[ad_1]
Dan Longrois, professor of anesthesia and intensive care, currently working in Paris, and one of the most prestigious experts in the field, explains in an interview with News.ro the case of the Pantelimon Hospital, where two female ATI doctors were accused of premeditated murder after the death of a patient who had reduced the dose of norepinephrine – What exactly does the principle of care in intensive care units mean, how norepinephrine is used at certain stages, and what legislative framework they have Many Western countries have adopted measures related to the limitation of treatment of patients in the terminal stage of the disease. “To conclude that the reduction of the dose of norepinephrine was the cause of death seems to me a bit excessive and not credible even if an autopsy was performed”, Professor Dan Longrois believes. Dan Longrois: With modern intensive treatment techniques, we can almost completely replace lung function, heart function, kidney function, part of liver function, we cannot replace brain function. “I want to make two comments. The first one is in the field of medical technology, which is absolutely essential when we talk about what happened to this patient and the treatment these doctors gave him. Patients end up in intensive care because they have serious health problems, generally speaking, their vital organs (such as heart, lungs, kidneys, liver, brain) are malfunctioning. The principle of care in intensive care is that doctors use treatments that mobilize what we call new functional reserves, that is, organs that are dysfunctional, but with the right care, can regain some of their function. Functions that sustain the patient’s life.
With modern intensive treatment techniques, we can almost completely replace the function of the lungs, the function of the heart, the kidneys, part of the liver, but we cannot replace the function of the brain. I insist that all these techniques make the assumption that, first, these organs have a functional reserve for a short period of time, and the second assumption that justifies intensive treatment is that these organs will recover and the patient will return to life, which can be said to be normal or close to normal. When there is no longer any type of functional reserve, we enter the stage called refractory shock. No matter how high the dose of norepinephrine is, there is nothing left and the probability of saving life is almost 0. In this case, I see nothing wrong with reducing the dose of norepinephrine.
Refractory shock means that there is no longer any function that can be mobilized, then no matter what the doctors do, the result of intensive treatment is death, there is no other option. So this patient, when he was admitted to the resuscitation hospital, as far as I know, no one in Romania knows all the details of admission to the hospital for resuscitation, intensive care, but from the information I have, it is clear that he was in a state of refractory shock, which means that no matter how high the norepinephrine dose was, there was no reserve and the probability of survival was almost 0. The fact that the norepinephrine dose was low in the case of refractory shock is not a mistake. In itself, why, because, at a specific moment, this norepinephrine has paradoxical effects, and increasing the dose very, very much, has harmful effects that we understand and know. So I do not think there is any mistake, and the physiopathological reasoning for reducing the norepinephrine dose is reasonable. Again, we are facing a situation where there are some known elements in the recommendations and international protocols that we are discussing, but part of the knowledge that we have is not solid enough at the international level to make recommendations and tell people doctors that this is what we must do, or absolutely not do. To conclude that the reduction in the norepinephrine dose was the cause of death seems to me a bit too much and would not be credible even if an autopsy had been performed”, argues Professor Dan Langrois. What other states are doing with regard to so-called “treatment restrictions” Patients, while still perfectly healthy, can express their wishes within a legislative framework as to what happens to them if they might need to be hospitalized for ATI. The legislative framework in France, for example, as well as in other countries, also stipulates what happens in the absence of an “advance directive” that the patient has not left: “The second important factor is that in many Western countries the legislator has created a framework that is not extremely strict and that the patient can write an advance directive in a register while they are in good health and can say that if something happens to me, or if I am admitted to hospital for resuscitation, I do not want to be intubated and put on mechanical ventilation. These advance directives can be changed at any time, can of course be shared with the family and are an element of reflection for the doctor. In the absence of these advance directives, the team of intensive care doctors may take into account the evolution of the patient’s condition, his chronic diseases, what happens to him in intensive care and the response or non-response to the treatment, so that the hope of success in intensive care is very, very small, if not zero, and then inform the family, the legislator provides that the intensive care doctors are in contact with other intensive care doctors so that they are not both actors and referees, and then they ask their colleagues to give their opinion on the patient’s condition and then decide, not necessarily … In France, there is no euthanasia, but the limits of treatment escalation are decided, such as the decision not to exceed 5 mg of noradrenaline per hour, and in any case after this has occurred, we decide that in case of cardiac arrest, the patient should not be resuscitated because he has no hope of getting out of resuscitation in a state compatible with life, that is, acceptable even if not normal”, explains the professor. Professor Langrois says that the role of the family in the treatment limitation procedure is essential. He adds that the legal framework could also be extended for terminally ill patients who are not in intensive care. “Society must accept the fact that at some point it is not justifiable to escalate terminally ill patients because they do not have any benefit, they suffer and it does not make sense”, explains Professor Langrois. “So these procedures are called treatment restriction procedures in France, they are very legal, the family is of course involved, the role of the family can be important, the family can say we don’t agree, or say we meet every day, depending on what we will see evolve, it is a dialogue within a fairly fair legislative framework, and there are very few medico-legal issues. This legal framework can be extended to terminal patients in addition to intensive treatment, and we have found the best solution in this legal framework, first of all the patient consents, the family consents, and then no medical economic or cost considerations intervene, it is completely human. Patients, including young people, who have spent days or weeks in intensive care units survive despite modern treatment, but those who survive say that the suffering they have endured in intensive care units is terrible, and those who survive usually have a very low quality of life. This legislative framework seems to me to be a fundamental element, all Western countries have adopted it, not the same model, each country has created an adapted legislative framework, so the problem is no longer medical, nor legislative, but social, that is, society must accept the fact that at some point it is not justifiable to escalate the terminally ill endlessly, because they do not benefit, they suffer, and there is no point. In my opinion, this is a very important factor, if there is anything to learn from such cases, it is that this legal framework for terminally ill, terminally ill patients, whatever their disease, allows us to find solutions that are good for both the patient and the family. As far as I know, such a legal framework does not exist in Romania, so this limitation of treatment methods could benefit from a legislative framework”, says the doctor. Professor Longrois believes that the existence of this legislative framework in Romania means something. What does it mean for states where considerations related to the medical-economic aspect are important? “Society recognizes that medicine does not have unlimited power, and secondly, it creates an understanding relationship between patients, society and doctors, and the accusation against doctors that ‘you did not try your best’ will no longer exist. Therefore, in my opinion, the most important and useful solution for society, patients and medical institutions is a compromise solution that prioritizes patient care. There are countries in Western Europe where medical-economic considerations are very important. It is said that: “Society does not have unlimited economic means to take care of the sick”, and then a medical-economic calculation is made, and it is said that how much a year of good quality life costs, an Anglo-Saxon term that is also sacralized in the UK, for example, it is said that society can afford to spend 60,000 pounds a year to have a good quality life. When treating an AIDS patient in Africa, for example, it costs 2000 dollars to get one year of quality life. Treating a patient with advanced cancer in the last 2-3 months, even if they are young, will cost 250-300,000 dollars per quality year. There are some huge amounts, there are some countries, it is not the case in France, which does not have any medical economic constraints, but there are some Anglo-Saxon countries that are forced to pragmatism and care for fiscal balance and they have this size. Well, I don’t think it can be an argument for this discussion. Professor Longrois offers his Romanian colleagues support and expertise in the creation of a legislative framework related to treatment limitations. “I would like to, if I can contribute, do it with great pleasure for my colleagues in the Society of Anesthesia and Intensive Care, with whom I have been working for many years, and if my experience in France can help, I will be very happy to find a legislative framework that protects all actors, mainly patients”. Dan Longrois is Professor of Anesthesia and Intensive Care in Paris. Since 2008 he has been working at the Bichat-Claude Bernard Hospital (Assistance Publique-Hôpitaux de Paris). During his training he obtained a Doctor of Medicine degree and a PhD in Cardiovascular Pharmacology from the University of Paris VI. He was a postdoctoral fellow in the Cardiology Department of the Brigham and Women’s Hospital, Harvard Medical School, Boston. Professor Longrois was Director of the Department of Anesthesia and Intensive Care in Nancy, France, President of the French Perfusion Society, member of the Scientific Committee of the French Society of Anesthesia and Intensive Care and of the Cardiovascular Subcommittee of the European Society of Anesthesiology (ESA) from 2004 to 2008. Currently he is a member of the Board of Directors of the European Society of Anesthesiology (ESA).
[ad_2]
Source link
