Vital Times 2017 - 72

Flogging the dead
For any of us who practice anesthesiology in a major
hospital - doing cardiac, thoracic, or liver cases, for
instance - there are days when all our efforts are spent
on behalf of a patient whose health is unsalvageable.
"Flogging the dead" is a phrase sometimes used to
describe prolonged and futile care in the operating room
or ICU.
Sometimes aggressive interventions are driven by a
family that wants "everything" done, because in their
innocence the family members have no idea how terrible
and dehumanizing the process of postponing death can
be.
In other circumstances, however, the decision of whether
to do surgery is driven by the mission and the financial
motivation of the health system to provide care. If care
doesn't occur, if the surgery isn't done, no one gets paid.
If the anesthesiologist walked up to the bedside of
an elderly, frail patient who is scheduled for a risky
operation, and explained bluntly that the patient might
die a prolonged and dismal death in the ICU, there would
be hell to pay if the patient or the family decided to back
out. The preoperative holding area, five minutes before
surgery, isn't the time or place to have that conversation.
Yet that's often when we meet our patients for the first
time.
The "risk of death" is always mentioned in the informed
consent documentation, but may be framed by physicians
and nurses alike as a theoretical concern rather than a
real possibility. The surgeon, the anesthesiologist, and the
hospital are incentivized to do cases, not to step on the
brakes and stop an operation. This is true even when the
operation may fix a specific surgical problem but could
lead to worse health, more pain, or loss of independence
during the last months of life.

"Our goal is not survival at all costs"
One lesson that Dr. Gawande said he has learned from
talking to patients is that they have priorities in life other

72 		|	 	 CSA	Vital	Times

than just survival. The goals will differ from person to
person. If we don't ask patients these difficult questions,
Dr. Gawande said, "the care we provide may be out of
alignment with their priorities." That kind of care may
cause more suffering than it alleviates.
One patient told Dr. Gawande that he would be okay
with his quality of life so long as he could "eat chocolate
ice cream and watch football." That's better than any living
will in terms of clarity, Dr. Gawande said.
He advised asking a patient, "What's your understanding
of where you are in your illness? What abilities are so critical
to your life that you can't imagine living without them?"
Understanding the patient's goals and fears can help the
patient, the family, and the medical team reach the best
decision about a plan of care, Dr. Gawande said.
"Our goal is not survival at all costs," Dr. Gawande asserted.
"Nor is our goal a good death. The goal is for our care to
match their goals. To deliver the right care, at the right time,
every time."
For this fundamental change in the culture of healthcare
to occur, payment models must change too, Dr. Gawande
said. "A switch from fee-for-service to fee-for-value is
absolutely critical for us to work successfully as teams. We
have to be part of driving the reinvention of how we're paid."
The team's success should be linked to an outcome that is
optimal in the view of the patient and the family, even if
the decision is not to do surgery.
Dr. Gawande praised the many contributions of
anesthesiology to improving processes of care and
promoting patient safety. But he urged the ASA to "move
from safety to outcomes as your priority."
To achieve the best outcome consistent with each
patient's goals, Dr. Gawande said, "we need to work as
teams before and after they come to the hospital. We need
to be willing to take part in the experiments and drive
the experiments so that we are paid as teams for better
outcomes."



Table of Contents for the Digital Edition of Vital Times 2017

Vital Times 2017 - Cover1
Vital Times 2017 - Cover2
Vital Times 2017 - 1
Vital Times 2017 - 2
Vital Times 2017 - 3
Vital Times 2017 - 4
Vital Times 2017 - 5
Vital Times 2017 - 6
Vital Times 2017 - 7
Vital Times 2017 - 8
Vital Times 2017 - 9
Vital Times 2017 - 10
Vital Times 2017 - 11
Vital Times 2017 - 12
Vital Times 2017 - 13
Vital Times 2017 - 14
Vital Times 2017 - 15
Vital Times 2017 - 16
Vital Times 2017 - 17
Vital Times 2017 - 18
Vital Times 2017 - 19
Vital Times 2017 - 20
Vital Times 2017 - 21
Vital Times 2017 - 22
Vital Times 2017 - 23
Vital Times 2017 - 24
Vital Times 2017 - 25
Vital Times 2017 - 26
Vital Times 2017 - 27
Vital Times 2017 - 28
Vital Times 2017 - 29
Vital Times 2017 - 30
Vital Times 2017 - 31
Vital Times 2017 - 32
Vital Times 2017 - 33
Vital Times 2017 - 34
Vital Times 2017 - 35
Vital Times 2017 - 36
Vital Times 2017 - 37
Vital Times 2017 - 38
Vital Times 2017 - 39
Vital Times 2017 - 40
Vital Times 2017 - 41
Vital Times 2017 - 42
Vital Times 2017 - 43
Vital Times 2017 - 44
Vital Times 2017 - 45
Vital Times 2017 - 46
Vital Times 2017 - 47
Vital Times 2017 - 48
Vital Times 2017 - 49
Vital Times 2017 - 50
Vital Times 2017 - 51
Vital Times 2017 - 52
Vital Times 2017 - 53
Vital Times 2017 - 54
Vital Times 2017 - 55
Vital Times 2017 - 56
Vital Times 2017 - 57
Vital Times 2017 - 58
Vital Times 2017 - 59
Vital Times 2017 - 60
Vital Times 2017 - 61
Vital Times 2017 - 62
Vital Times 2017 - 63
Vital Times 2017 - 64
Vital Times 2017 - 65
Vital Times 2017 - 66
Vital Times 2017 - 67
Vital Times 2017 - 68
Vital Times 2017 - 69
Vital Times 2017 - 70
Vital Times 2017 - 71
Vital Times 2017 - 72
Vital Times 2017 - 73
Vital Times 2017 - 74
Vital Times 2017 - 75
Vital Times 2017 - 76
Vital Times 2017 - 77
Vital Times 2017 - 78
Vital Times 2017 - 79
Vital Times 2017 - 80
Vital Times 2017 - 81
Vital Times 2017 - 82
Vital Times 2017 - 83
Vital Times 2017 - 84
Vital Times 2017 - 85
Vital Times 2017 - 86
Vital Times 2017 - 87
Vital Times 2017 - 88
Vital Times 2017 - Cover3
Vital Times 2017 - Cover4
https://www.nxtbook.com/allen/csvt/vital-times-2021
https://www.nxtbook.com/allen/csvt/2020
https://www.nxtbook.com/allen/csvt/2019
https://www.nxtbook.com/allen/csvt/2018
https://www.nxtbook.com/allen/csvt/2017
https://www.nxtbook.com/allen/csvt/2016
https://www.nxtbook.com/allen/csvt/2015
https://www.nxtbook.com/allen/csvt/2014
https://www.nxtbookmedia.com