Dialysis, HIV and terminal Pts. Abuse?

[Scarlette Wings]

i am having extremely mixed emotions about dialysis use/abuse, especially with the increase in the numbers of elderly and substance abuse hiv patients going on dialysis. i always worry how sterilized the dialysis equipment is when they dialyze someone with hepatitis, mrsa, or some other infection... so hiv patients have only made me worry more.

most of the new dialysis patients that i have seen coming in over the last 2-3 years are basically in the latter stages of one disease process or another, are elderly, have hiv, or are substance abusers still abusing and boasting about it. :hdvwl:

examples.

1. patient "x" is an 68 year old from the nursing home and has come in and out of hospital with multiple issues. pt "x" exists on peg tube feeds and has a history of multiple strokes. they are diabetic and hypertensive pt "x" is unable to follow simple instructions, is non-verbal, and unable to recognize or interact with caretakers or family. pt. is a total care patient and has been since they went into the nursing home 12 years ago. pt. "x" now comes in with a decubitus infection and dehydration, bun and creatinine through the roof and doctor "z" begins dialysis. pt. "x" discharged back to nursing home and with an outpatient dialysis clinic they will now be transported to 3 times a week.

2. pt. "y" comes into the er at 2 am. this is their third admission from the er for the same reason in the same month . the patient refused to go to their scheduled treatment and was too drunk, with their own mouth. urine tested positive for cocaine, opiates, and meth.

:devil:i really have issues with the deliberately non-compliant dialysis patient who tell you "i don't care."

3. pt. "z" is relatively young 53 year old who comes to the icu with a massive heart attack and survives. they are however now ventilator dependant with a trach, suffered massive brain cell death due to coding on arrival, requires tube feeds for nutrition, and dialysis for the renal failure that also occurred. they are basically stable so a nursing home is found that will take vent dependant patients and can get them to and from dialysis with a portable vent.

i don't know whatever happened to death with dignity or doctors knowing when to draw the line and say "enough is enough. what you have is terminal." i just think somehow that dialysis was once a medical miracle and is now an abuse. does anyone else feel this way ?

[redessa]

Wow, okay, um, as a human being, I am offended by your attitude about this.

I agree, in theory, that medical advancements have progressed to the point that we sometimes prolong life at the expense of quality of life. It's something medical and ethical communities could debate ad nauseum. But when it comes to an individual, a real live person, I don't think you or anyone else needs to be deciding where that line is for them.

In any of the cases you described, the person or their POA has the right to choose continued treatment. I certainly wouldn't want my Dr telling me too bad, you're going to die anyway, I refuse to do any more for you. It's one thing when they say we've run out of options, it's another to withhold available treatment just so you will go on and die already.

[I<3H2O, BSN, RN]

Wow, okay, um, as a human being, I am offended by your attitude about this.

I agree, in theory, that medical advancements have progressed to the point that we sometimes prolong life at the expense of quality of life. It's something medical and ethical communities could debate ad nauseum. But when it comes to an individual, a real live person, I don't think you or anyone else needs to be deciding where that line is for them.

In any of the cases you described, the person or their POA has the right to choose continued treatment. I certainly wouldn't want my Dr telling me too bad, you're going to die anyway, I refuse to do any more for you. It's one thing when they say we've run out of options, it's another to withhold available treatment just so you will go on and die already.

But you are alive and presumably well. If your kidneys shut down, you would need dialysis to survive. However, what the OP is saying is completely different. It seems absolutely insane to me that Pt. X and Pt. Z would be placed on dialysis. I cannot imagine a single person who would say "if I become a complete vegetable but dialysis would help keep me alive then do it. Even if I don't know who I am, where I am, etc." Pt. Y however, has the choice. THis pt. is able to make the decision and chooses to abuse their body in this way and expect someone else to fix it to keep them alive. While it disgusts me, I can't draw the same line with that pt.

OP, I think you make very valid points. I cannot imagine ANYONE would WANT to be kept alive in this manner. I can't imagine who would make the choice for their loved one, who is just a body who does not know them, to keep them alive in this manner. Animals are treated with more dignity.

[heron, ASN, RN]

Why should HIV, as opposed to other blood-born diseases, be a factor against dialysis? If the equipment is sterilized sufficiently to eliminate any hepatitis virus, then it's certainly getting rid of HIV, which is much more fragile.

All three of the scenarios you present would certainly give me pause, too. I've certainly seen and read of situations that seem abusive, both of and by the patient. I have no idea of where to draw the line, however.

[redessa]

OP, I think you make very valid points. I cannot imagine ANYONE would WANT to be kept alive in this manner. I can't imagine who would make the choice for their loved one, who is just a body who does not know them, to keep them alive in this manner. Animals are treated with more dignity.

I don't know, there's the post a few down about an end-stage aids patient placing himself on full-code status. I agree that I would not personally choose to be kept in a vegetative state or prolong the end of a terminal disease. I don't think my family would choose that for me either, but I'm not willing to make that call for someone else unless they are actually my responsibility (like my parents) and have given me specific directive. I know, for example, that my father would not want heroic measures taken on him if he were experiencing a life threatening illness (he's been there and thankfully pulled through but he was ready to die as opposed to being permanently dependent). I wouldn't presume that same choice for everyone else though.

[Scarlette Wings]

hi and thanks. i am not wanting to debate right to life issues or cause any contention. i am not saying whether someone should or should not be on dialysis. i just feel frustrated and think there is a point where it becomes almost cruel to keep doing things "to" a patient. does anyone share in that frustration?

there is almost an insanity to medicine. just because we "can" do a procedure, should it be done? it is all so ethical i know .... but before i am hung out to dry .... i have walked in those shoes. i buried both my parents when i was younger, one from massive stroke and one of throat cancer.

my own son died when he was preschool age after battling cancer, but there was no active cancer when he died. he had been coded (pneumonia-respiratory failure) and was essentially brain dead on a vent. had dialysis been possible where we were lived back then (it was still new and not many centers did dialysis) i am sure they would have tried it to help, but i don't think his little body couldn't have stood much more. i had to make the dnr decision for him. after watching him seizure most of the day, with blown pupils, and even with me not being a nurse back then, i knew it was time to let go.

it can just be too much. hippocrates said "first do no harm." it is hard to care so much but it is also hard to see the things medical interventions can sometimes create. does that make sense?

[JSBoston]

Every family has their own beliefs, religious or otherwise. Obviously they have a right to make their beloved family member a full code, but I DO completely understand some of the OP's statements and opinions.

Sometimes it is HARD to take care of a 96 year old terminal patient who is in a vegetative state, vent dependent, major wounds, Cdiff, MRSA, VRE, renal failure... you name it. The MD has attempted end of life discussion, and the family then asks "So when can we get another speech consult to see if he can eat snacks?"... I take care of many different patients with many different versions of that story full time.

It's just very very hard sometimes.

[nursejoed]

Redessa wrote: "In any of the cases you described, the person or their POA has the right to choose continued treatment. " Therein lies part of the problem. The taxpayer is forced to fund untold millions in health care dollars for obscenely inappropriate treatments- do they have a choice? The carte blanche mentality is easy to have, on someone else's dime....

[GHGoonette, BSN, RN]

You ask some very good questions, so I'll pose a few more for you. Patient has been diagnosed with TB, is put on treatment but does not continue with it. Community Health team traces the patient, gets him/her back on treatment; after a while, patient defaults again. What do we do? Do we allow patient to carry on merrily infecting unsuspecting contacts, or "arrest" him/her and confine them in a sanatorium until cured? In our "medical/nursing" eyes, they have committed a crime, but would the law agree with us?

Here's another one; HIV+ patient contracts TB, goes on treatment and defaults; already we have a situation of multi-drug resistant TB. Do we immediately confine them or are we breaching their constitutional rights?

It may seem a bit off-topic to you, but stop and think about it. SHOULD anyone have the right to decide who shall not be treated; SHOULD we have the right to enforce treatment on someone who stubbornly resists treatment?

OK! In the case of dread infectious diseases like TB there should be no argument-you report for treatment or you will be separated from the rest of the community and take your medicine until you no longer pose a danger; that makes sense. But should drug or alcohol abusers have unlimited right to expensive treatments to alleviate the consequences of their own stupidity? NO! Unless they can pay for it out of their own pockets!

The issue of people in vegetative states being put into sophisticated courses of treatment such as dialysis is to me a very sad one. Family hoping against hope for a miracle to save their loved ones. Only counseling can help in such situations, to enable families to come to terms with the fact that some conditions are irreversible.

[imintrouble, BSN, RN]

If rationed care becomes a reality, then someone will have to make those tough choices.

[Hospice Nurse LPN, BSN, RN]

CheyFire- First of all, I offer my condolences on the death of your child. No parent should ever have to bury their child.

As to your original post, I'm hearing you sister. Some times it's the doc who will not address end of life issues with the family, but often it's the families refusal to listen. I work in home hospice and have an pt who is 98 y/o, ES dementia, COPD, HTN, stage 3 decub. She eats 3 or 4 bites of food per day. This woman is on hospice, but the family keeps talking about taking her to the hospital is she gets "sick". Seriously, I just smile and continue teaching EOL care.

[Neveranurseagain, RN]

Cases like this are another example that Americans need to change their "death is considered a failure" attitude. The decision to resuscitate or not, including measures to prolong life, need to be made by educated medical personnel who will base their decision on medical rational, not emotional rational by the pt. or family.