Doctors that think they are god...

arizonanurse · Feb 7, 2007

What a difficult situation. I think it is simply that the doctor doesn't want to "fail." But his actions are totally inappropriate. It is wrong to be unrealistic like that, it is wrong to not listen to your patient's wishes, and it is wrong to try to turn family members against each other. I cannot believe she is on TPN with a PICC...that is absolutely ridiculous. The poor lady.

Unfortunately, there's not much you can do. It's up to the daughter. She's going to have to stand up on her own and defy the doctor, which obviously is an incredibly hard thing to do. If she asks for your advice, I would simply say that she needs to do what she believes her mother would want in that situation (after all isn't that what POAs are for?). Not what she wants, not what the doctor wants, but what her mother's true wishes would be if she was not incapacitated. And it sounds like this is quite clear.

The issue of prolonging death has always been a big one for me. I cannot ethically accept how much suffering we put people through so they can live another six hours on a vent. Now, I know I'm going to get flamed for this - every time I share these sentiments, I get stories of someone's 120 year old grandma who is still living at home and doing her own shopping. I'm not talking about those people. I am talking about terminally ill individuals who want to be left alone to die, but they are kept alive because their family - or their doctor - doesn't want to let them go.

carlarn, BSN, RN · Feb 7, 2007

wow! this has been a very passionate thread. there have been some good thoughts here. i would like to add you could also call for a "care conference". that brings the family and care givers together to come up with a plan for the patient.

for the op, you don't seem like you are "writing everyone off". i do understand that you are trying to assess each individual for their own needs. keep plugging away and don't forget you are the patient advocate.

btw, for all of the people who read this, whether you are in the medical field or not: dnr does not mean do not treat. as most of us in the medical field know, there are many illnesses that are treatable in someone who is a dnr. please don't confuse these. and i am not singling anyone out, i am just reminding all of us of the difference.

burn out · Feb 7, 2007

Good luck, I guess in the end you will have to work this out for yourself. Good luck with the doctors but remember the hospital will always back them. We all must make decisions that we can sleep with at night...even the doctors.

TachyBrady · Feb 7, 2007

DebRN06,

I think you are very insiteful and compassionate as a "newer" nurse.

burn out,

I would like to ask you how you think you will feel when you are 72 or 102 years old, chronically ill with multiple complications, hospitalizations, complaints, and ailments. When you are brought to the hospital for the umpteenth time with pain, respiratory distress, general weakness and lethargy, bed sores, confusion, aspiration, poor appetite, depression etc. etc. etc. how will you feel when we insist on moving your body from stretcher to bed, from bed to stretcher, poking and proding, procedures and testing, force feeding when you are not hungry, tubes down your throat when you refuse, tubes in every oriface and where there isn't an oriface, we will make one. If you don't want one, we'll knock you out with drugs and give you one anyway.

When all you want to do is rest and be comfortable, when it is your time to go and you so desperately wish to do so,,, would you like a compassionate nurse and doctor or shall we resort to chemical and mechanical means? We CAN keep you alive. Forget "quality" of life. That was gone long ago.

As you said,,, we all have our time to die. Do you really want your death to be so full of turmoil and distress? Or would you rather just be made comfortable with a peaceful passing?

If I forced interventions upon a patient when I knew it was against their wishes, I wouldn't be able to sleep at night. Anyone that could, is not in the business of 'helping' people.

LACrn · Feb 10, 2007

Wow!
The OP never said anything about euthenasia. She was talking about futile care in the face of long standing chronic illness and advanced age, and the patients wish that interventions be stopped.
Everything else that has been said is not related to the issue she has asked for advice about. I am glad that a couple people mentioned ethics committees. The other thing that is needed are advance directives and being sure the family knows her wishes so that they can help her deal with the docs.
The money thing has nothing to do with it. Just the need to never say never. Probably well intentioned, but not neccesarily right for the patient.
I think that some of the care given at times is futile,painful,wasteful, and done for the wrong reasons. That is why we need ethics committees.

I think that this is the closest answer to the problem presented.

The true problem here is Doctors that seem to feel like they are in a contest to keep a patient alive the longest. Ultimately GOD always wins this contest and takes the patient home with him. (we are all mortal and will die someday) By all means do whatever possible to keep the patient alive and well, with quality of life. Fight a good fight but know when to conceed.

Some doctors just will not be honest with patients and their families and it is just down right cruel sometimes. Patients and families should be given ALL of the information about the diseases/conditions they are dealing with as well as all possibilities for trearment and prognosis. Then and ONLY then can they make an informed decision about their course of treatment or withdrawl of treatment. The doctor should then defer to the wishes of the patient or if the patient is not able to communicate their wishes then to the POA. Telling a patient with a terminal illness that they can "take care of" it or cure the patient with no mention of quality of life or even how often the "cure" fails is just plain negligence and malpractice. Families of patients with teminal illnesses who are misled into believing that their loved one can be cured feel cheated of quality time when their loved one up and dies "unexpectedly". The patient given as an example wanted to spend her final days at home surrounded by her loved ones. She should be the one to make this decision and the MD telling the daughter that she could be cured is just clouding the issue and causing conflict within the family. The doctor should always be truthful in these matters. Obviously everyone knows of cases where patients in otherwise fine shape come in for a simple surgery and end up dying, this is not the issue here. If a patient has an illness whose course can not be changed and will end in death, be it 2 days or 2 years the patient has the RIGHT to be told the TRUTH not just what the DR thinks the family wants to hear!!!

LAC

burn out · Feb 11, 2007

DebRN06,
I think you are very insiteful and compassionate as a "newer" nurse.
burn out,
I would like to ask you how you think you will feel when you are 72 or 102 years old, chronically ill with multiple complications, hospitalizations, complaints, and ailments. When you are brought to the hospital for the umpteenth time with pain, respiratory distress, general weakness and lethargy, bed sores, confusion, aspiration, poor appetite, depression etc. etc. etc. how will you feel when we insist on moving your body from stretcher to bed, from bed to stretcher, poking and proding, procedures and testing, force feeding when you are not hungry, tubes down your throat when you refuse, tubes in every oriface and where there isn't an oriface, we will make one. If you don't want one, we'll knock you out with drugs and give you one anyway.
When all you want to do is rest and be comfortable, when it is your time to go and you so desperately wish to do so,,, would you like a compassionate nurse and doctor or shall we resort to chemical and mechanical means? We CAN keep you alive. Forget "quality" of life. That was gone long ago.
As you said,,, we all have our time to die. Do you really want your death to be so full of turmoil and distress? Or would you rather just be made comfortable with a peaceful passing?
If I forced interventions upon a patient when I knew it was against their wishes, I wouldn't be able to sleep at night. Anyone that could, is not in the business of 'helping' people.

I think that life is precious and the most valuable thing a person has. If death were to come calling right now I would Fight with everything I had to stay alive, I would want everything done to keep me alive. I can't imagine how years can possible change that. I think anyone given the option at the final moment if given a chance would choose to fight to live. I have seen the reverse of what you accuse me of. I have seen life saving treatment held because nurse have imposed their thinkings upon the family and painted a no hope picture for them. I think many nurse shove their "peacefull death" too far..after all it does soothe the conscience and eliminates alot of work and does cut costs. Let's make a deal, I'll not put you on a vent or code you if that is what you really don't want but please do it for me and let's not impose either of our wishes on others.

You ask if I would like a compassionate nurse or doctor. Yes I would not one that because I am old with multiple aliments doesn't want to treat me...at all costs. Are these nurses really keeping an eye on the tab of these patients becasue the original op states in her first complaint she didn't like the doctors keeping the patients alive "at all costs". Do they think they are going to see a pay raise if they help cut the cost of these inevitable deaths. I thought the doctor said the patient was not terminal , do we just stop treating them? The patient may want to go home to die but if the doctor said she is not terminally ill what is she dying from?

If she is septic do we stop antibiotics because she wants to go home to die? I can see withholding life support if the patient wishes but I can't see withholding medical care so the patient can die,

GregRN · Feb 11, 2007

For the docs who try everything they know to "cure" a patient and make them better? Good. God bless them. We need them, and in the face of poor odds I would want my patient's doc trying to do and think of every possible angle, solution and option to save my patient. That's what the docs do and we need them to do that.

Think about the other side for a moment. Let's say a patient is very sick and does just want to go home and die and we let them go. While home they chat with their family doc who discusses with them some other treatment options, options which were never made known to them because we were so quick to "honor their wishes" and send them home. These options may not have cured them but may have extended their life at their baseline level for a bit, allowing them to do a few more things they had wanted to do with their life. The docs have a responsibility to discuss these options, and their possible outcomes. Without it, the family may get angry for not knowing all their options, all for the sake of us wanting to honor their wishes of going home. Does that mean docs are being all holy? Does this mean we aren't being supportive of a family's decisioin? True story, by the way.

What can we do? We set up the situation appropriately on both sides. We tell the family: the docs are always thinking of options and outcomes in order to best treat patients and I will ask them to share those with you. Listen to them, ask them every question you can think of, and then make your decision. I will ask that they be completely honest of the benefits and outcomes of each option, no matter how good or bad. I'll be here to support you when you do talk to them. We also then tell the docs: the patient and the family is exhausted and are questioning the benefits of all the treatment they have been receiving and any future treatments. They are greatly appreciateive of all your efforts but it sounds to me like they are starting to consider comfort/palliative care, including home hospice as other treatment options. I'd like you to talk to them about any other treatment options you can think of, including the possible outcomes and benefits of each, if any. As always, the option of not treating should be mentioned, along with hospice and palliative care should the family choose. Can you please make sure they are aware of all their options? Thanks, and I'll be there to support you and the family when you speak to them.

I always say that in healthcare, regardless of it being surgery, medicine or nursing, our job is to carry out the wishes of our patient. If they want the full court press, they get the full court press. If after being fully informed of all their options and the likely outcomes of each, they want all treatment to stop, then we stop all treatment. We owe our patients the best care possible, no matter the outcome.

TachyBrady · Feb 11, 2007

I respect your wishes and your right to want to be treated for everything and to live forever. I respect all my patients' decisions who feel this way. I have no problem carrying out the orders for patients who feel this way; that is my job.

The problem lies, as the original poster stated, in forcing treatments on patients who no longer wish to be treated. In my experience, these are patients who have been around the medical block a few times. It becomes an issue of quality of life.

Keeping someone alive "at all costs" is an expression. It has nothing to do with financial gain. It has to do with disregarding pt/family wishes and futility of care.

Myxel67 · Feb 11, 2007

Many physicians see it as a personal failure when a patient dies. I think that admitting defeat is difficult for them. When I worked in Critical Care,

it was heartbreaking to see the extremes some doctors went to. And there's nothing pretty about coding a 95 year old pt.

I have recommended Hospice consults (and ethics committee consults) for many patients. Often, the doc will finally give up, write the order for hospice consult, and the patient dies the next day.

Just as bad in my opinion are family members who just won't accept that death is a part of living. We used the ethics committee for these issues as well.

We do face some cultural hurdles about how different groups view death. Many people here in Miami do not want family to die at home. They are superstitious about staying in a house where someone has died. So everyone is brought to the hopital so they don't die at home.

DebRN06 · Feb 12, 2007

If death were to come calling right now I would Fight with everything I had to stay alive, I would want everything done to keep me alive.

Yes..if it were to come RIGHT NOW. I would assume you are healthy, so you have not truly had to (as of yet) contemplate your own mortality. I will also guess that you have yet to lose both your parents, your siblings, your spouse, most (if not all) of your friends, cousins, aunts/uncles. I will also throw caution to the wind and take a gamble that you do not have a chronic, debilitating illness, are not constantly in pain, have not lost all independence, and most basic functions.

Some people lose their desire to live. THERE IS NOTHING WRONG WITH THIS!! THIS DOES NOT MEAN THEY DON'T LOVE LIFE!! This simply means that they have come to terms with their own mortality and that they have come a point in their life where they are, in fact, AT PEACE with the fact that they are, as we all are, going to die.

Have you not had the honor to witness this?? I hope you do because it is a beautiful thing to hear a person (and I only have experienced this with elderly friends) say that, "Yes, life was hard. It had its up and downs, but more ups... I have had a good life...a good family, husband...I wouldn't change a thing...I'm ready to go." To hear someone say these things is breathtaking...I can't even begin to express the admiration I have for these people and I feel extremely privileged to have heard their thoughts/feelings/insight.

jojotoo, RN · Feb 12, 2007

At what dollar limit do we stop? Is it the same for the medicaid patient (they already get treatedlike crap in the ER) as for the insured patient and should we even try to save the uninsured?

I've been a RN for 16 years and a travel RN for the vast majority of that time. I've worked all over the country, coast to coast, even in Alaska. I've worked in Level 1 Trauma Centers to hospitals that had a one bed ER.

I have NEVER seen a difference in treatment plans between insured and uninsured patients. As an RN, I don't usually even know if a patient has insurance or not unless they need to be admitted to the hospital. If that patient doesn't have insurance, I do try to get a county bed to transfer them to, because that's where my tax dollars go to help pay for these patients. But, guess what? If there's no county bed, and they need admission, they get admitted to my for-profit hospital, and we eat the cost.

So, I don't know quite what to say about your ER where some patients are treated "like crap".

jojotoo, RN · Feb 12, 2007

Nowadays, doctors themselves don't get extra money for keeping anyone in the hospital. We are repeatedly told to get these patients moving out of the hospital. With the billing being dependent on the DRG, it is not fiscally feasible to keep folks in the hospital longer than absolutely necessary.
traumarus

Are you sure about this? I know that the hospitals are capped on their reimbursements (no matter the length of stay), but I thought physicians were reimbursed per visit/ procedure.