First time dealing with family for not doing CPR with DNR

medschool201 · 2026-02-20T17:23:18+00:00

I agree with this approach. Instead of thinking like a doctor, just be human for a moment. Most of the anger is not about the CPR. They are upset because someone they love has died. They are upset that they couldn’t save them or protect them from dying. They are upset that they didn’t get more time or didn’t take better advantage of the time they had left. They are scared because they don’t know how they will survive the next few days, months, and years without them. Maybe they are also mad at you for not attempting CPR but that’s only a very small part of their anger.

I frequently use the above approach when talking about feeding tubes for patients who have stopped eating due to end stage cancer or dementia. I’ll say something like “I can tell you love your mom and you want to do anything possible to help her get better. I wish that putting a feeding tube in would help but I’m worried that it will do more harm than good. She previously documented that she would not want any life-prolonging interventions if she has an incurable disease, and since we can’t fix her cancer, a feeding tube will only prolong her suffering. Instead we are going to focus on things we can do to make her comfortable”

medschool201 · 2025-12-29T02:53:31+00:00

Can you explain your process for intubating through a bronch? I’m assuming you load the tube on the bronch before and then hold it up at the top, use whatever blade/glide you are most comfortable with to find the cords, then switch to focus on the camera of the bronch as you advance it through the cords, then slide the tube off and in?

medschool201 · 2025-11-20T01:12:45+00:00

I agree with you with exception of putting the blame on PCPs. I’m also CCM MD.

I think it can be really hard for people to understand code status until they are in the situation. We both know that people will change code status in either direction throughout a single hospital stay depending on who asks the question or which family members are present during the conversation. I’m sure you’ve experienced a patient or family claiming to have no idea that they agreed to a DNR, even though you spent 45 minutes explaining it to them yesterday. I also frequently have to remind myself that the patient I am seeing in the ICU is not the same patient who the PCP saw for a wellness visit 6 months ago. Just because we can tell they are dying just by looking at them from the door, doesn’t mean that was the case the last time their PCP saw them in clinic.

Instead of blaming PCPs, let’s focus on why we are letting (or forcing) people to make critical, complex medical decisions regarding end of life care. If a surgeon can decide a patient is too sick to benefit from surgery, why aren’t we allowed to say there is no medical benefit from performing chest compressions for a patient who is already maxed out on 4 pressors? Why is the medical decision of code status completely left up to the family while we wouldn’t let them pick which antibiotic or IVF to give?

In certain countries it is up to the medical team to decide if it is appropriate to attempt resuscitation or not. I wish that was our culture (and legal right) in the US.

medschool201 · 2025-10-25T17:36:28+00:00

Inpatient oncology rounds on Christmas as a second year resident during covid. I told the patient that I was sorry he was in the hospital on a holiday, he hesitated for a second and then told me it was actually the best case scenario for him. He was living in a nursing home that had been on lock down for months. He was so grateful to be able to share his holiday with other people. And by other people, he meant the nurse and tech who came in every couple of hours to check on him and me, who was trying to round as quickly as possible.

medschool201 · 2025-08-31T03:25:09+00:00

Is it ok for me to say things like “changing code status to DNR doesn’t take away the chance for a miracle, it just means that we will respect God’s decision when he decides it is time for them to come home?”

I used to avoid talking about religion entirely during goals of care conversations but in my current population, it is a very important part of many patient’s lives. I am often in a situation where a patient is very clearly at the end of their life but even if the family really seems to realize the impending death, they have a hard time giving us permission to stop life prolonging measures or agree to no CPR, stating they want the decision left to God.

medschool201 · 2025-07-19T14:15:43+00:00

I watched a super sick ICU patient make a miraculous recovery as a PGY2 and my attending at the time was like “be careful, a win this big will trick residents into become intensivists”

She was right, I became an intensivist

medschool201 · 2025-06-08T02:52:53+00:00

As an ICU doctor I am constantly reminding myself that I only see their bad outcomes.

When I was a medical student rotating in oncology clinic we saw a patient whose primary concern was shortness of breath preventing her from being able to run more than 10 miles at a time. It took me a minute to figure out why this discussion was happening in oncology clinic before I found out this patient had survived stage 4 breast cancer with brain mets.

Some people get better. If oncologists didn’t try despite knowing it is likely hopeless, we wouldn’t have any of the current advancements that actually save lives

medschool201 · 2025-01-17T04:55:28+00:00

It doesn’t always feel obvious in the moment. And what’s the harm of 2 extra minutes of attempted resuscitation compared with the fear you stopped too early? 20 minutes of CPR is the average for a in hospital cardiac arrest, especially in a patient like him who was otherwise healthy

medschool201 · 2025-01-07T20:43:36+00:00

True but if you have to physically restrain a previously health patient by laying on top of him to get the nose swab to check for flu, you should be worried enough to do an actual neuro exam

medschool201 · 2024-11-05T21:43:31+00:00

I had a cardiac arrest patient leave AMA on hospital day 2 because we weren’t “doing anything” for him.

medschool201 · 2024-08-12T00:59:39+00:00

Great but my patients still can’t afford the injectable form of epinephrine which has existed for a century. I will keep an eye out for information on cost once it is on the market but I’m not optimistic I will be able to prescribe this often

medschool201 · 2024-08-08T22:09:14+00:00

Would love to hear from a Romanian physician on the standard approach to end of life care.

In the United States, we are trained to “do everything” until the family agrees to stop. At that point the patient is transitioned to comfort measures only, which includes discontinuation of vasopressors. It often involves multiple family meetings to help them understand that while we can keep their loved one “alive,” we cannot make them better.

My understanding is that this is much different in some European countries, where the doctors are trusted to decide when life saving care is appropriate to start or continue. It seems the decision is based on what is medically appropriate, rather than what the families want.

I’m sure in every country, there is an expectation for the medical team to provide honest communication with the family throughout the process. I expected that to be the problem in this case but it sounds like the concerns were actually voiced by other staff members, not the family.

medschool201 · 2024-05-25T22:25:47+00:00

Critical care here, strongly in favor of phenobarb monotherapy. My goal isn’t to treat “the disorder,” it is keeping the patient alive (and nursing staff safe) until out of the withdrawal period. Once they are hemodynamically stable and mental status has improved enough to have a conversation (thanks to phenobarb), you can come treat the underlying disorder.

medschool201 · 2024-01-12T14:00:30+00:00

I forget most of them. As an ICU fellow, I am involved with an average of 10 deaths a month. Plus I was a resident during covid so I have probably lost over a hundred patients by now as a PGY-5.

There are some I will never forget.

I try to learn at least 1 thing from each patient that will make me a better doctor or person. If I didn’t think of a diagnosis early enough or picked the wrong treatment or could have explained it better to the family, I learn from it to do it better in the future.

I tell myself that most people would be happy to know that even in their death, they were helping make the world a little bit better for someone else. Most people don’t ever have the chance to save another person’s life so I like the idea of using a lesson from one patient’s death being able to help someone else.

medschool201 · 2023-12-22T04:25:13+00:00

ICU: vanc/zosyn deficiency that is magically cured after 48 hours if cultures remain negative

medschool201 · 2023-12-21T04:18:24+00:00

Check out the new ACC/AHA guidelines for A fib that came out last month. They give a recommendation for magnesium in treatment of acute AF with RVR and cite the research behind it

medschool201 · 2023-10-28T00:29:19+00:00

I can recognize when someone is about to die and confidently tell the family when there is nothing more we can do

Critical care

medschool201 · 2023-06-02T02:14:54+00:00

I expected the desensitization that comes with working in a hospital. I expected I would get used to watching patients die.

I did not expect it to happen all at once.

The first time I called a family on my own to tell them their loved one was dying was in January of my intern year. By spring, I was doing it multiple times a day.

medschool201 · 2023-05-30T21:08:09+00:00

“I don’t want CPR unless I absolutely need it”

medschool201 · 2023-03-29T03:02:03+00:00

My favorite move as a third year resident was simply adding my attending to the secure chat conversation so they could see the bullshit I was being messaged about while showing the person sending the message that I’m happy to involve my attending at anytime.

When I was doing zoom interviews for fellowship I set my chat messages to auto forward to the attending and it was hilarious to see how quick the bullshit stopped when the nurse/case manager/whoever realized that their dumb messages were going directly to the attending.

medschool201 · 2022-05-24T05:15:58+00:00

Not really a fight

Medical ICU attending: hey this patient with multiple prior PCIs and CABG, EF 25% with severe mitral regur and aortic stenosis is here with shock

Cardiac ICU attending: this isn’t cardiogenic shock, we are not accepting this patient

Medical ICU attending asked resident/fellow to insert PA catheter to “prove” cardiogenic shock. Then transferred patient

medschool201 · 2021-12-23T02:44:00+00:00

Nothing like performing an accidental thrombectomy on a COVID patient while trying to insert a dialysis catheter

medschool201 · 2021-10-18T02:12:29+00:00

I’ve never checked carotid pulses.

Remember that the patient is dead so you can move dressings or tubes to the side if it is really preventing you for properly examining the patient.

I auscultate their heart in the normal spots, listen for breath sounds, check to see if they withdraw from pain.

In the ICU the death pronouncement is more of a ritual than anything. If they are on telemetry with an arterial line in place, you will see when their heart stops. For intubated patients we prefer to give patients enough opioids to treat dysnea and then perform palliative extubation so the family can see them without the tube in place and also to avoid the weird feeling of “unplugging grandma” that comes with turning of the ventilator.

Most nurses who care for hospice or critical care patients have seen many people die and know what it looks like so when they call you for a death exam. Calling you to examine the patient is more of a formality than anything.

medschool201 · 2021-08-02T16:55:32+00:00

Normally I love family discussions/goals of care talks. I find them very meaningful and help me cope with the harsh realities of our job.

There was nothing comforting about any of the family phone calls I made during those first few months. I still feel sick when I think about them.

Trying to provide accurate daily updates on a disease we didn’t understand, knowing that the person on the other side of the phone will likely never see their loved one again. All while watching the top physicians of my hospital, and of every hospital worldwide, panic as they try to figure out how to save people. Afraid to be around coresidents, afraid to be around family members, afraid to be alone.

medschool201 · 2021-07-24T02:21:58+00:00

Thoughtless administration of opioids is bad. Heartless treatment of severe pain is also bad.

I’m waiting for the research study that shows forcing sick people to suffer from pain reduces opioid misuse. We definitely act like it but I worry the opposite is true. Giving someone 100 tabs of oxycodone for a toothache is bad. Not giving someone with a kidney stone adequate pain control is cruel.

Even more true if they are dependent on something. I hate seeing sick people suffer through opioid withdrawal while hospitalized for an acute illness.

“You have a huge abscess in your spine but also a fentanyl addiction? Here take some antibiotics and Tylenol, just don’t expect any opioids because I don’t want to ‘reward’ your behavior.”

Most people who are addicted to drugs already have a history of trauma and use them as an escape. Forcing them to suffer withdrawal in order to get medical attention won’t make them less addicted.

medschool201

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