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Comments on CPR
0021-9681/86$3.00+0.00 Pergamon Journals Ltd
J Clwm Dis Vol. 39, No. 8, P. 667, 1986 Printed in Great Britain
Letter to the Editors COMMENTS
ON CPR
to Goodwin and Goodwin for helping us to give some “Second Thoughts” to CPR in the commentary in Journal of Chronic Diseases Vol. 38, No. 8, 1985. My own second look at this issue suggested to me that minimal involvement of consultants, specialists, and other senior clinicians in hour-to-hour ward work, and the extra-central nature of medical education on issues of dying and death may be serious contributions to the present state of CPR referred to by Goodwin and Goodwin. An idea needing examination is that which suggests that the “disaffection, alienation, and dehumanization so chronic to house officers” results from the lack of senior supervision in the day-to-day practical application of CPR in a way that is done routinely in placing needles into body spaces such as spinal canals, chest linings, or abdominal cavities for diagnostic purposes. There are certainly problems with the ways in which new physicians are socialized/trained to deal with issues and needs of the person sick to the near death point. I would suggest that some key contributions to the problems are (1) that decision-making about and skills of caring for the person near dying or likely to die are too peripheral to the major points in clinical education, and that CPR is the archetypical case in point (rather than a specifically avoided situation), (2) that the standard clinical curriculum does not emphasize the practical skills involved in the classical Western medical principle primum non nocere (first, do no harm), bearing in mind that it requires skills training to not do harm (deciding when and when not to resuscitate being one undeniably needy situation), (3) that the disease process, and disease management orientation of much clinical teaching can proceed with the decreased presence of the senior clinician as the senior medical house officer gains in knowledge of pathophysiology and disease management, leaving the clinical situation of the person near death, or actually dying relatively untutored by maturity and judgement, understanding and compassion of the senior clinician, who can often be heard at morning rounds giving advice about the preceeding night’s CPR attempts which sound very much like the “Second Thoughts” of Goodwin and Goodwin. These issues are being taken to heart in several contexts. The Ombudsman Rounds of the Montefiore Medical Center, Bronx, New York, where ethicists (lawyers and philosophers) medical and psychiatric attending physicians, nurses, social workers, clerks, sometimes administrators, deliberate the issues with which this letter is concerned with persons receiving care and/or their families, in the presence of and with the participation of junior doctors and medical students, is just one example of serious responses to second thoughts shared by others. THANKS
WILLIAM H. WILKINSON
Bronx, New York U.S.A. REFERENCE 1. Strain JJ, Hamerman D: Ombudsman (medical-psychiatric)
667
rounds. Ann Int Med 88: No. 4, 1978
J Clwm Dis Vol. 39, No. 8, P. 667, 1986 Printed in Great Britain
Letter to the Editors COMMENTS
ON CPR
to Goodwin and Goodwin for helping us to give some “Second Thoughts” to CPR in the commentary in Journal of Chronic Diseases Vol. 38, No. 8, 1985. My own second look at this issue suggested to me that minimal involvement of consultants, specialists, and other senior clinicians in hour-to-hour ward work, and the extra-central nature of medical education on issues of dying and death may be serious contributions to the present state of CPR referred to by Goodwin and Goodwin. An idea needing examination is that which suggests that the “disaffection, alienation, and dehumanization so chronic to house officers” results from the lack of senior supervision in the day-to-day practical application of CPR in a way that is done routinely in placing needles into body spaces such as spinal canals, chest linings, or abdominal cavities for diagnostic purposes. There are certainly problems with the ways in which new physicians are socialized/trained to deal with issues and needs of the person sick to the near death point. I would suggest that some key contributions to the problems are (1) that decision-making about and skills of caring for the person near dying or likely to die are too peripheral to the major points in clinical education, and that CPR is the archetypical case in point (rather than a specifically avoided situation), (2) that the standard clinical curriculum does not emphasize the practical skills involved in the classical Western medical principle primum non nocere (first, do no harm), bearing in mind that it requires skills training to not do harm (deciding when and when not to resuscitate being one undeniably needy situation), (3) that the disease process, and disease management orientation of much clinical teaching can proceed with the decreased presence of the senior clinician as the senior medical house officer gains in knowledge of pathophysiology and disease management, leaving the clinical situation of the person near death, or actually dying relatively untutored by maturity and judgement, understanding and compassion of the senior clinician, who can often be heard at morning rounds giving advice about the preceeding night’s CPR attempts which sound very much like the “Second Thoughts” of Goodwin and Goodwin. These issues are being taken to heart in several contexts. The Ombudsman Rounds of the Montefiore Medical Center, Bronx, New York, where ethicists (lawyers and philosophers) medical and psychiatric attending physicians, nurses, social workers, clerks, sometimes administrators, deliberate the issues with which this letter is concerned with persons receiving care and/or their families, in the presence of and with the participation of junior doctors and medical students, is just one example of serious responses to second thoughts shared by others. THANKS
WILLIAM H. WILKINSON
Bronx, New York U.S.A. REFERENCE 1. Strain JJ, Hamerman D: Ombudsman (medical-psychiatric)
667
rounds. Ann Int Med 88: No. 4, 1978