Compassion or reality for obese patients?

Esme12, ASN, BSN, RN · Feb 27, 2011

I think it's foolish after all these years of trying various methods of approaching dangerously obese patients with weight loss goals to think that being gentle or realistic about consequences of obesity will make much difference. Both result in watching them proceed to not give a crap, eat junk, despise exercise, deteriorate, and become a societal burden in terms of lost productivity and increased medical care costs. You're not 'educating' a fat person when you tell them that being fat has consequences. If you think you are, you're deluded.
The problem is that people are lazy; let's give them all lap bands, lipo and drug therapy. Making things easy is the real solution to obesity. Of course, that's a modest proposal.

Do you feel that we should force feed the anorexic patient???? That because they are starving themselves to death and if we educate them that not eating has consequences like death they will suddenly be all better??? That reality is their magical cure for sticking their fingers down their throats refusing to eat more than a cracker and excercising like a lunatic will release them from their nightmare? If you do ...you're deluded. Do you believe That the anorexic is less of a societal and financial burden.... just because they eat less and take up less space and are easy to reposition in bed??? Do you think that becasue they purge, binge, don't eat at all tand excercise like a maniac that they are less cost on medical/hospital/psychiatric care?? or they have less of a lost productivity?? that if you just yelled at them to "JUST EAT SOMETHING YOU ARE KILLING YOURSELF!!!!" Will cause them to pick up a fork????? :confused:

Maybe we should just put a peg tube in them all so they can finally put some weight on and get a job!! Of course,that's a modest proposal.......

Sounds harsh???? In my opinion it is.....whether too big or small we need to practice tolerance, compassion to enable us to educate and treat.....just my :twocents:

nightengalegoddess · Feb 27, 2011

Franemtnurse.

Right on! You are my kind of lady! I in no way was speaking to the person with multiple health issues as yourself. I was talking about the regular person who has all their physical abilities in tact...who is physical enough to work at the bedside....not a person who has multiple challenges...You are the kind of person whom we can look up to, because you have had these experiences and live to tell the tale...obviously victorious. Whoever ends up in your "extra skin" ought to consider themselves very lucky. Perhaps some of your winning spirit will adhere to them as well. Kudos multiplied!!!!!!!

Conqueror+, BSN, RN · Feb 27, 2011

Do you feel that we should force feed the anorexic patient???? That because they are starving themselves to death and if we educate them that not eating has consequences like death they will suddenly be all better??? That reality is their magical cure for sticking their fingers down their throats refusing to eat more than a cracker and excercising like a lunatic will release them from their nightmare? If you do ...you're deluded. Do you believe That the anorexic is less of a societal and financial burden.... just because they eat less and take up less space and are easy to reposition in bed??? Do you think that becasue they purge, binge, don't eat at all tand excercise like a maniac that they are less cost on medical/hospital/psychiatric care?? or they have less of a lost productivity?? that if you just yelled at them to "JUST EAT SOMETHING YOU ARE KILLING YOURSELF!!!!" Will cause them to pick up a fork?????
Maybe we should just put a peg tube in them all so they can finally put some weight on and get a job!! Of course,that's a modest proposal.......
Sounds harsh???? In my opinion it is.....whether too big or small we need to practice tolerance, compassion to enable us to educate and treat.....just my :twocents:

This may be harsh but if someone stops eating they will probably drop dead and therefore NOT develop diabetes, HTN, kidney disease leading to dialysis and maybe some amputations and living on 1000 dollars worth of meds per month. So the cost would actually be much less than a chronically obese person. I have seen anorexic pts put on Peg tubes so I'm not sure what that means. And having done my time in nursing homes it doesn't take a team of clydesdales to reposition an anorexic.

Conqueror+, BSN, RN · Feb 27, 2011

Nightenglenurse, This message is for you hon. I too have been where you were; without running water, I collected rain water for my household use. I also was without electricity. I used a kerosene lantern. I raised 2 children who now have masters degrees in the professions of their choosing, and both are happily married. Could I ask for more? I have been truly blessed. Now, I'm not bragging either. I'm just stating the facts of my life here.
I grew up as a thin child, was a thin mom, and when I did gain some weight, I went to Weight Watchers to lose it. I was very successful for many years. Then when I graduated nursing school in 1996 at age 55, I had gained a little weight back. I then was wearing a size 16. So I went back to Weight Watchers, and managed to get my weight back down. Yes, I walked and walked, and walked some more.(I looked very healthy at age 60.) However, in 2001, I suffered a PE that nearly took my life. I was placed on massive doses of prednisone, blood thinners and pain meds to keep me alive. I also suffered from steroid induced myopathy, and was so weak I was unable to raise my head, but was I ever HUNGRY. The hunger took over my life for a while. The following year, I began a downward spiral. Pneumonia x 4, respiratory failure x 2, septicemia, CHF, and the diagnosis of COPD which I still have and will suffer from the rest of my life, and that's not all.
I am currently wheelchair bound and am on oxygen 24/7 and am wheelchair bound. I am also well over 200 pounds, but I saw a machine I think I can use in our pool room where I live. It's a machine I can sit on and paddle like a bike in a recumbent position. I aim to try that out. So you see hon, not all of us are able to exercise the way you suggest.
You raise some very valid points, and I like your plan, so please don't take offense at this message. None is intended. I am just trying to do the best I can by eating a sugar free, low fat diet that includes lots of vegetables and fruit, plus some protein, and get out and about in my chair with my one legged friend who lives down the hall from me.
I love to laugh, and I know that helps reduce stress, and I love my life even though I am a large person now. I have thought of a positive way to handle the fat. Yes I have thought of donating my extra skin to a skin bank. I love people, and I still want to help them.

I don't think anyone would classify you as one of the patients they are complaining about. You have obviously been through alot and continue to work hard on your life. You are an inspiration, NOT a statistic.

starzrn · Feb 28, 2011

I think we are speaking more of the person who can and won't rather than can't.

kcmylorn · Feb 28, 2011

Ethics is something that comes with age. And so is seeing the bigger picture.

SammiJoRNBSN · Feb 28, 2011

Although I agree that we as medical professionals should show compassion for all walks of life, it is our main goal to attempt (if not succeed) in helping the person turn their life around to make improvements. In regards to obese patients, many of them suffer from other underlying issues, which may be stress or depression. HOWEVER, people need to be accountable for their own actions and willing to make changes for the better. We can teach them and encourage them, but if they are unwilling then everything just falls by the wayside. Patients that smoke is a whole other can of worms....they are cooped up in the hospital for their COPD, but yet they want an aide to escort them off the floor to smoke?!?!!? I am sorry, but it is a waste of time to allow personnel to leave the floor to make sure that the patient gets their next puff in, only to demand a PRN breathing treatment when they return to the floor because they are hacking up a storm after sucking down a couple of cigs. If they are so inclined to continue their bad habit, then perhaps they need to find another mode of transportation (i.e. themselves). :twocents:

CharmedJ7 · Feb 28, 2011

I just want to weigh in one more time as the other side of the BMI-bashing:

BMI is an imperfect test that does not fit 100% of people or situations - it's role is as risk assessment for the general populace. The reason it is used is simply because it does have statistical significance and there is not a better test out there that is practical. Hydrostatic weighing is a much more accurate method of determining body composition, but it's totally impractical on a grand scale. Skinfold tests have some advantages but only measure subQ fat and are very dependent on an individuals fat distribution, plus require more training of practitioner and precision of execution and seem to be more accurate in a person over time then over the entire population. Bioelectrical Impedence analysis (the stuff that drives those scales) is easy but also not all that accurate. BMI is a reasonable starting point. BMI + waist circumference is even better since both have some credibility on their own but have limitations.

A very good article on BMI came out recently in the New England Journal of Medicine, Body-Mass Index and Mortality among 1.46 Million White Adults: http://www.nejm.org/doi/pdf/10.1056/NEJMoa1000367 (abstract) . It's a good study because the sample size is so large and they control for a lot of things including smoking and physical activity. I think it also is in line with a lot of other articles I've read and things I've heard mentioned here, that being a bit overweight BMI 25-29.9, isn't a huge big deal (hazard ratio 1.13 in this study, ie, a person with BMI in this range has a 13% increased odds of dying of any cause than the same person with BMI 20-25, or more accurately, there are 113 deaths in group B vs. 100 in group A) but start getting up there in BMI? >30: 1.44, >35: 1.88, >40: 2.51.

BMI works or doesn't work like any other screening test: it gives some information on a statistical level. It isn't tailor-fitted for your muscular husband or your oddly proportioned friend, they fall on the skinny part of the bell curve. That's why healthcare providers have other tools in their box. That is not a reason to say BMI is worthless. And please don't suggest we scrap it all together unless you've got a well-reasoned and researched proposal on a better screening test for obesity, it's just not helpful.

Evidence over anecdote, that's really the only way things can move forward in a meaningful way. Anecdote may drive research and lead to better evidence, in which case more power to it, but it doesn't stand alone.

Oh, and yes, skinny can be associated with smoking and drug use. It is also the cachexic cancer patients and the anorexics. I have yet to find an article that does not plot BMI and mortality risk as a J or U-shaped curve. That's also why smoking and drug use and that are separate questions on screening surveys.

metal_m0nk, BSN, RN · Feb 28, 2011

A very good article on BMI came out recently in the New England Journal of Medicine, Body-Mass Index and Mortality among 1.46 Million White Adults: http://www.nejm.org/doi/pdf/10.1056/NEJMoa1000367 (abstract) . It's a good study because the sample size is so large and they control for a lot of things including smoking and physical activity. I think it also is in line with a lot of other articles I've read and things I've heard mentioned here, that being a bit overweight BMI 25-29.9, isn't a huge big deal (hazard ratio 1.13 in this study, ie, a person with BMI in this range has a 13% increased odds of dying of any cause than the same person with BMI 20-25, or more accurately, there are 113 deaths in group B vs. 100 in group A) but start getting up there in BMI? >30: 1.44, >35: 1.88, >40: 2.51.

This study would be much more meaningful if there were no ethnic diversity to speak of - but because there is, and the study doesn't account for any of it, it loses a lot of its applicability.

Also, they added a full point (in the direction of the low end) of BMI to the reference range.

CharmedJ7 · Feb 28, 2011

This study would be much more meaningful if there were no ethnic diversity to speak of - but because there is, and the study doesn't account for any of it, it loses a lot of its applicability.
Also, they added a full point (in the direction of the low end) of BMI to the reference range.

I'm not entirely sure I understand your complaint - how much less ethnic diversity do you want? White non-hispanic is relatively specific, unless you want white of so-and-so origin. I have other issues with the study, including like you said the reference range they use. If you dismiss every study that isn't perfect though you won't get anywhere. It does not stand alone, that is true. That's why reviews of several studies together are regarded as a higher level of evidence.

Here's another couple interesting studies finding a link:

http://www.ncbi.nlm.nih.gov/pubmed/10511607 : On US adults

http://www.ncbi.nlm.nih.gov/pubmed/16926275 : On US adults 51-70

http://www.ncbi.nlm.nih.gov/pubmed/16926276 : On Korean adults only

However, you might enjoy reading this article more: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3041737/?tool=pubmed

It's an interesting review addressing whether we would do better to move away from any weight-based target or measure instead focusing on things like intuitive eating (ie, increasing awareness of when your body is actually hungry and full etc), body acceptance, and active embodiment (inc activity vs. exercise as such), it's called HAES. This is my first exposure to it, but they make a reasonable case.

It's all interesting. This field is pretty new, there's a lot that's come out in the last 20 years or so trying to flesh out the exact relationship between different measures of obesity and body fat or mortality or even if weight and body fat is even what we should be looking at in the first place. It's very complex and evolving, but while we're waiting for the true answers (if indeed they even exist), we ought to work with what we have and the best understanding that's out there and keep going from there.

Esme12, ASN, BSN, RN · Feb 28, 2011

This may be harsh but if someone stops eating they will probably drop dead and therefore NOT develop diabetes, HTN, kidney disease leading to dialysis and maybe some amputations and living on 1000 dollars worth of meds per month. So the cost would actually be much less than a chronically obese person. I have seen anorexic pts put on Peg tubes so I'm not sure what that means. And having done my time in nursing homes it doesn't take a team of clydesdales to reposition an anorexic.

SO......it's OK to force fed the anorexic to keep them alive while their bodies are in renal failure, cardiac failure, and cardiomyopathy from lack of nutrition because they are easier to reposition in bed. That the thousands of dollars spent on their meds, dialysis, psycharitrists, TPN (which by the way costs thousands of dollars) physical/psychological therapy for their disease and multiple hospital admissions from one opportunistic infection or another is OK because of their size and they are easier to position in bed????? I am not sure if a cost compairison has ever been done but you assume the obese person would cost more because they are so fat......right? :eek:

Does anyone else find this disturbing? To "fire" a patient because they won't lose weight. YOu tell them they have to stay off the limb but they have to excercise and lose weight or they don't have a doctor anymore....they can't excercise and don't lose weight....now they don't have medical care. :confused: What's next Euthanasia? What about the cancer patient with a poor prognosis and will probably die anyway....why waste the moneyon treatment when they probably won't survive anyways??? Besides they probably were a smoker.....right??? What is going on????? :eek:

I thought the first rule of medicine was.....DO NO HARM......... :crying2:

Esme12, ASN, BSN, RN · Feb 28, 2011

I assure I have no jealousy issue to be taken here. I don't know what they are teaching young nurses now a days. The role of the nurse is not to cram ,force your views on your patients There are boundaries to the Therapeudic Relationship and patient harassment and abuse. The nurse gives the information to the patient. It's the PATIENT's decision whether or not they want to take it. The nurse DOES NOT engage in a fight, a test of wills, with the patient. The nurse treats ALL patient with dignity, respect and without judgement. That's nursing's Standard of Ethics. The proposals on these threads about obesity and smoking are not only violating peoples CIVIL rights but a breach in the Ethical standards of practice. That is a suable offense. Punnishing, yes, punnishing people with unemployment, the denial of a American liberty to earn a living, that to is in the US CONSTITUTION. That's all these CEO's want- they want to bend the rules to suit them selves. They are employing young inexperienced minds to help them. They are perfectly aware that the older seasoned nurses are are of their tyranical BS and won't go along with it. When I say older seasoned- It's those of us who have had years of the hard knocks, rasied familys, the ups and downs of life, paid bills, battled for our own personallife struggles- wether it be with a mortgage company, tax collector or on the nursing job. Our minds are not that soft of persuasvie Bull crap and know bull when we hear it. It's called LIFE experience.
If an IV drug abuser patient comes into the hospital are they now refused care? It does seem where this is going we do need socialized medicine( putting practice issues, patient rights and worker's rights into the hands of the feds who do uphold the laws of this land), and more primary providers because given the rate of these discussions, these people whose lifestyles and habits the nurse, the CEO's and administrations personally don't agree, find distasteful, or offensive will be left in a corner to die. This is not jealousy. This is unethical elitist behavior, that goes against the very grain of the nursing profession. DO NO HARM!! When some on is denied employment, and FORCED to live on public assistance, and have to grabble for their basic needs( as per maslow), that is doing harm. Serious harm. Why stop there. If there are to many female babies born in the country- Euthanasia?, to old- euthanasia?, certain race or religion- eiuthanasia? There are countries in this world that do this. Then there is female castration- look up refugees from the country of Myamar/Burma- we have these patients in our hospitals also. Do we treat these womwn with disgust and distain? Nursing is a small cog in a big wheel but nurses are the front line- if these CEO's can influence the nursing staff to practice a certain way- it' makes their job alot easier- for what end purpose- their mega buck pay check security.
To the original thought- If a patient is obese and the doctor has deemed it permissiable, give that patient the infor, and tell the patient if they have questions , leave the dialogue open to asking. Do NOt force your beliefs on them. If they are an adult with a cognitive impairment- you are talking to a brick wall. and you have to realize that. It's called readiness to learn- it's part of the nursing care plan(either written or electronic)

Well said.!

BUT FOR THE GRACE OF GOD GO I.............translation. Those sweet young nurses will someday be old too and they will face challenges and health scares and challenges, you too someday may eat your words, never call the kettle black, people in glass houses should NEVER throw stones, you reap what you sow.......KARMA.