[neko11111]

hey guys - just wondering how your hospitals handle cases like this. I've got a pt who has been on my unit for over a month now. She came in with respiratory distress, talking to us. The daughter said the ems intubated her, and she has said in past that she does NOT want to be intubated - they extubated her, took her to regular med floor, then she developed resp distress, and came to our unit. within a week, somehow she was intubated again and put on a ventilator. The daughter ok'd this...... well, since then the pt has been taken off of sedation and has been unresponsive, no withdrawal to pain, not following commands or tracking with eyes for at least 3 wks now. The daughter still has her listed as a full code..... and apparently the day shift nurses say that the dr's and nurses have talked to her repeatedly about her prognosis and code status - but she is sticking to a belief that her mother is going to miraculously wake up and come out of this and be back to normal again.... her plan is now to take her to surgery, put a peg tube in her and transfer her to a long term care facility.....

This irks me sooo badly.... the pt is 82, trying to die, she does not have a look of peace on her face at all.... and we've seen tears in her eyes mutliple times in the last 1-2 days. What do you do? I know that I would not feel comfortable pounding on her chest and shocking her if her heart gives out! The daughter is in her 30's. she's old enough to know..... I think she just doesn't want to let go of her, but what about her mother's rights?

I keep asking things like - do we have an ethics committee to get involved here, or a pallative care team? This is a smaller, private hospital, so I don't think they do - but a lot of the nurses keep saying - what can we do? the dr's have talked to the daughter...... and that's it. What happened to being an advocate for the pt - and the pt's right to quality of life????

I guess I'm just looking for some more opinions or perspectives......

[sharrie]

this is one thing that I like about working in the UK, although we take on board what the family want at the end of the day resusciation decisions and escalation of treatment is a medical decision. We spend tome discussing the rationale for the desicions with the family but at the end of the day the decision is with the team caring for the patient

[elkpark]

Originally Posted by sharrie

this is one thing that I like about working in the UK, although we take on board what the family want at the end of the day resusciation decisions and escalation of treatment is a medical decision. We spend tome discussing the rationale for the desicions with the family but at the end of the day the decision is with the team caring for the patient

It is also the case in the US that physicians are not obligated to provide care they believe to be futile, and are supposed to exercise their own clinical judgment about such things, but the reality is that, because of the propensity of unhappy families here to sue, lots of these situations end up getting dragged out much longer than "medically indicated."

Neko -- your hospital does have some kind of an ethics committee; it's a federal requirement. I'm not telling you what to do, but, if the nurses are in agreement about something needing to be done, you could go up your own "chain of command" and get a higher level nurse manager or administrator to raise the issue with the physician(s) and the ethics committee. Have you all (nurses) actually spoken to the physician(s) involved about your concerns?

Or, you could just put that ol' PEG tube in and turf her out to a LTC ... If it's any comfort, if she's unresponsive to pain, not tracking with her eyes, etc., the expression on her face and the fact that she's producing excess tears doesn't really mean anything.

[ktwlpn]

Originally Posted by neko11111

hey guys - just wondering how your hospitals handle cases like this. I've got a pt who has been on my unit for over a month now. She came in with respiratory distress, talking to us. The daughter said the ems intubated her, and she has said in past that she does NOT want to be intubated - they extubated her, took her to regular med floor, then she developed resp distress, and came to our unit. within a week, somehow she was intubated again and put on a ventilator. The daughter ok'd this...... well, since then the pt has been taken off of sedation and has been unresponsive, no withdrawal to pain, not following commands or tracking with eyes for at least 3 wks now. The daughter still has her listed as a full code..... and apparently the day shift nurses say that the dr's and nurses have talked to her repeatedly about her prognosis and code status - but she is sticking to a belief that her mother is going to miraculously wake up and come out of this and be back to normal again.... her plan is now to take her to surgery, put a peg tube in her and transfer her to a long term care facility.....

This irks me sooo badly.... the pt is 82, trying to die, she does not have a look of peace on her face at all.... and we've seen tears in her eyes mutliple times in the last 1-2 days. What do you do? I know that I would not feel comfortable pounding on her chest and shocking her if her heart gives out! The daughter is in her 30's. she's old enough to know..... I think she just doesn't want to let go of her, but what about her mother's rights?

I keep asking things like - do we have an ethics committee to get involved here, or a pallative care team? This is a smaller, private hospital, so I don't think they do - but a lot of the nurses keep saying - what can we do? the dr's have talked to the daughter...... and that's it. What happened to being an advocate for the pt - and the pt's right to quality of life????

I guess I'm just looking for some more opinions or perspectives......

This won't be the last time you see something like this.Until advance directives are legally binding it will continue.And even then they are going to be somewhat open to interpretation-we all need to appoint a strong advocate in addition to making our living will.Someone capable of telling our adult kids " Stop being selfish-your mother did NOT want this" There is not much you can do.Google "advance directives" and read the headings of some of the forms available for downloading.Every one I have ever read says something like "should my doctor determine my condition is terminal " Not many docs are going to do that in this type of situation. It's very upsetting and frustrating.The trick is to not let yourself get burned out.The best you can do is to try to educate and support the daughter but she will make the decision that she is comfortable with.Be thankful it's not your mother and sister-then call your family and start a dialogue so this does not happen to you..

[neko11111]

The problem is that I work the night shift - so, typically I don't see the doc's or the family members while I'm there. I only saw the daughter the night that she was transferrred to us. I've had a few conversations with her - a while ago. In the beginning she would call in the middle of the night to see how she was doing - and I would truthfully, but tactfully let her know - ' she is not responding, tracking, etc... there is no improvement.' and sometimes she would ask, well what do we do? And I - being a brand new nurse, didn't feel comfortable with approaching this issue in depth yet - I would tell her, that her next step would be to talk with the dr. about her prognosis and what decisions might need to be made.....

I honestly don't know exactly what the dr has said - (not being there during the day shift), but the chart states 'poor prognosis' all over the place... and it has gotten to the point where the more seasoned nurses - agree and think it's ridiculous - she needs to let her mother go in peace - but yet - no one seems to be actively pursuring it?

I'm thinking about talking to my nurse mgr about it the next day that I'm on the unit..... I don't know - I'm new..... it makes me wonder if I'm overreacting? But these other nurses say they agree....... I'm at a loss - I just can't get it out of my head that this is unfair to the pt.