Critical Care and End-of-Life Issues with George A. Sample, M.D., F.C.C.P.

WebMD Live Events Transcript

Join George A. Sample, M.D., F.C.C.P., for a discussion on critical care of post-operative patients as well as end-of-life-issues.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Moderator: Welcome to WebMD's Live Program Health Focus. Today's discussion will be with Dr. George A. Sample. WebMD members are encouraged to ask their questions and bring up any concerns they may have regarding critical care; admission to end of life issues. This program will begin at 2pm Pacific / 5pm Eastern.

Welcome, Dr. Sample, and thank you for being with us today. Can you please begin today's discussion by telling everyone a little bit about your background and area of expertise please.

Dr. Sample: I'm a critical care specialist. I have been in practice since 1976. first in Oregon and now in Washington, DC. The practice currently is strictly the care of postoperative patients. That ranges from open heart surgery to simple appendectomies that have complications; that includes gunshot wounds and motor vehicle accidents. The critical care specialist is also known as an intensivist. My training is board certification in internal medicine, pulmonary medicine and critical care medicine.

Moderator: What do mean by an intensivist?

Dr. Sample: An intensivist is a specialist who is preferably board certified in one of four specialties... anesthesia, internal medicine, pediatrics, and surgery. After your board certification studies, you then do further training in critical care medicine, that's an additional 2 years, and an additional Board. Strictly speaking, an intensivist has no office practice and practices solely in an intensive cardiac unit, could be a surgical ICU, medical ICU, pediatric ICU. We are solely an in-hospital specialty. Our practice is solely in the Intensive Care Unit.

mjooo_WebMD: What is Critical Care Medicine?

Dr. Sample: Critical Care medicine is a discipline that combines the physician, nurse, and allied health professionals in the collaborative and coordinated management of patients with life threatening single or multiple organ systems failure. We call this multidisciplinary. In practice, it is care by one physician with his team caring for the entire patient, as opposed to one patient and four consultants giving fragmented care.

mjooo_WebMD: What is the law when a family refuses to stop medical care with a brain dead family member?

Dr. Sample: The physician has the responsibility to do what is best for the patient. In a patient who has been declared brain dead, it is in no one's interest, particularly the patient's, to go on with life sustaining measures. Therefore in somebody who is dead, the physician has the moral right and the legal authority to withdraw care.

Moderator: Does it make a difference to have an intensivist caring for you? Wouldn't it cost more?

Dr. Sample: Yes, it makes a difference. There are now a multitude of studies that show a qualified intensivist can reduce mortality rates, length of stay in the hospital, and reduces inefficient use of costly ICU resources. This is true because we try to avoid fragmented care, as I mentioned earlier, and instead of one physician for one failed organ, we have one physician for all failed organs. So it is our responsibility to assess and respond to the complex interactions which are the features of these critically ill and injured patients.

Moderator: In what situations should forgoing life-sustaining the therapy be discussed?

Dr. Sample: There are at least 3 areas that I'm familiar with. One is when the patient has a diagnosis with a grave prognosis. 2, when the burden of therapy outweighs the benefits (and, if I can inject, the question regarding the brain-dead patient would be in that category), and 3, when the quality of the patient's life is expected to be unacceptable to the patient. I have to add that all three of these are very difficult for intensivist to deal with, because there is no way to quantify this. All of these are relative and in some instances are judgment calls.

Moderator: Would an advance directive help? and can you define that?

Dr. Sample: Advance Directives became part of the legal jargon in the early 90s. They are instructions to one's family, friends, physician or others which describe an individual's wishes related to medical treatment when that patient becomes incapacitated. It's a generic germ for living will, durable power of attorney (health care), and surrogate decision makers. Would it help? is an awkward question because many of these Advance Directives do not address the specific problems that we are faced with. Most of the Advance Directives deal with a "terminal condition." Family members don't look at their teenage son who is unable to survive an automobile accident as having a terminal conditional. What is most helpful is durable powers of attorney in which the patient has talked to their Power of Attorney, which could be a friend or clergy, or whomever, and gave specifics as to what should or should not be done. For example, I want the ventilator stopped if all agree that there is no hope of recovery. I do not want food or hydration or I do not want to live in a persistent vegetative state. Unfortunately, it is extremely rare that we have that document in hand when the patient arrives on our doorstep.

Moderator: With so many people dying on transplant waiting lists, what can we do to increase the number of organs available?

Dr. Sample: The care I mentioned a moment ago about the teenager in the automobile accident we face commonly. Although 80% of Americans will experience critical illness or injury either, as a patient, family or friend, rarely is the discussion of organ donation ever brought up. So first of all there has to be a discussion amongst family members. I heard on NPR this morning a public thank you for a heart donation, and the thank you came from the family of the recipient. Those things need to be brought to public awareness. The other thing is the drivers license donor card. Everyone should put "donor down," or have a good reason why not. Many people don't understand that the health care community is reluctant to honor that drivers license designation if a family member objects. As a physician and father, I can think of no greater disservice to the rest of society than to deny organs being taken from a patient who, while alive, wished that to be done.

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