Allowed to die

nettie01 · Oct 1, 2005

hi nettie,
i also work in acute care, and see this quite often. ideally patients like this would stay in or return to their residential living to die. however, for a variety of reasons this rarely happens once they'd been admitted to hospital.
i'm not sure, reading your post, which aspect you found troubling: was it that she died in hospital, or that she did not have fluids, nutrition or antibiotics?

a lot of people feel disturbed by the idea of not feeding or hydrating someone. we can treat infections but to decide not to is quite significant. i think what we were doing is passive euthanasia.

she wasn't "terminal", she didn't have cancer. she was a dependant long term care resident with an infection. the doctors with family decided not to treat it or give her fluids. i know that some people find this wrong and i'm uncomfortable with it that's all. to society she didn't have high value and she was totally vulnerable and dependant. maybe she wanted to die, i don't know. i know that life has an end and because of what medical science can achieve we have more ethical dilemmas than we did in the past.

the british medical association statement helped me.

http://www.gmc-uk.org/standards/whwd.htm

however, on just looking for the weblink for you, i discovered that there was quite a bit of opposition to this statement - from british doctors and others.

it's just controversial and it won't go away i believe (like the abortion debate) because it touches on what people believe fundamentally about life.

jeanette

Cubby · Oct 2, 2005

We deal with this problem frequently. We call it "Comfort Care Measures Only" the family decides-'enough is enough' and we allow the resident to die with a tad bit more dignity than trying to 'beat death' with various IVAB, PEG tubes etc. I find that once "Family" has decided that they don't want anything else done, the resident improves-at least for a while. Death always comes, but usually is way laid by a brief period where the resident is cognizant, and happy that they have some control over their life, even if it is at the end.

Laurell28 · Oct 2, 2005

Antibiotics do not always cure infection especially if someone has chronic infections and has been on them repeatedly. Also the side effects can be quite uncomfortable. So an infection can be a "terminal" condition. Allowing someone to die with dignity and comfort is not passive euthanasia.

nettie01 · Oct 2, 2005

antibiotics do not always cure infection especially if someone has chronic infections and has been on them repeatedly. also the side effects can be quite uncomfortable. so an infection can be a "terminal" condition. allowing someone to die with dignity and comfort is not passive euthanasia.

oh, i thought it was quite clearly passive euthanasia - not treating something that could be treated and so allowing nature to take its course. that's not to say that all euthanasia is bad.

jeanette

allnurses Guide · Oct 2, 2005

On my unit under comfort measures if it hurts we dont do it, that includes turning , the patient attempting to swallow or any meds that have to be given rectally.

I think I'd rather be in hospital with an IV for my comfort pain meds, rather than rectal. Not all LTC can do IV care, here they send folks to us for anything IV.

talaxandra · Oct 2, 2005

oh, i thought it was quite clearly passive euthanasia - not treating something that could be treated and so allowing nature to take its course. that's not to say that all euthanasia is bad.
jeanette

except that there are many things that can be treated that we chose not to treat, for a variety of reasons. for example, we don't consider a heart transplant for a demented ninety-year-old from long-term care with virl cardiomyopathy. sometimes treatment is futile, and can even be construed as causing a harm to the patient - with family consent (and, on at least one occasion, at family insistence) we've withdrawn antibiotics on patients because of the resulting diarrhea, or because maintaining iv access requires physical and chemical restraint.

the vatican, who has the most formal, comprehensive, and life-saving policy on intervention, explicitly permits the withdrawal or withholding of futile treatment. of course, a lot depends on the interpretation :rolleyes:

CapeCodMermaid, RN · Oct 2, 2005

at the risk of getting hollered at.....

Surely you're not suggesting we take our lead of what is right and wrong from the Vatican?!?!?

talaxandra · Oct 2, 2005

Surely you're not suggesting we take our lead of what is right and wrong from the Vatican?!?!?

Heavens no! What I meant was that even the most conservative organisations accepts that there are occasions where it is appropriate/acceptable to withdraw or withhold life prolonging (vs life saving) interventions. It could therefore be argued that this is a generally morally and ethically acceptable practice. Though, as I said, a lot depends on the interpretation of 'futile'.

honeybun · Oct 5, 2005

:stone hi, i just had a family member to pass away after years(>5) of lying in a ltf. he was born mr, but had a happy growing up life. for 7 years he slowly couln't recognize ne one. he got a trach, feeding tube, catheters, o2. he was taken such good care of. wonderful job. i don't know why he hung on so long. they finally decided no more hospitalizations when getting worse. no code, and keep comfy. they kept antibiotics when they could give per tube. my grief was my inlaws refused to give up the feedings. i think this was what made him hang on, but for what?!?! :uhoh21: she could not stand the thought of him not eating?!?!. like he could taste it.(she's like 300 lbs) thank god, he( the great lord of host) decided the take him home. i know he a wearing a crown of gold and jewels. he deserves it if ne body does. he could not make decisions for himself and he was at the mercy of someone elses decision. he could have passed on from this world to another one so much sooner. only god knows why. but for your question, i don't think it inhumane to allow someone to pass on peacefully and comfortably. it's not like they will ever be able to get up and dance again or smile at you with knowledge of what they are smiling at. there is a better place, with no suffering.

hello, i'm writing from new zealand. it's really interesting reading your posts - usually i write in the hospice section but i thought i'd 'come over' to talk to you geriatric experts.
last week i looked after an elderly lady who'd been admitted during the night with urinary sepsis. she was from a rest home and quite dependant for her adls; she had some dementia. the decision (by the husband, son and doctors - i wasn't there so i don't know who had the most 'sway' in the discussion) was for no antibiotics, no fluids, no feeding. she was 'cast' in bed, being turned two hourly - it seemed the relatives expected her to die.
do you have this scenario often in your work?
i'm not 100% sure that what we were doing was morally acceptable: it seems 'murky' ethically to me.
jeanette:stone

nettie01 · Oct 5, 2005

:stone hi, i just had a family member to pass away after years(>5) of lying in a ltf. he was born mr, but had a happy growing up life. for 7 years he slowly couln't recognize ne one. he got a trach, feeding tube, catheters, o2. he was taken such good care of. wonderful job.

hi thanks for your story. it sure does seem silly to have all that intervention. i think the hard thing for the decison-makers is knowing when to stop and then knowing that death will be the result. death is so alien to us - life is what we know about.

thanks

jeanette

Nurse Cozmo · Oct 6, 2005

In the United States, "Hospice" is health care philosophy, delivery system and maybe most importantly (especially the way administration sees it) a Medicare Benefit paid for by the Federal Government. The are some very strict rules or guidelines that must be followed, one of which is the patient must agree to forgo all "treatments that are seen as cure-seeking." However, things like nutrition, hydration, oxygen and even antibiotics can all be looked at as palliative, with a talented bunch of billing agents and MD's that can talk the talk. I don't know about New Zeleand, sometimes I feel we unnessesarily hasten death but we always work as an interdiscipinary team, with one goal in mind: a "good death", pain free physically, spiritually and emotionally.

markm739 · Oct 6, 2005

This thread has me thinking about a situation which occurred yesterday in the ICU unit where I am on orientation.

My preceptor and I cared for an end-stage COPD pt. 2 days this week. He was on BIPAP with terrible labored breathing, and I saw his LOC decline significantly during the day on Day 1. Day 2 a.m. he was unresponsive most of the morning; about noon, he was able to squeeze my hand weakly upon command, but had no other response to anything except pain at any other time.

My preceptor went in and talked to the wife about his code status and the potential use of a ventilator, which he might never come off of; this all resulted in her saying that the pt. had previously stated that he didn't want to be put on machines. When the doctor came in about 1300, he was officially made a DNR.

Now, I know this is a commonplace and commonsense scenario taking place regularly throughout this country, and that the wife needed guidance as to what to do so as to not prolong the suffering of her spouse of 51 years. It was the next thing which happened which I am looking at with a critical eye in light of what is being discussed here.

When the md wrote the DNR order, we also revamped his entire med list to reflect the new approach; again, common sense. Our unit has a formal deescalation protocol, but this was not being implemented, as this man had not been on a vent.

The new med list included morphine, of course...I think it was 2-4 mg, can't remember the frequency, probably q 1-4 hours. It was not the morphine drip starting at 10 mg/hr on our deescalation protocol.

At 1700, my preceptor came up to me and asked me how I felt about giving this guy morphine. The pt. was resting quietly in bed with no agitation or signs of pain or increased vitals. I asked him why, since there seemed to be no immediate indication for the morphine; he said that if this guy were to hang on too long, let's say, 3 or 4 days, the wife may start to doubt her DNR decision, and that would just add to her misery. I said, "You mean, give him morphine to slow down his breathing so he won't hang on 3 or 4 days?" My preceptor nodded. This was a new concept for me, as there seems to be quite a difference between not engaging in futile treatment and actively giving drugs to hasten the end. No one would want this COPD guy to suffer any longer than necessary, but actively giving him morphine for RR effect is a little on the proactive side, it seems.

My preceptor walked over and indicated he was giving the morphine; when I left at 1900, the gentleman's RR was down to 8.

I was thinking about this last night, and suddenly thought to myself, "How would I feel if I knew my own husband's end in this ICU was hastened by possibly a couple of days by a nurse who felt it would be detrimental to my mental well-being to let my spouse 'hang on' (in other words, die without intervention), and that this decision to consciously slow down his breathing to hasten his end was done without my consent or knowledge?"

I am becoming increasingly more uncomfortable throughout the day as I contemplate what happened. I know there is probably a euthanasia/ethics thread that this might fit under more appropriately, but you all really have me thinking here. Should I post this also under any other thread? (I am relatively new to posting.)

And believe me, I know that what happened makes absolutely no difference to the pt.'s long term welfare; it's just that the wife had no say in this, it is dangerously close to euthansia (if not equivalent), and is the stuff lawsuits are made of.

Since I am new on the scene, I am wondering if the problem is that this is a common practice that no one talks about, and that I am just naive about what really goes on. My preceptor's motives were not bad (the euthanasia movement's aren't either), but this really blows away the idea of informed consent to medical treatment. I imagine that all sorts of things go on in ICUs across the country that no one would admit to, but I would really like to get some reactions from seasoned ICU nurses and nurse ethicists as to whether this is common practice, this guy is unusual, or I am naive enough to still be hanging on to nursing school habits and ideas, and am too "black and white" in my thinking.

ICU Newbie

BSN May 2005

NCLEX survivor July 2005