In today’s podcast we set the stage with the story of Dax Cowart, who in 1973 was a 25 year old man horribly burned in a freak accident. Two thirds of his body was burned, most of his fingers were amputated, and he lost vision in both eyes. During his 14 month recovery Dax repeatedly demanded that he be allowed to die. The requests were ignored. After, he said he was both glad to be alive, and that the doctors should have respected his wish to be allowed to die.

But that was 1973, you might say. We don’t have such issues today, do we?

Louise Aronson’s recent perspective about her mother in the NEJM, titled, “Beyond Code Status” suggests no, we still struggle with this issue. And Bill Andereck is still haunted by the decision he made to have the police break down the door to rescue his patient who attempted suicide in the 1980s, as detailed in this essay in the Cambridge Quarterly of HealthCare Ethics. The issues that are raised by these situations are really hard, as they involve complex and sometimes competing ethical values, including:

• The duty to rescue, to save life, to be a “lifeguard”

• Judgements about quality of life, made on the part of patients about their future selves, and by clinicians (and surrogate decision makers) about patients

• Age realism vs agism

• The ethics of rationale suicide, subject of a prior GeriPal episode

• Changes in medical practice and training, a disconnect between longitudinal care and acute care, and frequent handoffs

• The limitations of advance directives, POLST, and code status orders in the electronic health record

• The complexities of patient preferences, which extend far beyond code status

• The tension between list vs goals based approaches to documentation in the EHR

And a great song request, “The Cape” by Guy Clark to start and end.

Enjoy!

-@AlexSmithMD