Critical Care and End-of-Life Issues (cont.)

mjooo_WebMD: Is there age limits to be an organ donor and what are they?

Dr. Sample: It varies by organ and the age of donation varies by the organ donated, the age of the patient who is to be the donor. We have accepted organs from patients who are in excellent health into their late 50s.

Moderator: What does the Critical Care Team entail?

Dr. Sample: The Critical Care team is the core of what we do on a daily basis. The team is comprised of obviously the patient, obviously the family, we health care practitioners, including allied health professionals, as well as clergy. On a weekly basis, in our institution, we have meetings on our sick patients with these team members. In some instances, we've been known to meet on a daily basis when the patient's condition warrants it. The clergy and social workers play an extremely important role in making the teamwork function. Again, it's the absence of fragmented care during a life-threatening illness but rather the involvement of an intensivist delivering care to the entire patient in his life-threatening multiple organ dysfunction.

Moderator: What is multiple organ dysfunction?

Dr. Sample: Let me answer in a round about way to tell you what a critical illness is. Critical illness includes overwhelming infection, heart attacks, major trauma from cars or guns, major complications from surgical procedures. The one common denominator is a reduction of blood flow and oxygen to the entire body. This disturbance will disrupt the function of the kidney, brain, lungs, liver, etc. So that's where the term "multiple organ dysfunction" comes from, multiple organs which are impaired simultaneously. If left untreated, or more importantly, if treatment is delayed, this condition will threaten the viability of organs, limb and life itself. This is where our expertise comes in to play, in the ability to recognize what I call "yellow flags," warnings that something bad is about to happen. It's almost impossible to do that from home or from the office.

mjooo_WebMD: What role does the primary care doctor take when the patient is in the ICU and dying?

Dr. Sample: The primary care physician (could be the family doctor/general practitioner, internal medicine, surgeon) is the most important part of the critical care team, particularly in this circumstance. We intensivists do not have the advantage of a long-term relationship prior to the patient coming to the hospital. They present at our doorstep in the throes of desperation and without us knowing who they are. Although we know most of the time what the problem is, the primary care doctor is instrumental in the who part of the question. By his knowledge of the patient and the family, he can speak for the patient and what his patient's wishes would be under these particular circumstances. Additionally, although there is a phenomenal bond that transfers between intensivists and the patient's family, the family always turns to the primary care doctor for guidance and help. It's the primary care physician's -- if he is performing as we all would like in a perfect world, the advance directive would have been discussed ahead of time.

Moderator: When you are teaching residents about patient care, is cost ever a consideration?

Dr. Sample: Absolutely. Despite many drawbacks with managed care, it has made us focus on the cost of care. Every day on rounds, we question whether there is a less expensive, but yet still effective drug/test/intervention, etc. that we can do for the patient. The cost of medical care in the intensive care unit is extraordinarily high and the most recent data I have goes back to about 1994, 1996. At that time, it was estimated we spend approximately 80 billion dollars on ICU care in the U.S. That represents about a third of all hospital costs. Medicare beneficiaries, that is mostly patients over 65, have an extraordinarily high expenditure. What 's interesting is that only 10% of those patients account for almost 70% of all the expenditures. And almost a third of the dollars spent are spent in the last year of their lives. Needless to say, we need to figure out how best to allocate these resources to those who are going to benefit most from it.

Moderator: What is the most unusual case(s) you have seen?

Dr. Sample: Some time ago, a patient was admitted to our surgical ICU at the Washington Hospital Center, with severe brain injury and whom we knew was ultimately and shortly going to die. He was accompanied by his 2nd wife and both were in their middle ages. When she was told he would not survive his brain injury, she made one request. She requested that we retrieve his sperm and preserve it in a sperm bank. Our group has perhaps over 100 years of critical care experience collectively, and no one had ever been faced with that request. It raised legal/ethical/moral/medical questions which we've never had to confront. It took us about 3 to 5 days to iron out all of the issues, while the wife patiently waited. Eventually her wish was granted, following which he was removed from the ventilator and allowed to die peacefully.

Moderator: What is the most difficult part of your practice?

Dr. Sample: The most difficult part of the practice involves the foregoing of life-sustaining measures. I've been doing this as I said since 1976 and in each instance, it's different from any other. Each family is different from all others, and it is something that cannot be taught or learned.

mjooo_WebMD: What type of Education is available for the public on Organ Donation?

Dr. Sample: Each state has a transplantation program, usually located at the medical school. I would first try there, also there is a what's called transplant consortium, that has a national 800 number .... Your local hospital particularly a kidney specialist, would very definitely know.

Moderator: What do you think about the TV show "ER"?

Dr. Sample: I have a love/hate relationship with the show. I hate the soap opera drama that attracts many viewers but I love the medical action that takes place. I love it for a couple reasons.. I love looking for mistakes of which there are plenty and I tape every show. I take the video tape back to the residents and quiz them on what went wrong and what the mistakes were, and sometimes what went right. And I'm fascinated by how the show has grown in it s knowledge and expertise over the years.


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