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Administrative Problems

The administrative disputes that arise between house officers and attending physicians usually involve the house officer's role in emergency treatment situations. The most common problem involves performance of cardiopulmonary resuscitation (CPR) on a terminal patient. A patient dying of a chronic or incurable disease may have several episodes of cardiopulmonary collapse. It may be possible to resuscitate the patient for a while, but it will not improve the underlying condition or significantly prolong the patient's life. These episodes can be very hard on family and friends who must endure the shock of the patient's "death" several times. They are also extraordinarily expensive, in both time and money. A typical CPR team may include four or five specially trained nurses and technicians, two or three physicians, and a chaplain or social worker. Large quantities of equipment and drugs are used, so the hospital may charge a set fee of $10 to $20 per minute on a procedure that can last a few minutes to a couple of hours. There is also the problem of other patients may have to be postponed. At night, the CPR team usually includes many or all of the house officers and most of the special care nurses.

If the hospital has a CPR team, there must be written rules to govern when a "code" is called, who answers it, who is in charge of the team, and what will be done. The house officer or other physician in charge will be responsible for deciding when the effort is hopeless and will have the legal responsibility for pronouncing a patient dead. The house officers and staff physicians will be bound by these rules, as should the members of the medical staff.

The problem arises when an attending physician does not wish to write an order stating that a patient is not a candidate for CPR. The patient and family may agree that they do not want "extraordinary measures" taken to prolong life, or the physician may realize these measures would be futile. But, unless there is a written record of this decision, the CPR team must automatically initiate extraordinary measures when the patient is in extremis.

Some attending physicians will try to get around the protocol by giving verbal orders to the nurses or house staff to "go slowly" or "not to try too hard" if the patient has a cardiopulmonary arrest. The quality control manager must make it clear to every physician who practices in the hospital that the written protocols for emergency procedures will be followed in all cases unless there are specific written orders to the contrary. Nurses and house staff should be instructed to refuse any verbal order, such as "go slow on the CPR." They should be instructed to report any physician who tries to give this type of order because the patient or family were not aware of the decision to let the patient die, the acceptance of such an order could involve the hospital in serious liability.

The risk manager should encourage the proper resolution of disputes between the house officer and the attending physicians. While it may be unpleasant for the members of the attending staff to have their authority questioned, it is more unpleasant to be a defendant in a malpractice lawsuit. The primary goal must be the prevention of patient injuries. To this end, the risk manager must keep disputes out in the open rather than let one group pressure the other in silence.

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