End Of Life Issues---The Good, The Bad, and the Ugly

**VivaLasViejas**, ASN, RN

Right now I have three different residents in three different stages in the process of casting off the human shell that has housed their souls for over eight decades. One of them, Allie*, had been in fairly good shape until the night she had a massive GI bleed and was going into shock while I wrangled with the 911 dispatcher ("She's HOW old? What's her advanced directive say?"). After the EMTs saw for themselves that I wasn't exaggerating---why do they assume we LTC nurses know nothing?---they scooped and ran, and after a few days in the hospital she was returned to us with a DNR order and an inoperable, fast-growing mass in her lower colon that could rebleed at any time. Her family, however, was unwilling to give up, and it wasn't until this past week, when she had a stroke that destroyed her ability to speak and paralyzed half her body, that they finally began to understand that whatever quality of life she had was gone.

While they have declined our suggestion to bring in hospice, they agreed to comfort measures such as liquid morphine and stopping unnecessary medications, and they've been coming in every few hours to do mouth care and lotioning. Allie is still with us, and though it's clear to all that she won't be much longer, at least she's surrounded by acceptance and can die in peace.

Not so, I'm sorry to say, with another of our ladies, whom I've known since the night she arrived at my assisted living facility four years ago, utterly exhausted from a day of flying across the country with her cat and two suitcases filled to bursting with expensive clothing, hats, and jewelry. Maryann* later followed me to the nursing home, where she has declined slowly but steadily over the past year; now her kidneys are just about gone and her once-sharp sense of humor right along with them. She's been in and out of the hospital now for several months, and each time she returns it's with a diagnosis of "dehydration" and we are once again urged to push fluids, push fluids, push fluids.

Well, guess what? Maryann doesn't LIKE to drink fluids. They make her go to the bathroom too often. She also doesn't like to take her meds---too many pills, she says. She's tired of taking pills. She's tired of living. She wants to stop taking all those pills so that she can be with her husband and her cat again. I don't blame her.

But Maryann's son, who brought her out here from Philadelphia after his father's death, is having none of it. There is a grandson's wedding coming up in June, he tells us, and "if Mom were in her right mind" she'd want to be around for the event. So we are to encourage/force her to drink at least 2 liters of fluids per day, take all of the 20+ medications she's on PLUS the new ones that were prescribed after her most recent hospital stay. "If she wants to 'go' after the wedding, she can," says the son, "but she really WOULD want to stick around for this. We can't let her die yet, so whatever it takes to keep her going, just do it." All this despite an advanced directive that says no resuscitation, no feeding tubes, not even antibiotics except for "comfort".

I want to tell him that this is the most inhumane thing I've ever heard of, that his ideas are so wrong on so many levels that I can't even wrap my mind around it, but I can't. Why? Because this ISN'T the worst thing I've ever seen happen to a resident with a controlling family. That distinction is reserved for the 95-year-old gentleman down the hall whose fate is in the hands of a late-middle-aged couple, neither of whom is related to him by blood. This unfortunate fellow has outlived all but one of his children, who is estranged for unknown reasons; and if he were in his right mind, I think he would be madder than a wet cat at having to live like this. "Grampa" is as demented as they come; his speech is unintelligible, he is combative at times and incontinent ALL the time, he's missing half his right foot due to infection and doesn't know he can't stand up without falling. He has ischemic colitis, CHF, chronic renal failure with a GFR of about 8, degenerative joint disease, osteoporosis.........yet this couple just can't seem to let nature take its course.

We've sent Grampa to the ER no fewer than five times this year, despite the belief of facility staff that we are flogging his failing body for absolutely NO useful purpose. I've sent him out for diarrhea that wouldn't stop. I've sent him out for pneumonia. I've sent him out for low BPs, twice. And yesterday I had to send him yet again, this time because he was obtunded AND his BP was in the toilet AND the diarrhea was back. Why? His POA demanded it, despite the fact that he has a DNR order and the paramedics give us hell every time we call about this man. Yes, we all know that "do not resuscitate" doesn't mean "do not treat", but every time he's sent out he winds up being admitted to the hospital for several days on the insistence of the POA. While he's there, he's tied down and force-fed medicines and IV fluids to rehydrate his body; when he returns to us he goes back to swatting at the hands holding a cup or a spoon to his lips. Doesn't anyone understand what he's trying to tell us?

I won't even go into the reasons why this is a waste of limited healthcare resources or how selfish it seems to me for families not to let their loved ones go when they fall into hopeless circumstances and life becomes a burden. No, what keeps me awake at night sometimes is the conflict between my job and my ethics, which holds that forcing people to stay alive is as morally wrong as killing them outright via euthanasia.

It's not that I would ever impose my personal beliefs on a resident or family, but as a nurse I've seen some of the worst sorts of suffering there is......and not all of it is physical in origin. Some of it is the loss of who the individual was; another large part of it is the loss of independence and dignity. But when those things are combined with medical problems that cause one to feel miserable every day of his or her life, well......would YOU want to live like that? I know I wouldn't. But even though I have an advanced directive (and have threatened my family that I would haunt them forever if they don't let me die when it's my time!), I'm less than confident that my future caregivers will know when to say "we've done enough".

They used to call pneumonia the "old man's friend" back in the days before antibiotics. While I wouldn't trade today's technology for yesterday's more realistic approach to end-of-life issues, I wonder sometimes if we as a society have become so arrogant that we keep people alive long past their natural lifespans merely because we can.

Just a few thoughts on an evening when I have more quiet time than usual to contemplate. If you've read this far, thanks for hanging in there this long. What are your thoughts?

*Names have been changed to protect privacy.

End Of Life Issues---The Good, The Bad, and the Ugly

About VivaLasViejas, ASN, RN

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