ethical issues with aggressive treatments and end of life

  1. Last night I had patient for the first time who is in her late 50s. She has already been resusitated once(just barely) due to serious arrthymias. She has been a renal dialysis patient for several years and has a deadly lung condition which is killing her slowly. The woman had a automatic implantible defib. device inserted shortly after the recent resusitation. As you all know these things are very expensive to buy and insert. But let's not consider the money here, let's talk about the patient. She is alert and oriented a very nice person even though she has been through hell. However, the thought popped into my mind that they cheated her out of a quick relatively painless death only to have her die a slow death of suffocation and kindney failure. Would you believe I am not passing any judgement here, just wondering about our healthcare system and the way people seem to be offered the expensive aggressive treatment. She said the doctor told her she had to have this thing inserted or she would die. Well everyone is going to die. If I were in her shoes knowing what I know I would have declined having the device inserted but most people don't know what I know. Also, I just think I would decline to have device inserted. I don't really know what I would do in that situation. I guess with her age and everything the situation is very borderline.
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  2. 14 Comments

  3. by   leslie :-D
    do you have any idea on how the pt. feels? obviously she must be a full code....just wondering. if it's something the patient wants then she needs to make herself a dnr, in other words, it's her call. it really doesn't matter what we think. now it would be another matter if she did not want to be resuscitated and they did it anyway.
  4. by   Stitchie
    This sounds to me like a classic case of the physician not explaining all of the available options to her, one of which is a gentle death.

    My philosophy is 'just because we can doesn't mean we should'. You're right, everyone is going to die someday, and if her condition has now caused her to become a cardiac cripple, or endure a lifetime of dialysis, is this really what she wanted?

    Is she still a patient on your unit? Can you talk to her about end of life issues? It's difficult, but sometimes the best thing to do is talk about her options, such as hospice and DNR status. Sometimes the greatest advocate you can be for your patient is to give them options for a gentle sendoff. None of us are promised endless tomorrows.

    As someone posted in another thread, it's all about the $$$, and if there's a big fancy 'operation' that will keep her alive the last thing anyone talks to the patient about is quality of life!
    Last edit by Stitchie on Apr 25, '04
  5. by   oramar
    She has been on my unit several days and has just made herself a DNR for first time. She obviously was not a DNR when she was resently revived and had the device inserted. At the urging of the nurses on the floor our medical director talked to her about end of life issues and options. It probably was the first time she heard that approach. However, she was transfered to us from a high, high tech institutions where they always seem to do the most expensive intervention first and talk later. My sleeply little hospital is like a refuge from the storm for people like her.
  6. by   gwenith
    Hate to push the "free" vs "pay" medical system but it has been my experience that high tech interventions that are not truely in the patient's best interests are less commonly offered under a "free" system. They are discussed but they are very darefully discussed so that the patient knows exactly what they are getting into,

    I know that ethically there are arguments both ways but this is the observed reality. I keep thinking of my Aunt - Bronchiolitis Obliterans - had a severe brain damage from cardiac arrest prior to intubation in a private hospital and they did a trachy 2 days before they switched off the ventilator due to brain damage - I was not able to be near her so I do not know the whole story but it always sounded strange to me - if she had been in a public system they would have continued with intubation rather than the expense of a trachy if we had any suspicion that there was irreversable brain damage.
  7. by   jemb
    Many times I believe that our technology has overcome our humanity.
  8. by   jnette
    You know, nine times out of ten I would agree with you on this one, Oramar... but something here with this case doesn't seem to fit in with my usual feelings on this.

    Late fifties... I'm headed that way. In a couple months I turn 56. Hey, I am NO where ready to push up daisies ! I feel like I still have a whole lifetime ahead of me ! And as far as dialysis, if that was helping me to live right now, hook me up !

    MOST of our dialysis patients live relatively healthy and productive lives.... they enjoy their families, grandchildren, go on vacations, travel, and I can't conceive of them saying.. "nah, think I'd rather just lay down and die right now".

    Yes, there are a few who have numerous comorbidities, and in combination with their advanced age (eighties and up), they might be more ready.

    But if this lady is not suffering, is in no real PAIN (I don't know what her lung condition is, nor how it currently affects her quality of life, or if she is in pain...), then I'd have to agree with Earle 58 on this one.

    Does SHE want to live? If she wants this device and it gives her hope and assurance, then by all means she should have it.

    If her life is so deteriorated, however, that she cannot enjoy or live painfree, then it might be a different story. Guess I just don't know enough about her condition to say one way or another.

    I'm just trying to put myself in her shoes here. If it was merely a matter of "age" and a lung condition which will eventually kill her...? Well, what's eventually? And does it cause her daily pain? We're all going to die of SOME condition... even those on dialysis will die of a renal condition eventually, some might have another condition to go along with it. But how is she living NOW, and is she content with her life as it is? Is it satisfactory enough for her to want to prolong it?

    Guess that would be my question.
  9. by   nialloh
    It seems to be a case of all reasonable care Vs all possible care. Just because you can do something, doesn't mean you have to.

    I have seen terrible things done to keep people alive a few more days, even when that person was as good as brain dead.

    One woman was on a vent and coded. Her kidneys had shut down and she was too weak for hemo. She was so bloated from fluid retention (she was on TPN), we had to change 6 pads an hour because of weeping edema. She passed when her heart gave out, not because the vent was turned off. :angryfire

    Another man was only being kept alive because of meds/vent/hemo. The family only made him a DNR when his legs started rotting off him. His arm turned black 2-3 weeks before. This man had been totally non-responsive for 2 months. He lasted 2 more weeks (still on meds/vent/hemo). :angryfire

    So do I think that too much is done at times, YES I DO. Are there times when we should let them go with dignity and respect, again, YES.

    I'm not saying for a second that we should turn off all machines on old people, or not supply care to the frail, but sometimes enough is enough.

    I care for all my patents, and it upsets me greatly when they are abused to make family feel better.

    Sorry for the vent, but as much as I love nursing, I hate this...
  10. by   jnette
    Quote from nialloh
    It seems to be a case of all reasonable care Vs all possible care. Just because you can do something, doesn't mean you have to.

    I have seen terrible things done to keep people alive a few more days, even when that person was as good as brain dead.

    One woman was on a vent and coded. Her kidneys had shut down and she was too weak for hemo. She was so bloated from fluid retention (she was on TPN), we had to change 6 pads an hour because of weeping edema. She passed when her heart gave out, not because the vent was turned off. :angryfire

    Another man was only being kept alive because of meds/vent/hemo. The family only made him a DNR when his legs started rotting off him. His arm turned black 2-3 weeks before. This man had been totally non-responsive for 2 months. He lasted 2 more weeks (still on meds/vent/hemo). :angryfire

    So do I think that too much is done at times, YES I DO. Are there times when we should let them go with dignity and respect, again, YES.

    I'm not saying for a second that we should turn off all machines on old people, or not supply care to the frail, but sometimes enough is enough.

    I care for all my patents, and it upsets me greatly when they are abused to make family feel better.

    Sorry for the vent, but as much as I love nursing, I hate this...
    I can agree with all of the above cases... most definately. As I stated, more than not, I do take this stand myself.

    It was just this one particualr case Oramar described which threw me off a bit. But, as said, I'm not familiar with ALL aspectsof her condition, either.

    But yes, for these cases here, I agree 100%.
  11. by   oramar
    Quote from oramar
    I guess with her age and everything the situation is very borderline.
    Did you notice the last line on my original post in this thread? I have mixed feelings about this one and that is why I felt the need to post. One of the people who responded to this post said, "what does the patient want". That about sizes it up does it not.
  12. by   jnette
    Quote from oramar
    Did you notice the last line on my original post in this thread? I have mixed feelings about this one and that is why I felt the need to post. One of the people who responded to this post said, "what does the patient want". That about sizes it up does it not.
    Exactly, Oramar. That's really what it boils down to. What does SHE want?

    As far as you last line in the original thread, I must have taken it the wrong way... thinking you were thinking late fifties was "old"........ :uhoh21:

    Heh... sorry ! :kiss
  13. by   oramar
    Quote from jnette
    ... thinking you were thinking late fifties was "old"........ :uhoh21:

    Heh... sorry ! :kiss
    Well if she is old then I am old because we are the same age. What exactly is the source of my discomfort in this case? I say I am happy with the patient being in control of what is done or not done so why do I feel conflicted. I strongly suspect that the proceedure was presented in a way that played up the benefits of having it done and played down the negative aspects. Why do I suspect that? Because I used to work on the unit that she came from and I know what goes on over there. It is all go, go, go, do, do, do!!! These expensive proceedures are money makers all around for the healthcare industry and where the situations is border line they will always do as opposed to not do. Most of the nurses that post here know exactly what I am talking about because they have seen it also.
  14. by   nialloh
    Quote from oramar
    Most of the nurses that post here know exactly what I am talking about because they have seen it also.

    Sad to say, it is seen all too often.

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