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

Last Editorial Review: 10/23/2003

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.

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.

Moderator: If someone is going under general surgery what can be done to lessen his or her risks of complications?

Dr. Sample: Any surgery whether it requires a general anesthetic or even a regional anesthetic... the patient should follow some good common sense rules. If you're a smoker, you should stop smoking. If you have high blood pressure or heart conditions, you should stay on your medicines, and in all instances, you should see your primary care physician for clearance. And in some instances, perhaps, more than most docs would admit, I would ask if there's an intensivist at that hospital if something ... if there's a complicating.

DebbieDavis_WebMD: Are you affected by the on the job trauma that occurs daily? How do you cope?

Dr. Sample: Absolutely yes. It is impossible to avoid the impact by the patient's struggle with life, the terror in families' eyes. Part of the coping mechanism is the collaboration within the critical care team. The other is the support from your colleagues, the critical care team, family, and watching ER for laughs on occasion.

Moderator: What does DNR mean? When is it implemented?

Dr. Sample: DNR stands for Do Not Resuscitate. It is an order that is written on the patient's chart that instructs physicians and nurses not to attempt to restart the patient's failed heart or respiration. It is implemented at least in those 3 instances that I mentioned earlier, about the grave prognosis, the burden of therapy, the quality of patient's life is unacceptable. We have a generic term called "medical futility" that encompasses this concept. That is, when all has been done, and all will be lost, the patient should have a DNR order placed on the chart. The next step is to talk to family about the withdrawal or the foregoing of life support as I mentioned at the beginning of the show.

Moderator: We are almost out of time Dr. Sample. Is there anything else you would like to add before we say good bye?

Dr. Sample: Thanks for this opportunity. Hope I can do it again. If the "lurkers" have specific questions, they can email me at [email protected].

Moderator: Unfortunately that's all the time we have. I would like to thank Dr. George A. Sample, for being our guest speaker on WebMD Live this afternoon. This discussion has been very informative. I encourage WebMD members to check the program schedule to see what other shows we have coming up. Thank you and have a wonderful day.

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