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madwife2002, BSN, RN Guide 101,881 Views

Joined Jan 17, '05 - from 'Ohio'. madwife2002 is a Director of Nursing Services. She has '26' year(s) of experience and specializes in 'RN, BSN, CHDN'. Posts: 10,284 (21% Liked) Likes: 6,090

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  • Dec 5

    A cautionary tale: Children are not always the best medical POA. Appoint someone who is able to listen to medical advice and understand it.

    My mother-in-law appointed her daughter as her medical POA. She spent her last 3 months of life in and out of hospitals and nursing homes. The daughter made terrible decisions that were against the advice of the doctors and nursing staff at both facilities. This caused my mother-in-law to spend her last few months in a tremendous amount of pain. She could have had a peaceful transition with the help of hospice. But the daughter refused to listen to anyone except herself.

    Make sure that your medical POA can listen to medical advice, is able to understand or ask people who do understand to explain what is being said AND asks you what you want. This person can have a lot of input into how you end your life.

  • Dec 5

    When my mother got her cancer diagnosis, even with 2 lawyers in the family, we were all very surprised to discover that Massachusetts does not recognize living wills. You can write your wishes down, but it's not legally binding. When she was actively dying a few years later, we had to fight hard for me to be named her health care proxy because of her mental state.

  • Dec 1

    Quote from Anonymous865
    My mother passed away last January.

    Mom had talked with us extensively about what she would and would not want. Whenever a difficult case was in the news, mom talked about what she would want if that were her.

    Mom had a lawyer complete a living will.

    She gave Medical Power of Attorney to her children and her husband.

    We still had a difficult time with the medical staff particularly a palliative care NP.

    If mom hadn't raised a hoard of strong, assertive children, we might have been badgered into doing what the medical staff wanted instead of what mom wanted.
    I am sorry to hear that you had a difficult time despite knowing what your mom wanted.

    You bring up an important issue in end-of-life care.
    The cornerstone of ethics in the United States is autonomy / independence - patients are encouraged and asked to participate in decision-making regarding their wishes. Thus, we have to respect patient's liberty to make decisions that may be not congruent with our own ideas or clinician's recommendations.

    But - and like everything in healthcare - this has become much more complicated. To enforce autonomy and liberty, patient-centered care with shared decision-making was introduced more into the medical community. Patients and their families are often lay people when it comes to medical decision-making but need to make decisions that will have impact on their life, quality of life, or even end their life. The idea is that the patient trusts the provider who also provides a recommendations - which should include considerations about what is in the patient's best interest.
    Nowadays, with our growing arsenal of technology and "advances", we can easily border on futility. When the "highest" goal is to maximize the life-span, aggressive interventions and treatments are often chosen even though the outcome may be negative and leads to "suffering". A patient has the right to "suffer" if that is what they decide to accept and to go through in order to gain more time. They are allowed to sacrifice comfort for the sake of more time but it is important that they understand this implication.
    Physicians can not be forced to provide futile treatments. After all, many interventions are medical orders and a physician has the right to "not offer" this treatment if the patient is not a candidate because the risk is too high or the outcome negative. Examples are surgeries or heart catheter interventions but could also include dialysis. Patients accept more easily when the surgeon or cardiologist says that the risk is too high and that is not an option because it would most likely result in death. That option is not available and thus patient autonomy does not include to choose a futile options. The same with dialysis - only that patients and families have a hard time with that decision. Nowadays patients who are 90 year old undergo dialysis to extend their life but if a person has other comorbidities, the nephrologist may not offer this treatment and refer to medical management.

    There is also technology like high flow oxygen, which was thought to be a bridge until a person gets better or dies. But I think nobody really thought about the consequences of this device. When offered to end-stage COPD or similar patients who are so sick that they cannot come off but also do not wish to be trached and live on a ventilator - there is no place for them to go. They "live" in the hospital, which is not the same as home. Lately, I heard more often "if I had known that this is not like regular oxygen and I cannot go home with this - I would have not wanted it".

    There are a lot of dilemmas all around.
    As a palliative care nurse, I have no "agenda" - my goal is to provide information and care to help patients to live best with a serious illness. There is a huge grey zone where patients do not want to have pain for example or shortness of breath - but also want to be a full code - and though are limited in what can be realized. But it is not my place to pressure somebody into a decision or coerce them - that would take away the liberty in decision-making.

    Nurses feel different about suffering than physicians, which is researched. Nurses care and have a hard time when patients suffer "needlessly". Patients and families on the other hand often have their own agenda and are not up front. We see a lot of problems related to not being able to cope with death and not being able to face "loosing somebody" - which ultimately can lead to requests for futile care.


    As a palliative care nurse I also have a responsibility to realize when the patient asks for palliative care in the sense of "hospice" but this decision is driven by not understanding ones choices. There are cases where nurses or physicians request a palliative care consult because "the patient does not want any treatment and is ready to die" indicating they respect autonomy but the patient is not competent to make this decision due to mental illness or otherwise incapacitated. Or the patient clearly does not understand that for example life with dialysis is possible or that people can live at home with tube feeds.

    There is a lot of room for conflict and friction at the end of life that can make everything more stressful for everybody.

    Here is a good article:

    What’s the Role of Autonomy in Patient- and Family-Centered Care When Patients and Family Members Don’t Agree?, Jan 16 - AMA Journal of Ethics (formerly Virtual Mentor)

  • Nov 30

    I think you make a great point when you point out that advanced directives are an important matter to ensure that there is somewhat control over one's care.
    I also agree that we need to establish a culture within our society that permits the discussion of end-of-life wishes or general thoughts on what constitutes quality of life.

    However, a living will is not the most important document and there seems to be some ongoing confusion around advanced care planning.

    I would like to add some information:

    - the one single document that any competent adult over the age of 18 years should have is the Health Care Power of Attorney, also called Health Care Proxy (HCP). In this form, that differs from state to state, any competent adult over the age of 18 can name a person (or several) who will make healthcare decisions in case that person is unable to do so (as determined by a physician). Anybody above the age of 18 should have one. If something happens to somebody and they are now unable to convey wishes or are not competent due to an illness/accident, and there is no decision maker named, it can place a huge burden on the next of kin. In some cases and states the next of kin has to go to court to ask for guardianship, which takes time but also restricts the guardian in a different way. A person who does not have a health care proxy form filled out, usually also does not get accepted to rehab. In any way - if there is one form that anybody should do - it is that form. Usually no expensive lawyer is needed, the form needs to be witnessed by adults.

    - Living Will - this is a document where a person conveys what they would like to be done or not done or how in case of certain circumstances.While it is great to have a document that provides guidance, it is also a document that is not statutorily recognized in all states. For example, the state of Massachusetts does not recognize a "living will" as binding. If somebody presents a living will, the health care proxy can still use it for their own guidance in decision making. So - since not all states recognize the living will it is really the most important thing to do the health care proxy form and to talk to that person about the wishes. Otherwise they may struggle with decision making or not make the decision that the person would want.
    And - a living will depends still on the interpretation by the medical professional and how the HCP understands the circumstances. When people write in their will "if there is no meaningful recovery" - what does that really mean???
    And - a living will cost money that a lot of people do not have or want to spend, especially if it is a state that does not recognize the document as binding.
    And - when there is a situation where the living will says one thing but the HCP says something different - the physicians will usually do what the HCP wants. Nobody wants to get sued. I have seen patients who never wanted to be intubated, who even had a provider order not to intubate. When the HCP panicked or thought that they are not ready to accept death and ask the MD "to do everything" that patient will still get intubated.

    POLST/MOLST: Provider order for life sustaining treatments - this is a medical order (!) for people with serious illness or high age that is filled out with the MD/NP/PA and details if the patient should get intubated/chest compressions/ dialysis/ artificial nutrition and so on and forth. It is a portable order and goes with the patient.


    It is always good to have conversations about one's wishes. I could get into a terrible car accident tomorrow and end up in the ICU on a vent - hopefully my spouse knows my wishes and would enforce them. We have talked about those situations so we know what the other one would want. My spouse would want extreme measures unless his head is "cut off" or he "can't think anymore". I asked my oldest child before he left for college and we had discussions, I gave him a health care proxy form to fill out.
    There is a huge amount of confusion out there about advanced directives ....

  • Nov 30

    Great article, madwife.

    Belinda, my wife who is a medical nurse, and I regularly talk about death. If we're watching some movie where a major health crisis is invovled, I'll pause the movie to bring it back home. "What would you do if that victim was me?" "What would you wish to have done?" Etc.

    I have had a living will, designated Power of Attorney for Healthcare and Finances backup in case something happens to Belinda, along with pre-paid funeral arrangements for several years now.

    Doing so has given me some piece of mind.

  • Nov 30

    My mother passed away last January.

    Mom had talked with us extensively about what she would and would not want. Whenever a difficult case was in the news, mom talked about what she would want if that were her.

    Mom had a lawyer complete a living will.

    She gave Medical Power of Attorney to her children and her husband.

    We still had a difficult time with the medical staff particularly a palliative care NP.

    If mom hadn't raised a hoard of strong, assertive children, we might have been badgered into doing what the medical staff wanted instead of what mom wanted.

  • Nov 24

    Here’s some of our best Thanksgiving threads - enjoy!

    When Thanksgiving isn’t exactly as we planned…Thanksgiving Humor

    Are you working Thanksgiving 2016? Here’s a great story: Why I’m Grateful to Be Working on Thanksgiving

    Thanksgiving is a time to be thankful for everything we have and here are two articles with great examples:

    Thankful to Be a Nurse on Thanksgiving

    A Nurse Who Gives Thanks on a Thanksgiving Holiday

    And our current thread about what you are thankful for this Thanksgiving:

    Thanksgiving Thoughts: What are YOU Thankful For this Year?

  • Nov 1

    Unlike IQ-EQ can be managed and improved


    It's not true that IQ can't be "managed and improved." Studies have shown that when impoverished children receive better nutrition, get more rest, and are placed in an environment more conducive to learning (more supportive of education, less stress and conflict, etc.), their IQs do improve.

  • Oct 21

    I am ready to leave the nursing profession after 6 years. I have a bachelor's degree in biology and got my associate's in nursing. In high school, I decided that I wanted a career in nursing. By the time I entered college, I decided I wanted to become an OB/GYN. Halfway through college, I realized I didn't want to be a doctor. I wasn't sure what I wanted to do but I wasn't going to change my major and start over. Fast forward about 8 years, I considered nursing and applied to nursing school and here I am.....back at square one. I wish I had sacrificed and endured one or two more years of college by changing my major and pursued something else.

    I often-times cringe when I think of going to work. My attitude changes, my heart races, and anxiety sets in. My coworkers are nothing less than awesome. Most of my patients rock. Both have been unexpected blessings to me and I thank God for our paths crossing. But management, the physicians, and the facility at which I work have made nursing a profession that I wished I had not entered. I never have to wonder how devalued I am when I'm at work. Our voices are not heard, and as a matter of fact, our concerns are considered complaints.

    Not only am I a caregiver, but I am the business office, auditor, waitress, maid, logistics, IT, quality assurance, babysitter, personal assistant, and the list goes on. When doctors fall short, it is our job to clean the mess up.....and, no, I'm not speaking of mistakes that affect patient care. I speaking of simple documentation that they are supposed to take care of. I understand the importance of having all "I"s dotted and every "T" crossed, but when will the physicians be held accountable? I can't be chasing down physicians when they forget to check the correct box especially when it has little or nothing to do with a patient's outcome. That's not my job. We nurses are stressed, afraid, furious, and just plain depressed as a result of these added responsibilities. We already worry about our patients even after quitting time. After leaving work, many of us call back up to the floor or unit checking on our patients. We are genuinely concerned about them, but it is very obvious that management's agenda is not the patients. Whatever management's agenda is becomes our agenda, right? WRONG!!! I'm here to take care of patients, not physicians.

    There are so many nurses, YOUNG, fairly new nurses, that I know that started their nursing careers with a clean bill of health. They are now on antidepressants, benzos, blood pressure meds, and others due to the stress and unhappiness. Nursing has gotten away from patient care. It's about making money for the organization which is about making the physicians happy. If that means being stripped of our dignity, we are to do what it takes. I feel as though it is second nature to provide excellent care to our patients. WE have saved many lives anywhere from observing changes in our patients to discoverering mistakes made by others (physicians) and correcting them or directing attention to the oversight. I wish they would let us do OUR jobs and provide care and management can can run up behind THEIR "customers". If we can keep those two jobs separate, that would be great.

    We are a vital part in patient care, but yet, we are so underapprecited and taken for granted. We make a positive impact in many lives, but we are the first ones cursed out because someone is having a bad day. Not only are we unappreciated, but we are very disrespected, and in many occasions we are unfairly belittled and we are just supposed to accept those words because "it's part of the job." I'm done accepting it. I'm reminded everyday there are replacements waiting in line. I'm reminded that any fool can do my job. I don't want a pat on my back everytime I do a great job, just acknowledge that I am a vital part of the team. I understand human resources has a stack of nursing applicants on their desks. I just don't have to be reminded of that everytime all my paperwork isn't on the chart (because I'm still working on it), or if I come back from lunch two minutes late.

    I am not cut out to take jabs and low-blows without throwing them back. I have so many responsibilities that I take on from the time I punch the clock to the time I punch out and I refuse to be disrespected by someone with a title because I happen to not move fast enough or I am having to clarify an unclear and, most of the time, an unfinished or incorrect order. I'm helping YOU out!! We genuinely worry and care about our patients that it often consumes us. When a patient codes or expires, we are crushed. I once had a patient who got stuck at least 15 times by various staff members, including physicians, to get IV access. The patient took those sticks like a champ, but I still went home and boo-hooed because I hated to see him go through that. We hurt when our patients hurt. On top of carrying out our responsibility as nurses, we are holding in so much emotion associated with our patients.....yet we get very little to no respect. Don't get me wrong, there are some physicians that I'm in contact with whom are polite and value my opinion and I do appreciate them. Of course I'm not always right or may not make the most intelligent statements, but they acknowledged my voice. Again, I don't want a cookie. I just want to be acknowledged as a professional.

    I understand customer service includes dealing with angry, rude, and the dissatisfied. But when I have poured my heart, soul and emotion into my job and my customers and I am still allowed to be mistreated and insulted, then that becomes a problem. I feel I have no rights as a nurse. Who is protecting me? Who is my voice? Who is standing in my defense?

    So at this point, it's time for me to bow out from the nursing profession gracefully and while in good standing with the organization, my family, and myself before I am forced out or OD on my meds(or somebody else's). My family, happiness, health, dignity, and peace of mind is worth leaving. They tell me Costco employees never leave.

  • Oct 19

    This is in no way justification of staff truely poorly treated but I wonder how many of us have some sort of healthcare related stock in our retirement portfolios. As in we want our stocks to perform well but not impact us in our individual work.

    Or in other companies for that matter that may be providing or doing something we object to.

  • Oct 17

    The other name I see used for "they" is "TPTB" or "The Powers That Be", meaning those who actually hold and wield the power to make those decision and take those actions that impact our policies and resources to care for our patients.
    I am heartened to hear from so many nurses who have not forgotten what it's like on the clinical side and genuinely struggle to balance budgetary prioroties with excellent patient-and staff-care. There need to be more of you.Please keep on fighting for our patients AND those of us still in the trenches with them, Quixotic though it may seem at the present.

  • Oct 14

    I am one who believes the detached approach administration ("they") uses is a double edged sword. It takes many skills, interpersonal and decision making alike, to weild this sword.

    "They" to a degree must remain autonomous. They must make decisions that have a ripple effect throughout the facility they oversee. No matter how well they choose and implement new measures, someone dislikes it.

    Nursing has an advantage over "they" in that our purpose is focused and we'll defined. We use pt outcomes as our guiding beacon when a difficult decision must be made. And we should. They do not have this luxury.

    I've been in middle management and am acutely aware of how no matter what you do, legions of people are going to disagree. Some are so discontent, they will even go beyond disagreement. That is when sabotage rears it's ugly head.

    With that said, I feel I need to say something after reading your article: "Never take your personal experiences as everyone else's reality."

    The "they" you have become and work beside sound like they ride home on Puff the Magic Dragon and clean their houses by singing a song to bring the broom and dustpan to life.

    This is not the reality in the majority of healthcare facilities.

    Corporate America has made its objectives the priority in modern healthcare. To refuse to humor them is to accept closing your doors.

    Yet agreeing to humor them means having to run with minimal staffing, arbitrary and misguided policy making and having to be content with a grade school definition of customer service.

    That is the riddle they face. Forced to partner with other "they" who have an agenda that does not support ours. They are damned if they do, damned if they dont.

    Sounds like the same riddle we as nurses say we are facing. Trickle down perhaps?

    Most "they" solve this riddle by submitting to the Corporate America agenda. Then they try to achieve the original agenda of superior patient care by squeezing the life out of the nurses.

    Less representation, lower wages, smoke and mirrors benefits, scarce supplies and support staff, being demeaned instead of recognized, higher standards with less support.

    This is the solution most "they" find themselves implementing, regardless of what their original intentions were.

    They burn out, just like nurses do. Of course they do. And when they do, the results are devastating to everyone who must endure their tenure.

    Most (not a select few, not some........most) "they" are either struggling to solve the riddle I spoke of and on their way to being burnt out or are already there. See, that's something else we have in common with them.

    This is the reality of "they".

  • Oct 14

    I don't buy it, and I don't mean it with disrespect to you personally, but the sole reason me leaving bedside was because of "them". It's easy to say things behind a desk, walking on high heels eating corporate served bagels and coffee while my ER colleagues struggled to even have proper staffing let alone be served a cup of kool-aid. Then I see "them" walking with a smile and making comments about "we care about patients and our staff", I laugh at this. No one becomes an administrator to "affect the community in bigger impactful way", you get out because life is less stressful and less demeaning at the desk in a suit compared to working with short staffed department all day long and get chastised because you didn't meet sepsis bolus time or patients complain because they didn't get their pain med or a retarded second pillow. It's easier to set goals and policies when you don't really have to abide by them physically. They are the reason I will never work at a bedside or hospital ever again unless I am "them." all I gotta do is act like a give a crap but just rake in my bonus and cut corners for all the other cronies to make more bonuses, if you can't beat them you gotta join them.

  • Oct 14

    I get it. I understand what you are saying. "They" do have good
    intentions, are not evil tyrants living solely to kick back in a leather
    chair and line their own pockets every day. "They" have a job to do
    just like the rest of us.

    The Director of Nursing at my hospital has a job to do, and if her job
    is not done effectively, she's fired. She's not all powerful, she has
    people over her making sure her job is done effectively.

    Many times when staff doesn't get what they, understandably want
    such as better benefits, better hours, better nurse to patient ratios,
    they blame "them". Sometimes "they" really are to blame, because
    they are doing their jobs poorly. Other times, "they" are doing the
    best they can to make things better for the floor nurses, though the
    floor nurses may not realize that.

    I've been a member of administration. I've been a case manager.
    At this point I would rather be passing out medications, wiping butts
    and charting, as opposed to having the responsibility of a manager,
    case manager, or administrator.

  • Oct 14

    I am "they" in a way. I am a member of the nurse practice counsel and "they" are grateful to have a "real live" perspective.


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