“He is only MOSTLY dead. Not ALL dead.”
by Jed Delmore, MD —
I apologize if you are unfamiliar with “The Princess Bride,” in my opinion one of the most quotable movies in the memorable past.
In one scene, the Dread Pirate Roberts, aka Westley, has been tortured and is presumed dead by his companions. They take him to Miracle Max (Billy Crystal) in hopes of a miracle to bring him back to life. Max goes on to explain the difference between mostly dead and all dead.
Westley has no say in the matter. Everything that transpires is decided by his friends and Miracle Max. As it turns out, that was in his best interests.
I mention this scene as it pertains to the ideal that all of us should have the opportunity/obligation to express our wishes related to the extent of care we desire, life-prolonging measures and, ultimately, resuscitation.
Recently, Phillip Brownlee, executive director of the Medical Society of Sedgwick County, and I met with members of the steering committee of the TPOPP (Transportable Physician Orders for Patient Preference) initiative – Carolyn Harrison, Drs. Barbara Coats, Kimberly Hartwell and Terry Merrifield. The MSSC, along with Wesley Medical Center and Via Christi Health, were members of the initial steering committee.
The TPOPP principle is based on the belief that individuals have the right to make their own health care decisions as their lives near an end. The process starts with a conversation between patients or legal designee and their health care provider. The process culminates in a physician-signed bright-pink TPOPP form with the detailed wishes of the patient clearly outlined.
Anyone in an advanced stage of chronic, progressive illness or terminal illness should be offered the option of this signed form, outlining the individual’s wishes and signed by his or her physician. Often, this would involve primary care specialists and their patients, but it can involve other specialists as well.
Any time the patient presents to a hospital or its emergency department, or is transferred from one health care facility to another, the signed form should be presented to assure patient wishes are followed.
In years past when most physicians admitted and rounded on their own patients, the knowledge of the existence of such a form would be easier. Increasingly, the patient is assessed and admitted by a hospitalist or is cared for by the medical director of a nursing facility who frequently will not have a long-term relationship with the patient.
To provide the best care for our patients, we should all be comfortable having the end-of-life discussion and documenting their requests. The MSSC has offered to work with the TPOPP committee and local hospitals to facilitate immediate recognition of the patient’s wishes, presence of the TPOPP form and where to look for it once the patient is admitted. The form describes the patient’s wishes regarding extent of care and resuscitative measures, and with the required physician’s signature is designed to serve as a medical order.
All the local hospitals document advanced directive wishes of the patient, though in various locations in the EMR. Additionally, in many cases, the paper documents are scanned into the electronic record after dismissal.
As members of the MSSC, we should be supportive of the TPOPP initiative, and help our patients make and document their wishes.
Absent that effort, they may run the risk of meeting Miracle Max.