Figure 16.1 Functional reserve is needed when a person faces a stressful situation. As persons age, they draw on their functional reserve to maintain relatively normal function, and as a consequence, they have less reserve to meet a new, stressful challenge such as a major surgical operation and the demands of recovery.
(4) Remind all involved that it is one thing to keep a heart beating, but quite another to restore a meaningful life as defined by the patient’s previous statements.
(5) Distinguish prolonging death from extending life.
(6) Involve pastoral services to help the family deal with their dread and grief. For many people, there is belief that death is a transition to another (better) existence.
Case resolution
As a therapeutic trial, the lengthy and complex operation initially had limited success in so far as the patient made slow progress. When it became evident that his situation remained tentative with virtually no chance that the patient could tolerate any major set back, consideration of initiating DNR would have been appropriate for two purposes: (a) it was in line with the patient’s advance directives; and (b) it would have been a clear signal to his surrogate-family members that expectations for reaching his stated goals were diminishing day by day.
Most importantly, the failure to have a DNR order in place at the outside facility resulted in an inappropriate transfer back to the hospital and futile attempts to salvage what clearly was a fatal event given his already extremely limited reserves.
Key points
• In end-of-life care, focus on the patient’s goals, not merely the individual procedures involved.
• Be willing to discontinue aggressive care if the goals cannot be achieved.
• Recognize that “comfort care” is an important and continuous form of caring.
• Deal with the demand that “everything be done” sympathetically but realistically.
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Conflicts of interest in research funding
Physician conscientious objection in anesthesiology practice
Opioid therapy in addicted patients: background and perspective from the US
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