Instruction: Female, 50, 5 5, 215 pounds, never smoked, seizures, chronic stomach issues like abdominal migraine and ileuses, breast cancer.I have lifelong chronic digestive issues, stemming from a major exploratory surgery when I was 5 years old. About 20 years ago, I started having major issues requiring hospitalization with NG tubes and all kinds of other fun stuff because of the adhesions from the 1974 surgery hardening and choking my intestines.Starting in 2006, after many other things failed, doctors treated both the pain and the hyperactive bowels using Dilaudid. Over the past 13 years, my tolerance has increased, through absolutely nothing but closely monitored physician prescriptions and instructions. Through all of these years, I have taken some hefty narcotics for about one week every month, and not at all the other three weeks. I have thanked God a thousand times that I don't appear prone to any type of addiction (Never smoked, drink a couple of times a year, no illegal drugs whatsoever, couldn't care less about gambling, etc. My worst vice is Amazon.)Between this and absorption/metabolic condition, I get extremely little relief from the highest oral dosage that my PCP is comfortable with: 8mg every 6 hours.I'm currently in breast cancer treatment, halfway through Herceptin infusions that are supposed to continue through September. From the very beginning, Herceptin gave me diarrhea, and it has worsened to date to the point that I am in the hospital about one out of every three weeks because such severe diarrhea that I am dehydrated, critically low on magnesium, excruciating cramps because it flares my chronic condition, and you can imagine the rest.Two weeks ago I went to the emergency room with the usual symptoms, was given my now usual dose of two milligrams IV Dilaudid immediately followed by 1 mg every 3 hours for the next 8 days inpatient. Normally, they start tapering off by spreading out doses around day 4 and I am home and much more comfortable by day 8. This time, however, they noticed significant thickening of my colon on a CT scan, so on day six, when the Dilaudid had just calmed my bowels and decreased my pain, they had me do colonoscopy prep, which not surprising brought excruciating pain back with 18 hours of non-stop diarrhea.SO... hospitalist has access to 13 years of hospital records outlining the progression of all of this, has recent records showing mastectomy, Herceptin, labs consistent with six months of diarrhea... yet still harangued me the entire visit, accusing me of being there basically faking it for the Dilaudid. I could never keep him focused enough on my actual issues to get any help from him or get any questions answered because he was so convinced that there was no illness, only addiction. He claimed he read my records. I couldn't get him to call any of my other doctors. I couldn't get him to look at the December prescription bottle the nurses took from my purse and locked up that was still half full. The day of the colonoscopy, for the first time in my life, I told them I was a 9 on a scale of 1 to 10 in pain ... I'm very conservative with those numbers. Asked if I could have just one dose of 2mg of Dilaudid to get me back on track and was denied. Then he started the discharge process that day... with renewed diarrhea every couple of hours and 9 on the pain scale AND no tapering of Dilaudid. Being on Medicare (disability on the first try, approved in 2017 in less than 90 days due to the severity of illness), I threatened to report him because I didn't believe I was ready for discharge, and he told me with hostility that I could stay one more day but then I was out.I was discharged with the same level of diarrhea I went in with, more pain that I went in with, and spent three lovely days in bed crying my way through Dilaudid withdrawal. All caused by a doctor who lectured me for 4 days on the opioid epidemic. I can't imagine how many people would have become addicted in my situation instead of just gutting out the withdrawal.How do I get this to stop? Isn't there any overarching agency or physician type or anything I can do to have it documented once and for all that there has never been an addiction problem and that there is a room full of files documenting the illness and the reason for the medication?I'm seriously considering stopping life-saving breast cancer medication because on top of all of the pain and diarrhea, I can't face another week like the week he put me through. This wasn't my first experience with a doctor so obsessed with this notion, but it was by far the worst.What the hell are people with decades of documentation, debilitating chronic illness, and zero evidence of any addiction at any time supposed to do?

Output: I read it somewhere in this but you need to 1) go to a pain clinic and 2) have a medication contract that may even cover pain crisisDilaudid isn't a great chronic opiod and ideally you should be switched to methadone or buprenorphine, but again, that's something that should be discussed at the pain clinic.Also, I would reexplore with a GI your hyperactive bowels and see if you can find an alternative to opioids for it's management.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Female, 50, 5 5, 215 pounds, never smoked, seizures, chronic stomach issues like abdominal migraine and ileuses, breast cancer.I have lifelong chronic digestive issues, stemming from a major exploratory surgery when I was 5 years old. About 20 years ago, I started having major issues requiring hospitalization with NG tubes and all kinds of other fun stuff because of the adhesions from the 1974 surgery hardening and choking my intestines.Starting in 2006, after many other things failed, doctors treated both the pain and the hyperactive bowels using Dilaudid. Over the past 13 years, my tolerance has increased, through absolutely nothing but closely monitored physician prescriptions and instructions. Through all of these years, I have taken some hefty narcotics for about one week every month, and not at all the other three weeks. I have thanked God a thousand times that I don't appear prone to any type of addiction (Never smoked, drink a couple of times a year, no illegal drugs whatsoever, couldn't care less about gambling, etc. My worst vice is Amazon.)Between this and absorption/metabolic condition, I get extremely little relief from the highest oral dosage that my PCP is comfortable with: 8mg every 6 hours.I'm currently in breast cancer treatment, halfway through Herceptin infusions that are supposed to continue through September. From the very beginning, Herceptin gave me diarrhea, and it has worsened to date to the point that I am in the hospital about one out of every three weeks because such severe diarrhea that I am dehydrated, critically low on magnesium, excruciating cramps because it flares my chronic condition, and you can imagine the rest.Two weeks ago I went to the emergency room with the usual symptoms, was given my now usual dose of two milligrams IV Dilaudid immediately followed by 1 mg every 3 hours for the next 8 days inpatient. Normally, they start tapering off by spreading out doses around day 4 and I am home and much more comfortable by day 8. This time, however, they noticed significant thickening of my colon on a CT scan, so on day six, when the Dilaudid had just calmed my bowels and decreased my pain, they had me do colonoscopy prep, which not surprising brought excruciating pain back with 18 hours of non-stop diarrhea.SO... hospitalist has access to 13 years of hospital records outlining the progression of all of this, has recent records showing mastectomy, Herceptin, labs consistent with six months of diarrhea... yet still harangued me the entire visit, accusing me of being there basically faking it for the Dilaudid. I could never keep him focused enough on my actual issues to get any help from him or get any questions answered because he was so convinced that there was no illness, only addiction. He claimed he read my records. I couldn't get him to call any of my other doctors. I couldn't get him to look at the December prescription bottle the nurses took from my purse and locked up that was still half full. The day of the colonoscopy, for the first time in my life, I told them I was a 9 on a scale of 1 to 10 in pain ... I'm very conservative with those numbers. Asked if I could have just one dose of 2mg of Dilaudid to get me back on track and was denied. Then he started the discharge process that day... with renewed diarrhea every couple of hours and 9 on the pain scale AND no tapering of Dilaudid. Being on Medicare (disability on the first try, approved in 2017 in less than 90 days due to the severity of illness), I threatened to report him because I didn't believe I was ready for discharge, and he told me with hostility that I could stay one more day but then I was out.I was discharged with the same level of diarrhea I went in with, more pain that I went in with, and spent three lovely days in bed crying my way through Dilaudid withdrawal. All caused by a doctor who lectured me for 4 days on the opioid epidemic. I can't imagine how many people would have become addicted in my situation instead of just gutting out the withdrawal.How do I get this to stop? Isn't there any overarching agency or physician type or anything I can do to have it documented once and for all that there has never been an addiction problem and that there is a room full of files documenting the illness and the reason for the medication?I'm seriously considering stopping life-saving breast cancer medication because on top of all of the pain and diarrhea, I can't face another week like the week he put me through. This wasn't my first experience with a doctor so obsessed with this notion, but it was by far the worst.What the hell are people with decades of documentation, debilitating chronic illness, and zero evidence of any addiction at any time supposed to do?. ### Response: I read it somewhere in this but you need to 1) go to a pain clinic and 2) have a medication contract that may even cover pain crisisDilaudid isn't a great chronic opiod and ideally you should be switched to methadone or buprenorphine, but again, that's something that should be discussed at the pain clinic.Also, I would reexplore with a GI your hyperactive bowels and see if you can find an alternative to opioids for it's management..


Instruction: Awaiting my follow up appointment after questionable minimal supravermian atrophy that was found on my brain MRI last week. Im unable to find valuable information with the phrase supravermian atrophy online. Im hoping someone can shed some light on what a finding like this could possibly be related to. Im too impatient to wait until my follow-up to learn more about it.27F, 5 8, 138 lbs, European ancestry. I work full-time as a critical care RN in a peds ICU. History of gangrenous appendicitis age 5, Guillain barre related to a suspected tick-borne pathogen age 8, asthma (controlled by corticosteroids,) anxiety (relieved with PRN benzos,) vasovagal syncope episodes during ovulation since the age 16. I spent my early childhood on military bases with known toxic contamination (Fort McClellan, Fort Bragg.) I dont do drugs, I drink maybe 1-2 times a month. PALB2 & CHEK2 gene mutations. Dad was diagnosed with stage IV Glioblastoma, age 48. Paternal uncle died of a brain tumor age 3. Paternal aunt had endometrial cancer at 27. Mom has history of substance abuse, Sjogrens, rheumatoid arthritis. Maternal grandpa received a heart transplant (acquired heart disease,) maternal grandma and aunt had ductal cell carcinoma (after menopause.) I was out of work for over a month due to an intermittent fever ranging 99-103. No pathogens detected in my pancultures. Blood work was normal: CBC, BMP, TSH, HIV, Syphilis, B12, Vit-D, thiamine, folate. In the past year Ive had the following symptoms: fatigue (I could sleep 16 hours a day if I was able,) dizziness, occasional double vision, compulsive sighing/feeling out of breath, itchy/burning armpits, twitching throughout my body, headaches (~3/week,) cold hands and feet, high blood pressure, stress and urge incontinence (especially around ovulation,) severe abdominal pain right before a bowel movement, sometimes I pass out from the pain. Ive noticed changes in my speech: fluency, long pauses between words, losing track of sentences. I cant hear people or retain information unless Im staring directly at them, and I have worsening sound sensitivity. My memory has suffered. I will quickly lose new information and have difficulty recalling information on the spot. I find bruises on myself because Im clunky and clumsy.I want to feel young, healthy, and happy. Please help.

Output: Can you post the full MRI report? I too have trouble understanding what that term means; the vermis is a part of the cerebellum, but the space above it (supravermian) in my experience refers to a space containing CSF, not brain tissue.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Awaiting my follow up appointment after questionable minimal supravermian atrophy that was found on my brain MRI last week. Im unable to find valuable information with the phrase supravermian atrophy online. Im hoping someone can shed some light on what a finding like this could possibly be related to. Im too impatient to wait until my follow-up to learn more about it.27F, 5 8, 138 lbs, European ancestry. I work full-time as a critical care RN in a peds ICU. History of gangrenous appendicitis age 5, Guillain barre related to a suspected tick-borne pathogen age 8, asthma (controlled by corticosteroids,) anxiety (relieved with PRN benzos,) vasovagal syncope episodes during ovulation since the age 16. I spent my early childhood on military bases with known toxic contamination (Fort McClellan, Fort Bragg.) I dont do drugs, I drink maybe 1-2 times a month. PALB2 & CHEK2 gene mutations. Dad was diagnosed with stage IV Glioblastoma, age 48. Paternal uncle died of a brain tumor age 3. Paternal aunt had endometrial cancer at 27. Mom has history of substance abuse, Sjogrens, rheumatoid arthritis. Maternal grandpa received a heart transplant (acquired heart disease,) maternal grandma and aunt had ductal cell carcinoma (after menopause.) I was out of work for over a month due to an intermittent fever ranging 99-103. No pathogens detected in my pancultures. Blood work was normal: CBC, BMP, TSH, HIV, Syphilis, B12, Vit-D, thiamine, folate. In the past year Ive had the following symptoms: fatigue (I could sleep 16 hours a day if I was able,) dizziness, occasional double vision, compulsive sighing/feeling out of breath, itchy/burning armpits, twitching throughout my body, headaches (~3/week,) cold hands and feet, high blood pressure, stress and urge incontinence (especially around ovulation,) severe abdominal pain right before a bowel movement, sometimes I pass out from the pain. Ive noticed changes in my speech: fluency, long pauses between words, losing track of sentences. I cant hear people or retain information unless Im staring directly at them, and I have worsening sound sensitivity. My memory has suffered. I will quickly lose new information and have difficulty recalling information on the spot. I find bruises on myself because Im clunky and clumsy.I want to feel young, healthy, and happy. Please help.. ### Response: Can you post the full MRI report? I too have trouble understanding what that term means; the vermis is a part of the cerebellum, but the space above it (supravermian) in my experience refers to a space containing CSF, not brain tissue..


Instruction: Hi so I (23f) have had a sudden onset of joint pain mostly in my hands and arms. It may have been more gradual than I noticed, but this week has been very brutal! Its like my finger joints are just VERY achey and my elbows are also in pain fairly frequently (mostly when my elbows are bent).I work on a computer all day, but am not a typist. I am usually working on excel spreadsheets doing data analysis which I guess I never thought of as typing as its more of a critical thinking thing as my main task. That being said my hands are on a keyboard for the majority of the day.Now my FIL had surgery for carpal tunnel syndrome last year, and it feels like exactly what he described and I am panicking a bit bc I didnt really think that I was a candidate for having this issue so early on in my life! Is it possible that I have carpal tunnel syndrome? What else could it be?Im just scared of the financial ramifications an issue like this may have (Im broke as shit!! But I do have insurance!), but I obviously want to take care of it ASAP instead of letting it get worse. What should my course of action be/how long should I wait before getting it checked out in person?Thanks in advance for your time!ETA: not sure if this is relevant to this issue, but I am in relatively good health. I am overweight but have lost around 50 pounds since the beginning of the year and am well on my way to a healthy weight. I eat mostly cleanly and walk a lot. I used to be an avid weightlifter but have not gotten back into it after a knee injury in 2018 (big part of how I became overweight... lack of movement & depression from losing my job & other stresses due to my injury). I also was a 4 sport athlete in high school: softball, swimming, track & field (discus & shot put), and volleyball. I dont know if any of this is helpful but if it could be a contributing factor I thought I would mention it.

Output: Yes, it's possible for you to have carpal tunnel- it just really depends on your level of activity with hands.You aren't locked into surgery. I'd start with getting an ergonomic setup for yourself and taking frequent breaks from typing. I would also look into getting a wrist brace to sleep with at night, and begin using that for a week or two and seeing if you improve. Chances are if you take early action you won't need surgery for quite some time- if ever.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Hi so I (23f) have had a sudden onset of joint pain mostly in my hands and arms. It may have been more gradual than I noticed, but this week has been very brutal! Its like my finger joints are just VERY achey and my elbows are also in pain fairly frequently (mostly when my elbows are bent).I work on a computer all day, but am not a typist. I am usually working on excel spreadsheets doing data analysis which I guess I never thought of as typing as its more of a critical thinking thing as my main task. That being said my hands are on a keyboard for the majority of the day.Now my FIL had surgery for carpal tunnel syndrome last year, and it feels like exactly what he described and I am panicking a bit bc I didnt really think that I was a candidate for having this issue so early on in my life! Is it possible that I have carpal tunnel syndrome? What else could it be?Im just scared of the financial ramifications an issue like this may have (Im broke as shit!! But I do have insurance!), but I obviously want to take care of it ASAP instead of letting it get worse. What should my course of action be/how long should I wait before getting it checked out in person?Thanks in advance for your time!ETA: not sure if this is relevant to this issue, but I am in relatively good health. I am overweight but have lost around 50 pounds since the beginning of the year and am well on my way to a healthy weight. I eat mostly cleanly and walk a lot. I used to be an avid weightlifter but have not gotten back into it after a knee injury in 2018 (big part of how I became overweight... lack of movement & depression from losing my job & other stresses due to my injury). I also was a 4 sport athlete in high school: softball, swimming, track & field (discus & shot put), and volleyball. I dont know if any of this is helpful but if it could be a contributing factor I thought I would mention it.. ### Response: Yes, it's possible for you to have carpal tunnel- it just really depends on your level of activity with hands.You aren't locked into surgery. I'd start with getting an ergonomic setup for yourself and taking frequent breaks from typing. I would also look into getting a wrist brace to sleep with at night, and begin using that for a week or two and seeing if you improve. Chances are if you take early action you won't need surgery for quite some time- if ever..


Instruction: Wow, that is great news! Will that help with the elbow pain as well? Also do I still need to see a specialist or set something up with my primary care physician?

Output: It can help with the elbow as well, yes.If you end up seeing a doctor they will tell you what I just did. I'd say hold off and start with what was mentioned unless it progresses significantly or it starts actively impacting your ability to function.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Wow, that is great news! Will that help with the elbow pain as well? Also do I still need to see a specialist or set something up with my primary care physician?. ### Response: It can help with the elbow as well, yes.If you end up seeing a doctor they will tell you what I just did. I'd say hold off and start with what was mentioned unless it progresses significantly or it starts actively impacting your ability to function..


Instruction: Hey, for the past year or so I've been smoking socially (about twice a month). I know that death/critical care rates are much higher for smokers, but I haven't smoked in about a month and don't plan to start again so where does that put me? I'm an otherwise healthy, moderately fit 18 year old. I know info isn't available for covid19, so if you know this regarding respiratory infections in general let me know, anything is helpful

Output: Puts you somewhere between the smokers and the non-smokers, closer to the non-smoker side of things. Good on you for planning not to smoke again. That's about the best thing you can do.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Hey, for the past year or so I've been smoking socially (about twice a month). I know that death/critical care rates are much higher for smokers, but I haven't smoked in about a month and don't plan to start again so where does that put me? I'm an otherwise healthy, moderately fit 18 year old. I know info isn't available for covid19, so if you know this regarding respiratory infections in general let me know, anything is helpful. ### Response: Puts you somewhere between the smokers and the non-smokers, closer to the non-smoker side of things. Good on you for planning not to smoke again. That's about the best thing you can do..


Instruction: Age: 30sSex: MaleHeight : 5Ft 8inWeight: 180Race: LatinoDuration of complaint: 5 months+Location: Texas, US. Abdominal pain, blood in stool.Medical Issue: Had recurring blood in stool that increased in intensity and frequency. Saw doctor and prescribed Cipro after which frequency of bowel movements and amount of blood increased. Given prednisone which seemed to increase amount of blood in stool. Had CT scan of abdomen which revealed hepatic mass lesions. Primary care doctor advised and arranged for admission to emergency room for an MRI of the abdomen. ER doctor however reviewed scans from CT and believed they were cysts and wouldn't proceed with MRI. ER doctor emphasized need for colonoscopy first which I have scheduled for 31st, but he worries that is too far away. For reference it took me 6 weeks to get the CT scan. I didn't get a referral/authorization for an MRI from my primary care doctor. ER doctor told me to return on Monday and that I may possibly be scheduled for colonoscopy through their hospital. How critical is all this? I'm worried as I now have to wait the weekend at minimum, but likely will have additional weeks of waiting for paperwork/insurance authorization/scheduling before I can get these procedures.

Output: You didnt mention any blood test results (e.g. liver function test).Also, did the imaging study not reveal anything in your GI tract?Either way, yes you should undergo a colonoscopy as soon as possible. The results of the colonoscopy will inform further management decisions.If you feel like fainting, or experience any symptoms that you consider to be drastic, go to the ER.Best wishes.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Age: 30sSex: MaleHeight : 5Ft 8inWeight: 180Race: LatinoDuration of complaint: 5 months+Location: Texas, US. Abdominal pain, blood in stool.Medical Issue: Had recurring blood in stool that increased in intensity and frequency. Saw doctor and prescribed Cipro after which frequency of bowel movements and amount of blood increased. Given prednisone which seemed to increase amount of blood in stool. Had CT scan of abdomen which revealed hepatic mass lesions. Primary care doctor advised and arranged for admission to emergency room for an MRI of the abdomen. ER doctor however reviewed scans from CT and believed they were cysts and wouldn't proceed with MRI. ER doctor emphasized need for colonoscopy first which I have scheduled for 31st, but he worries that is too far away. For reference it took me 6 weeks to get the CT scan. I didn't get a referral/authorization for an MRI from my primary care doctor. ER doctor told me to return on Monday and that I may possibly be scheduled for colonoscopy through their hospital. How critical is all this? I'm worried as I now have to wait the weekend at minimum, but likely will have additional weeks of waiting for paperwork/insurance authorization/scheduling before I can get these procedures.. ### Response: You didnt mention any blood test results (e.g. liver function test).Also, did the imaging study not reveal anything in your GI tract?Either way, yes you should undergo a colonoscopy as soon as possible. The results of the colonoscopy will inform further management decisions.If you feel like fainting, or experience any symptoms that you consider to be drastic, go to the ER.Best wishes..


Instruction: Sorry in advance for the formatting. My mother is the patient. She is a 62 year old female, 52, ~140 lbs, a caucasian, and she has several issues with chronic pain/osteoporosis/degenerative disc disease/some nerve issues/arthritis that her doctor has prescribed a 12.5 mcg fentanyl patch for that she changes every two or three days. She was on a higher dose when she started using the patches but she did not like the side effects, so her doctor cut the fentanyl dose in half to 12.5 mcg. She is taking lexapro, wellbutrin, a blood pressure medication (I think bystolic), montekulast, and possibly a diuretic (unsure if shes still taking that) daily. As needed, she is prescribed voltaren gel and voltaren pills, Valium, and norco (hydrocodone 10/325). She has some additional health issues that arent relevant to my concerns (high bp, asthma, primary lymphedema, some allergies. Dementia runs in her family, but the people who have had it have all been very sharp until their early 80s.Since she has been on the fentanyl patch for a few months now, my fatherwho is a physician himselfand I (who live with her) have noticed some very concerning things. We all see the same physician, so he knows all of us and our character. I would like to tell the doctor about these concerns using a letter, but Im not sure if Im being too wordy or if I should contact him another way. Please give me your constructive criticism as to how I can effectively communicate with him so these concerns get addressed. Heres what I have written:Dr. Doctor,I am writing out of concern for my mother, [major_bummers mom] (DOB XX/XX/XXXX). I am aware that I have no power regarding my mothers care and no right to her personal health information. However, as a daughter, I have some concerns regarding my mothers current usage of the fentanyl patches you prescribe her. I wanted to reach out to you about them personally because I dont think she has the mental ability to realize how much of a toll these patches have taken on her. I realize not all of these concerns I have about her cognitive ability/memory/ability to preform daily functions could be attributed to her use of the fentanyl patches, but the timing leads me to think it is the cause.My father and I noticed that about two weeks after my mother began using the fentanyl patches, her overall productivity became much less than normal. She is now spending her days sleeping as much as she can (10 hrs per night with a 3-4 hr nap) and gets a significantly less amount of work done compared to before she started using the patches. She says she thinks her pain is under better control with the patch, but her avoidance of physical activity and her daily complaints of increasing or new pains tell me it is not working as well as originally hoped.My mother has seemed to slowly lose her critical thinking skills, her ability to remember things, and speak/think at her normal speed. She was the type of person to remember where everything in the house is, even years after it was put somewhere, but now she has started to lose things such as everyday items, important documents/records, and even her own controlled medications. (She normally hides them so she has to think about where they are before taking a narcotic, but recently she forgot where she put all of her scheduled medications and had my dad and I flipping the house upside down looking for them for about 6 hours. She also separated one fentanyl patch from the others and has been saying she has been unable to find it for days, making me wonder if she actually put two on.) Along with my concerns about her memory is that in the past month and a half or so, she has started remembering things that have never happened/things shes made up in her head and has been unintentionally giving my father and I completely false information, which has caused a lot of frustration within the family. She will become unnecessarily upset with us as she genuinely doesnt realize some of her memories are extremely inaccurate or have never been real. Usually, this results in an argument with her until she either gives up or understands our explanations as to how and why what she remembered couldnt have happened. She often asks the same basic question (such as are you going to work today?) several times per day because she doesnt remember the answer from the first three times shes asked. Her accounts of something that weve both seen are usually inaccurate.On bad days, her speech is sometimes very slowalmost incomprehensibleand my dad and I have to either work on completing her sentences for her or ask her to form a complete thought/statement before speaking. I dont feel like the person Im talking to is my mother and is instead someone that is either mentally handicapped, drunk and drowsy, or demented. She often seems mentally absent or half asleep when I am trying to have a normal conversation with her, even with no distractions.Lastly, my biggest concern is that her ability to react to things has slowed down substantially since she began having a strong opiate in her system on a constant basis. When I have the opportunity, I ask/offer to drive her places because she is a danger to herself and others behind the wheel. She has made a habit of going below the speed limit and stopping at places she has the right-of-way to be a safer driver, in her words. This is a woman that used to love to drive fast cars on racetracks. She has started to slam on the brakes when she approaches a stopping point because she does not slow down in time to stop properly/safely. It seems that her situational awareness has taken a nosedive since she started using the patches. If she were to cause an accident, which she has almost done on many occasions since starting the fentanyl patch, a police officer would absolutely see she is driving while incapacitated/under the influence of a drug.It pains me to see my mother like this and hope you understand my concerns. I am grateful for your time reading this letter and hope you will keep my observations in mind when proceeding with my mothers care. My family and I very much appreciate all that you have done for us. If you need further detail or have any questions, please dont hesitate to give me a call.Sincerely,Major_bummerEdit: added some additional health information and fixed grammar

Output: Make it shorter and send it. The goal of pain management (in patients without terminal illness) isnt to completely eliminate pain or get people on government disability. Its to get their pain to a level that is tolerable enough for them to main functionality (keep being employed, for example). Sounds like your mom is on too many narcotics. Based on the problems you told me (all musculoskeletal), she probably needs to be tapered off narcotics completely.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Sorry in advance for the formatting. My mother is the patient. She is a 62 year old female, 52, ~140 lbs, a caucasian, and she has several issues with chronic pain/osteoporosis/degenerative disc disease/some nerve issues/arthritis that her doctor has prescribed a 12.5 mcg fentanyl patch for that she changes every two or three days. She was on a higher dose when she started using the patches but she did not like the side effects, so her doctor cut the fentanyl dose in half to 12.5 mcg. She is taking lexapro, wellbutrin, a blood pressure medication (I think bystolic), montekulast, and possibly a diuretic (unsure if shes still taking that) daily. As needed, she is prescribed voltaren gel and voltaren pills, Valium, and norco (hydrocodone 10/325). She has some additional health issues that arent relevant to my concerns (high bp, asthma, primary lymphedema, some allergies. Dementia runs in her family, but the people who have had it have all been very sharp until their early 80s.Since she has been on the fentanyl patch for a few months now, my fatherwho is a physician himselfand I (who live with her) have noticed some very concerning things. We all see the same physician, so he knows all of us and our character. I would like to tell the doctor about these concerns using a letter, but Im not sure if Im being too wordy or if I should contact him another way. Please give me your constructive criticism as to how I can effectively communicate with him so these concerns get addressed. Heres what I have written:Dr. Doctor,I am writing out of concern for my mother, [major_bummers mom] (DOB XX/XX/XXXX). I am aware that I have no power regarding my mothers care and no right to her personal health information. However, as a daughter, I have some concerns regarding my mothers current usage of the fentanyl patches you prescribe her. I wanted to reach out to you about them personally because I dont think she has the mental ability to realize how much of a toll these patches have taken on her. I realize not all of these concerns I have about her cognitive ability/memory/ability to preform daily functions could be attributed to her use of the fentanyl patches, but the timing leads me to think it is the cause.My father and I noticed that about two weeks after my mother began using the fentanyl patches, her overall productivity became much less than normal. She is now spending her days sleeping as much as she can (10 hrs per night with a 3-4 hr nap) and gets a significantly less amount of work done compared to before she started using the patches. She says she thinks her pain is under better control with the patch, but her avoidance of physical activity and her daily complaints of increasing or new pains tell me it is not working as well as originally hoped.My mother has seemed to slowly lose her critical thinking skills, her ability to remember things, and speak/think at her normal speed. She was the type of person to remember where everything in the house is, even years after it was put somewhere, but now she has started to lose things such as everyday items, important documents/records, and even her own controlled medications. (She normally hides them so she has to think about where they are before taking a narcotic, but recently she forgot where she put all of her scheduled medications and had my dad and I flipping the house upside down looking for them for about 6 hours. She also separated one fentanyl patch from the others and has been saying she has been unable to find it for days, making me wonder if she actually put two on.) Along with my concerns about her memory is that in the past month and a half or so, she has started remembering things that have never happened/things shes made up in her head and has been unintentionally giving my father and I completely false information, which has caused a lot of frustration within the family. She will become unnecessarily upset with us as she genuinely doesnt realize some of her memories are extremely inaccurate or have never been real. Usually, this results in an argument with her until she either gives up or understands our explanations as to how and why what she remembered couldnt have happened. She often asks the same basic question (such as are you going to work today?) several times per day because she doesnt remember the answer from the first three times shes asked. Her accounts of something that weve both seen are usually inaccurate.On bad days, her speech is sometimes very slowalmost incomprehensibleand my dad and I have to either work on completing her sentences for her or ask her to form a complete thought/statement before speaking. I dont feel like the person Im talking to is my mother and is instead someone that is either mentally handicapped, drunk and drowsy, or demented. She often seems mentally absent or half asleep when I am trying to have a normal conversation with her, even with no distractions.Lastly, my biggest concern is that her ability to react to things has slowed down substantially since she began having a strong opiate in her system on a constant basis. When I have the opportunity, I ask/offer to drive her places because she is a danger to herself and others behind the wheel. She has made a habit of going below the speed limit and stopping at places she has the right-of-way to be a safer driver, in her words. This is a woman that used to love to drive fast cars on racetracks. She has started to slam on the brakes when she approaches a stopping point because she does not slow down in time to stop properly/safely. It seems that her situational awareness has taken a nosedive since she started using the patches. If she were to cause an accident, which she has almost done on many occasions since starting the fentanyl patch, a police officer would absolutely see she is driving while incapacitated/under the influence of a drug.It pains me to see my mother like this and hope you understand my concerns. I am grateful for your time reading this letter and hope you will keep my observations in mind when proceeding with my mothers care. My family and I very much appreciate all that you have done for us. If you need further detail or have any questions, please dont hesitate to give me a call.Sincerely,Major_bummerEdit: added some additional health information and fixed grammar. ### Response: Make it shorter and send it. The goal of pain management (in patients without terminal illness) isnt to completely eliminate pain or get people on government disability. Its to get their pain to a level that is tolerable enough for them to main functionality (keep being employed, for example). Sounds like your mom is on too many narcotics. Based on the problems you told me (all musculoskeletal), she probably needs to be tapered off narcotics completely..


Instruction: Would a bulleted list be more appropriate for a busy doctor?She has been on narcotics for years as her spine is not in good shape at all (we almost went overseas for better spine surgery technology but couldnt afford it) so I doubt shell get off of the narcotics entirely anytime soon. Shes one of the few patients with enough pain that she qualifies for disability and deserves a relatively strong opiate, but not as strong as fentanyl. I still feel like she was doing better mentally taking more hydrocodone daily instead of using a constantly releasing fentanyl patch. Granted I wasnt in the room when he initially prescribed the fentanyl patches, but it seems like a huge leap to go from 3 hydrocodone per day to fentanyl without trying something like an extended release opiate that isnt as strong as fentanyl + comes with less risks. I know shes tried things like gabapentin and lyrica before but her body didnt like them too much and she reacted to them strongly.

Output: There is no evidence that opioids work any better than over the counter meds for chronic, non-cancer-related musculoskeletal pain, so your assertion that she deserves a strong opioid is specious at best. Fentanyl is no better or worse than long-acting opioids, it is the dose that is most important. Regardless, her current situation is not acceptable (being zonked all day long) and I would argue that you have an obligation to notify their prescriber.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Would a bulleted list be more appropriate for a busy doctor?She has been on narcotics for years as her spine is not in good shape at all (we almost went overseas for better spine surgery technology but couldnt afford it) so I doubt shell get off of the narcotics entirely anytime soon. Shes one of the few patients with enough pain that she qualifies for disability and deserves a relatively strong opiate, but not as strong as fentanyl. I still feel like she was doing better mentally taking more hydrocodone daily instead of using a constantly releasing fentanyl patch. Granted I wasnt in the room when he initially prescribed the fentanyl patches, but it seems like a huge leap to go from 3 hydrocodone per day to fentanyl without trying something like an extended release opiate that isnt as strong as fentanyl + comes with less risks. I know shes tried things like gabapentin and lyrica before but her body didnt like them too much and she reacted to them strongly.. ### Response: There is no evidence that opioids work any better than over the counter meds for chronic, non-cancer-related musculoskeletal pain, so your assertion that she deserves a strong opioid is specious at best. Fentanyl is no better or worse than long-acting opioids, it is the dose that is most important. Regardless, her current situation is not acceptable (being zonked all day long) and I would argue that you have an obligation to notify their prescriber..


Instruction: Age 16Female110lbs, maybe lessRussiaHello doctors,Our relative was hit by a car. We don't know many details at this time except that she is out of critical condition, but still unconscious.The reason for posting is because it's Russia and for most part, doctors don't really care for their patients, especially if it's a public hospital.Can someone please tell me what are some of the must be done tests, scans, blood work after an accident.Thank you

Output: It's impossible to know without knowing how exactly they were injured. I would assume that if she is unconscious, they would do some kind of imaging of her brain to make sure there isn't any bleeding in there.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Age 16Female110lbs, maybe lessRussiaHello doctors,Our relative was hit by a car. We don't know many details at this time except that she is out of critical condition, but still unconscious.The reason for posting is because it's Russia and for most part, doctors don't really care for their patients, especially if it's a public hospital.Can someone please tell me what are some of the must be done tests, scans, blood work after an accident.Thank you. ### Response: It's impossible to know without knowing how exactly they were injured. I would assume that if she is unconscious, they would do some kind of imaging of her brain to make sure there isn't any bleeding in there..


Instruction: For example, this morning we had a 63 yo patient that had been sinus tach since her admission a day or two ago. She was alert but not fully oriented during morning rounds. This morning, over the course of an hour, she slowly went from 115 to the 40s. She ended up bradying down and a code was called. There was a short run of vtach right before we started coding her. She ended up regaining spontaneous circulation and was moved from step down to ICU.As far as her history, I barely saw her chart. I know she was suffering from c diff and chest pain. There was critical care protocol for fentanyl and propofol but other than that I have no idea.Is this something related to electrolytes? Cardiac issues? Need more information? Her ekg strips were normal sinus tach prior to the event. Ive also seen this in other patients that were DNR where they just Bradyd to asystole. Any insight is appreciated.

Output: Definitely need more info. Bradying down essentially just means someone is dying. So for that patient in the ICU I'm gonna assume she has lots of possible reasons to die. Electrolytes absolutely, acid/base yes, hypoxia, hypotension, MI, PE etc etc. The list is literally endless. Brady codes are the most frequent ones I have seen usually.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: For example, this morning we had a 63 yo patient that had been sinus tach since her admission a day or two ago. She was alert but not fully oriented during morning rounds. This morning, over the course of an hour, she slowly went from 115 to the 40s. She ended up bradying down and a code was called. There was a short run of vtach right before we started coding her. She ended up regaining spontaneous circulation and was moved from step down to ICU.As far as her history, I barely saw her chart. I know she was suffering from c diff and chest pain. There was critical care protocol for fentanyl and propofol but other than that I have no idea.Is this something related to electrolytes? Cardiac issues? Need more information? Her ekg strips were normal sinus tach prior to the event. Ive also seen this in other patients that were DNR where they just Bradyd to asystole. Any insight is appreciated.. ### Response: Definitely need more info. Bradying down essentially just means someone is dying. So for that patient in the ICU I'm gonna assume she has lots of possible reasons to die. Electrolytes absolutely, acid/base yes, hypoxia, hypotension, MI, PE etc etc. The list is literally endless. Brady codes are the most frequent ones I have seen usually..


Instruction: I'm trying to understand a current family situation where I believe doctors are being hasty with care.My brother in law, about 30 years old 6ft 250lbs, is currently in the hospital for acute pancreatitis due to alcoholism which stressed the one kidney he had (genetic one kidney). He's currently sedated on vent, dialysis crrt, and insulin drip. He was admitted a week ago after he called an ambulance. With only symptoms being nausea and stomach pain. Since being admitted he was bumped down to 30% oxygen with breathing therapy, 5.0 PEEP, and his vitals and blood work were all in normal ranges for an adult male. Then they lessened his sedation and he was responsive. Hand squeezing and pointing. However other blood work and vitals dipped a bit after he had breathing trouble from bile due to pancreatitis.Additional: I think initial intubation was due to shock/hyperventilation upon admission or lung infection? Doctors have said all organs are viable. Torso MRI showed a good gallbladder, liver, and lungs without liquid. Family told they should not worry about organ donation yet(family match donation to improve health). Organs are not necrotic.I'm not trying to decide if my BIL needs a DNR. That's not my choice to make. I'm just curious how doctors factor offering it or when it's needed.TLDR; So, why would a doctor recommend a DNR for such a young patient that could seemingly recover? When do you consider patients to be at a point of no return? Is it standard to ask any critical patients to sign a DNR? Do Doctors weigh stats before offering or just their judgement?If you were this patient would you ask for a DNR?

Output: Your BIL is critically unwell and requiring multiple organ support. He has de-facto multi-organ failure because his kidneys are needing dialysis, his blood pressure is being supported by drugs and he is being ventilated for what sounds like ARDS.The DNAR is if these things stop working, so he does not undergo futile CPR. If he recovers and leaves ICU theyll tear that DNAR up (or you can ask them to), but it wont affect the quality of his care to have one in place.Currently -depending on where you are- he isnt a transplant candidate due to the alcohol, as well as being critically ill.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: I'm trying to understand a current family situation where I believe doctors are being hasty with care.My brother in law, about 30 years old 6ft 250lbs, is currently in the hospital for acute pancreatitis due to alcoholism which stressed the one kidney he had (genetic one kidney). He's currently sedated on vent, dialysis crrt, and insulin drip. He was admitted a week ago after he called an ambulance. With only symptoms being nausea and stomach pain. Since being admitted he was bumped down to 30% oxygen with breathing therapy, 5.0 PEEP, and his vitals and blood work were all in normal ranges for an adult male. Then they lessened his sedation and he was responsive. Hand squeezing and pointing. However other blood work and vitals dipped a bit after he had breathing trouble from bile due to pancreatitis.Additional: I think initial intubation was due to shock/hyperventilation upon admission or lung infection? Doctors have said all organs are viable. Torso MRI showed a good gallbladder, liver, and lungs without liquid. Family told they should not worry about organ donation yet(family match donation to improve health). Organs are not necrotic.I'm not trying to decide if my BIL needs a DNR. That's not my choice to make. I'm just curious how doctors factor offering it or when it's needed.TLDR; So, why would a doctor recommend a DNR for such a young patient that could seemingly recover? When do you consider patients to be at a point of no return? Is it standard to ask any critical patients to sign a DNR? Do Doctors weigh stats before offering or just their judgement?If you were this patient would you ask for a DNR?. ### Response: Your BIL is critically unwell and requiring multiple organ support. He has de-facto multi-organ failure because his kidneys are needing dialysis, his blood pressure is being supported by drugs and he is being ventilated for what sounds like ARDS.The DNAR is if these things stop working, so he does not undergo futile CPR. If he recovers and leaves ICU theyll tear that DNAR up (or you can ask them to), but it wont affect the quality of his care to have one in place.Currently -depending on where you are- he isnt a transplant candidate due to the alcohol, as well as being critically ill..


Instruction: Absolutely this. DNR is NOT the same thing as comfort care or withdrawing life sustaining treatments. Them asking about a DNR in this case probably means they think he is unlikely to survive or have a good outcome from CPR. But its important for everyone to consider what they would want done if they were to have a catastrophic health event, regardless of their current health.Okay but studies have shown that a DNR can result in lower quality of care, and typically do. In the BIL's case, although he is critical, he is responsive, and has only been in the hospital for a week. He has made significant recoveries like oxygen levels being reduced and other blood work levels being stabilized to healthy amounts.We are being told both organs have capacity to recover or with the kidney some function. They aren't necrotic. Couldn't he still qualify from a family member match willing to donate? Doctors have not moved towards that idea either.I guess my question is- how does a doctor stack the odds like that? Yes, on paper he has three machines doing organ functions. But is there not potential for recovery? If the oxygen intubation progresses with therapy, he could also remove feeding tube. There is also potential for getting pancreatitis managed, and kidney support with regular dialysis treatments or donation.Does a doctor weigh statistics or is it just judgement? And what helps them make that judgement? Because I feel like someone with the potential to recover, who is pretty young, would not be a candidate for a DNR.Now if there was a clearer document that outlined CPR in a worst case scenario then yes I see that. But signing a generic DNR with chances of recovery and treatment options seems very pessimistic. Especially given that BIL has a condition that can cause asphyxia and there have been cases where DNRs do result in vent being removed.

Output: Simple answer is at the moment none of his organs need replacing- or rather theyre broken in a way a transplant wont fix. An organ isnt like a broken gear, the whole system needs to work for the organ to work.And nobody is taking him off life support prematurely due to a DNAR. Its simply stating if his heart stopped beating that would be the end of treatment. irrespective of age, if he reaches that point he isnt surviving in his current condition.As previously mentioned, if he continues to make progress forwards then theyll tear up the DNAR anyway, but at the moment your BIL is not somebody I would expect to survive chest compressions- it would be another organ not working, without the ability to support it or replace it to ensure survival.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: Absolutely this. DNR is NOT the same thing as comfort care or withdrawing life sustaining treatments. Them asking about a DNR in this case probably means they think he is unlikely to survive or have a good outcome from CPR. But its important for everyone to consider what they would want done if they were to have a catastrophic health event, regardless of their current health.Okay but studies have shown that a DNR can result in lower quality of care, and typically do. In the BIL's case, although he is critical, he is responsive, and has only been in the hospital for a week. He has made significant recoveries like oxygen levels being reduced and other blood work levels being stabilized to healthy amounts.We are being told both organs have capacity to recover or with the kidney some function. They aren't necrotic. Couldn't he still qualify from a family member match willing to donate? Doctors have not moved towards that idea either.I guess my question is- how does a doctor stack the odds like that? Yes, on paper he has three machines doing organ functions. But is there not potential for recovery? If the oxygen intubation progresses with therapy, he could also remove feeding tube. There is also potential for getting pancreatitis managed, and kidney support with regular dialysis treatments or donation.Does a doctor weigh statistics or is it just judgement? And what helps them make that judgement? Because I feel like someone with the potential to recover, who is pretty young, would not be a candidate for a DNR.Now if there was a clearer document that outlined CPR in a worst case scenario then yes I see that. But signing a generic DNR with chances of recovery and treatment options seems very pessimistic. Especially given that BIL has a condition that can cause asphyxia and there have been cases where DNRs do result in vent being removed.. ### Response: Simple answer is at the moment none of his organs need replacing- or rather theyre broken in a way a transplant wont fix. An organ isnt like a broken gear, the whole system needs to work for the organ to work.And nobody is taking him off life support prematurely due to a DNAR. Its simply stating if his heart stopped beating that would be the end of treatment. irrespective of age, if he reaches that point he isnt surviving in his current condition.As previously mentioned, if he continues to make progress forwards then theyll tear up the DNAR anyway, but at the moment your BIL is not somebody I would expect to survive chest compressions- it would be another organ not working, without the ability to support it or replace it to ensure survival..


Instruction: When you sign a DNR it isnt just a genetic DNR. There are different sections to it. It asks if you are ok being on a vent if needed. It asks if you are ok having a feeding tube if needed.You can be ok with life support, just not CPR if it comes down to it.

Output: This is a difficult question to answer without knowing the full clinical picture. What is his day to day ventilation settings? Just because he is down to 30% doesn't meet his PEEP is down. How has his spontaneous breathing trials go? What does his CXR show? What do you mean the blood work is great? What are his I/Os? How is his kidney function?

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: When you sign a DNR it isnt just a genetic DNR. There are different sections to it. It asks if you are ok being on a vent if needed. It asks if you are ok having a feeding tube if needed.You can be ok with life support, just not CPR if it comes down to it.. ### Response: This is a difficult question to answer without knowing the full clinical picture. What is his day to day ventilation settings? Just because he is down to 30% doesn't meet his PEEP is down. How has his spontaneous breathing trials go? What does his CXR show? What do you mean the blood work is great? What are his I/Os? How is his kidney function?.


Instruction: He's got a feeding tube because he's been sedated. But he's had bowel movements. Constant IV hydration drip but no urine in catheter.They had been doing breathing therapy with him that is when they lowered his sedation and oxygen. He seemed to be doing better with 30% and then bile in the tube then his condition worsened. He's now at 50% again. They have done several torso scans but they haven't given details on the scans diagnostics.That's most of what I have based on what I've been given. They said his kidney and pancreas are not necrotic. He did have an infection in his lungs when he was admitted but they cleared out several days ago. However since he had bile with the intubation he has liquid in the lungs again.

Output: There's far too many details still being missed here to state that his care is hasty. You have an individual who has one kidney on continuous dialysis while having low blood pressure. He is making no urine at all. For some reason, he was intubated for pancreatitis, so I assume it was because of ARDs. He sounds critically ill.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: He's got a feeding tube because he's been sedated. But he's had bowel movements. Constant IV hydration drip but no urine in catheter.They had been doing breathing therapy with him that is when they lowered his sedation and oxygen. He seemed to be doing better with 30% and then bile in the tube then his condition worsened. He's now at 50% again. They have done several torso scans but they haven't given details on the scans diagnostics.That's most of what I have based on what I've been given. They said his kidney and pancreas are not necrotic. He did have an infection in his lungs when he was admitted but they cleared out several days ago. However since he had bile with the intubation he has liquid in the lungs again.. ### Response: There's far too many details still being missed here to state that his care is hasty. You have an individual who has one kidney on continuous dialysis while having low blood pressure. He is making no urine at all. For some reason, he was intubated for pancreatitis, so I assume it was because of ARDs. He sounds critically ill..


Instruction: To clarify, just because the organs aren't necrotic doesn't mean they are functioning. Also organ donation has nothing to do with DNR. The appropriateness of someone to donate only comes after they have died or are literally about to. In the US people self-declare at the DMV so the organ donation services already know their intent in most cases.He has multisystem organ failure, plus underlying conditions which will make his recovery harder than someone without those (alcoholism, solitary kidney) based on what you have written, so it is absolutely imperative to find out what his wishes might be regarding code status. In the absence of any clear directives from the patient in the past, the family is asked to predict what the patient would choose for themself if they were able to sit in on the discussion and weigh in--basing this off of past comments, how they engaged (or avoided) healthcare interventions on their own, etc.I suggest that his designated healthcare agent and any other family present, have a care conference with the intensivist. This is a time set aside in a nearby conference room, not at the bedside or in the hall. Include one of his nurses if possible, any specialists who can make it (often harder to arrange) and then the unit's social worker/case manager. The purpose is to outline exactly where he is on his trajectory, what the major challenges are, what the expected chances of recovery appear to be at this point, and then a discussion of next steps. Find out more about why the doctor was recommending DNR. Hear what they have to say about this based on their experience. It might be because they don't feel he will likely be resuscitated if they make attempts, therefore, to attempt shocks and compressions would be futile. If they feel it would be futile, then it would represent only harm to the patient and not comfort or cure. I cannot predict what they are thinking so you need to find out, but this has been my experience from working in ICU as an RN and Care Manager.If he cannot be weaned off of the vent shortly, he will need a trach and a PEG (feeding tube in his side). If he stabilizes enough to be discharged from ICU (off of CRRT, off of high vent settings, off of any vasopressors that are stabilizing his BP, only on X number of antibiotics, etc) then he will meet criteria to transfer to a ventilator rehabilitation hospital or LTACH (long term acute care hospital).If this happens, it is a long slog. Is it something he would want? Also, he might not survive it and could have a downturn at any time, heading back to the hospital. Knowing this, is this something the family would predict HE would want? If so, you have your answer. If not, then it is appropriate to consult hospice to make him comfortable. Another service to consult if you have it available is Palliative Care. In many hospitals they are consulted for complex cases like this who are taking a long time to recover. They are particularly helpful to the patient to improve quality of life while recovering, as well as provide support and guidance to family.At the end of this long post, I offer you two things. One-you are in my thoughts. I know how difficult this is and you are on a crash course of learning right now. Two, please use this resource that many families in your position find extremely helpful--patients let us know so often this has helped them in cases like yours: Hard Choices for Loving People booklet

Output: If this was me I would want a DNR and a DNI signed. More importantly, I would want a MOLST form singed indicating exactly the care that I would want, the care that I don't want, and for how long. That is to say, give me antibiotics for one week and see how I do, if nothing's happening then stop all unnecessary treatments.What I like to see in patients is an end goal. What happens far too often, is patients will sit in an ICU for an extended period of time deconditioning and not getting better, but family does not want to do anything for fear of making the situation worse or feeling like they are murdering a family member by taking away care. Recognize that his pancreas is not well at all. His kidneys are not well at all. His liver is not well at all. Assumedly, his lungs aren't either.Let's say he is extubated. Now we have a burnt pancreas. And kidney. And liver. If you are this young and have liver dysfunction or failure, that's a life of slowly getting sicker and sicker until you can possibly but probably not get a liver transplant in the future. It's painful. If his kidneys are truly shot and he requires dialysis in the future, that's 50 years of spending 3 days a week going to get dialysis and sitting there having your blood cycled over and over for hours, just to go home and not feel well. Then you do it again. Then you do it again. That's a lot of stress for a 30-year-old. A 30-year-old that already has alcoholism. If your pancreas is constantly becoming inflamed, diabetes maybe in the future or at least insulin dependence. A 30-year-old diabetic will have a low quality of life.DNR and DNIs are to preserve a patient's dignity thinking about the long-term consequences to their health and quality of life. The idea that saving people is enough, is not enough. By stating do not resuscitate, You're saying to give a chance, but don't take it farther than he would like given all that has happened, and will happen in the future.The doctor sees this all the time. The doctor sees a family that holds on to hope that everything will be okay because their family member is " a fighter, " but neglects to see that the patient has already fought 25 rounds and has been knocked out three times. And also neglects to see that, if they come out of the fight, they essentially will have an agonizing future for the rest of their life.

Below is an instruction that describes a task. Write a response that appropriately completes the request. ### Instruction: To clarify, just because the organs aren't necrotic doesn't mean they are functioning. Also organ donation has nothing to do with DNR. The appropriateness of someone to donate only comes after they have died or are literally about to. In the US people self-declare at the DMV so the organ donation services already know their intent in most cases.He has multisystem organ failure, plus underlying conditions which will make his recovery harder than someone without those (alcoholism, solitary kidney) based on what you have written, so it is absolutely imperative to find out what his wishes might be regarding code status. In the absence of any clear directives from the patient in the past, the family is asked to predict what the patient would choose for themself if they were able to sit in on the discussion and weigh in--basing this off of past comments, how they engaged (or avoided) healthcare interventions on their own, etc.I suggest that his designated healthcare agent and any other family present, have a care conference with the intensivist. This is a time set aside in a nearby conference room, not at the bedside or in the hall. Include one of his nurses if possible, any specialists who can make it (often harder to arrange) and then the unit's social worker/case manager. The purpose is to outline exactly where he is on his trajectory, what the major challenges are, what the expected chances of recovery appear to be at this point, and then a discussion of next steps. Find out more about why the doctor was recommending DNR. Hear what they have to say about this based on their experience. It might be because they don't feel he will likely be resuscitated if they make attempts, therefore, to attempt shocks and compressions would be futile. If they feel it would be futile, then it would represent only harm to the patient and not comfort or cure. I cannot predict what they are thinking so you need to find out, but this has been my experience from working in ICU as an RN and Care Manager.If he cannot be weaned off of the vent shortly, he will need a trach and a PEG (feeding tube in his side). If he stabilizes enough to be discharged from ICU (off of CRRT, off of high vent settings, off of any vasopressors that are stabilizing his BP, only on X number of antibiotics, etc) then he will meet criteria to transfer to a ventilator rehabilitation hospital or LTACH (long term acute care hospital).If this happens, it is a long slog. Is it something he would want? Also, he might not survive it and could have a downturn at any time, heading back to the hospital. Knowing this, is this something the family would predict HE would want? If so, you have your answer. If not, then it is appropriate to consult hospice to make him comfortable. Another service to consult if you have it available is Palliative Care. In many hospitals they are consulted for complex cases like this who are taking a long time to recover. They are particularly helpful to the patient to improve quality of life while recovering, as well as provide support and guidance to family.At the end of this long post, I offer you two things. One-you are in my thoughts. I know how difficult this is and you are on a crash course of learning right now. Two, please use this resource that many families in your position find extremely helpful--patients let us know so often this has helped them in cases like yours: Hard Choices for Loving People booklet. ### Response: If this was me I would want a DNR and a DNI signed. More importantly, I would want a MOLST form singed indicating exactly the care that I would want, the care that I don't want, and for how long. That is to say, give me antibiotics for one week and see how I do, if nothing's happening then stop all unnecessary treatments.What I like to see in patients is an end goal. What happens far too often, is patients will sit in an ICU for an extended period of time deconditioning and not getting better, but family does not want to do anything for fear of making the situation worse or feeling like they are murdering a family member by taking away care. Recognize that his pancreas is not well at all. His kidneys are not well at all. His liver is not well at all. Assumedly, his lungs aren't either.Let's say he is extubated. Now we have a burnt pancreas. And kidney. And liver. If you are this young and have liver dysfunction or failure, that's a life of slowly getting sicker and sicker until you can possibly but probably not get a liver transplant in the future. It's painful. If his kidneys are truly shot and he requires dialysis in the future, that's 50 years of spending 3 days a week going to get dialysis and sitting there having your blood cycled over and over for hours, just to go home and not feel well. Then you do it again. Then you do it again. That's a lot of stress for a 30-year-old. A 30-year-old that already has alcoholism. If your pancreas is constantly becoming inflamed, diabetes maybe in the future or at least insulin dependence. A 30-year-old diabetic will have a low quality of life.DNR and DNIs are to preserve a patient's dignity thinking about the long-term consequences to their health and quality of life. The idea that saving people is enough, is not enough. By stating do not resuscitate, You're saying to give a chance, but don't take it farther than he would like given all that has happened, and will happen in the future.The doctor sees this all the time. The doctor sees a family that holds on to hope that everything will be okay because their family member is " a fighter, " but neglects to see that the patient has already fought 25 rounds and has been knocked out three times. And also neglects to see that, if they come out of the fight, they essentially will have an agonizing future for the rest of their life..