of 0.50 ABIM MOC points
This activity is intended for internists, surgeons, geriatricians, cardiologists, intensivists, oncologists, and other physicians engaged in the care of patients in whom "do not resuscitate" (DNR) and/or "do not intubate" (DNI) orders may be considered.
The goal of this activity is for learners to be better able to describe the implications of "slow" or "show" codes on patient autonomy, the patient-physician relationship, and professional integrity, according to an American College of Physicians Ethics case study and commentary.
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Ethics case studies are developed by the American College of Physicians Ethics, Professionalism and Human Rights Committee and the ACP Center for Ethics and Professionalism.
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CME / ABIM MOC Released: 4/25/2023
Valid for credit through: 4/25/2024, 11:59 PM EST
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"Do everything." Ms Smith's family members have been saying this from the start of her latest hospital admission, which started 3 weeks ago after a myocardial infarction. Two years ago, a stroke left Ms Smith, age 89 years, with left-sided hemiplegia but no cognitive impairment. She also has type 2 diabetes and hypertension. Her oldest child, Jean Carey, has been at the hospital every day. She relocated to become her mother's primary caregiver after the sudden death of her father 3 months ago. Before that, Mr Smith had cared for his wife with the assistance of a home health aide.
Internist Frances Belmont has been caring for Ms Smith for many years, although she had not had much interaction with her children except for meeting Ms Carey at her mother's last office visit. On Ms Smith's admission to the coronary care unit with renal, respiratory, and heart failure, Ms Carey called Dr Belmont trying to get more information. After giving a clinical update, Dr Belmont noted that whenever she tried to have advance care planning discussions with Ms Smith, Ms Smith would respond that her daughter knew her well and "would take care of everything" in the event of a serious illness. Dr Belmont also advised her in the past to speak with her family about her preferences and goals. In fact, Ms Carey is Ms Smith's agent under her durable power of attorney for health care. There are no written instructions in her advance directive. With diminished orientation and alertness, Ms Smith is now unable to participate in conversations about her goals of care and treatment preferences.
Having lost their father and favorite aunt in the past 6 months, Ms Smith's 3 children are, understandably, distraught. The doctors have been discussing their mom's condition and prognosis at length and have now broached the topic of a do-not-resuscitate (DNR) order for Ms Smith, but the family members are very opposed and want "everything possible" to be done. Ms Carey has left a message for Dr Belmont asking for advice.
Dr Belmont thinks a DNR order is appropriate and is contemplating how events might unfold without a DNR order. She fears that the treatment team may resort to a "show" code for the family. She is concerned for the family but feels strongly the primary obligation is to the patient. A colleague she consults with also questions the use of a code team in such a case, but another colleague asks, "Wouldn't it demonstrate caring to the family and acknowledge their grief? And just be easier?"
How should Dr Belmont discuss the DNR order and its implications with Ms Smith's daughter when she calls her back?