Do Not Resuscitate - An Inconvenient Truth About Our Healthcare System

[Skwidward]

An excellent, moving article that really slaps you in the face with some not-so-palatable reality ?

https://medium.com/@mrkjamesbb/do-not-resuscitate-1e4c177dcc92

[LibraNurse27, BSN, RN]

I almost cried reading this description. These are the types of patients that I find it most difficult to care for, because the “care” feels like torture. I wonder how we can prevent this.

[brownbook]

It is a horrible story. I just hope, assume, these cases are really, REALLY, rare. I honestly can't imagine any ethical, or health care professional with just plain common sense, doing this to a patient! Maybe I'm naive? I haven't worked ICU/CCU for many years.

[JKL33]

Disappointed. And surprised at the end to see this was written by a nurse.

Quote

If a patient is unable to make decisions for themself [sic], they have no third party to advocate, and they have no written advanced directives — legal documents that state what a patient wishes to be done or not done if incapacitated — the hospital or medical facility is legally obliged to continue to do everything in its power to keep the patient alive. To not do so would be to invite legal action possibly from a surprise relative or patient advocate group.

If they have the aforementioned overly-simplified legal obligation then this assertion is immediately problematic:

Quote

A lesser known fact about the healthcare industry is how patients are kept alive and cycled through facilities in order to keep producing revenue.

The questions of "futile"/medically-inappropriate care, autonomy, beneficence/nonmaleficence are complicated matters (beginning right at the start with how terms are defined) with very few (if any) easy answers and engaging them with such lack of nuance is irresponsible.

[Wuzzie]

I'm sorry but I did not find this moving at all. Gratuitous and un-educated would be more accurate. In the case of a patient like this, at least in my state, the hospital would ask the court to assign a guardian to act in the best interest of the patient. The court, upon reviewing all of the circumstances, can give the guardian authority to agree to a DNR order if the physician deems it appropriate. I have NEVER experienced a physician eager to continue to flog the body of such a patient merely for the revenue and doubt the reimbursement to the hospital would be enough to make the bean counters rub their hands with glee. The only time I have seen this happen is when the FAMILY insists that everything be done regardless of endless hours of education by the medical and nursing staff. Horrible article with absolutely no credible facts to support the author's viewpoint.

[LibraNurse27, BSN, RN]

I do agree that in most cases if the patient has no family/advocates the unnecessary care ends sooner than when they do have family that is insisting the futile and torturous care continues. I have seen patients that have lived in SNFs for 20 yrs that are basically brain dead and immobile, kept alive by long-term vents/G-tubes, etc. I don't know why people subject their family members to a life of absolutely no quality but it does happen frequently and it is terrible to participate in this type of care. But agree with Wuzzie it is not often due to reimbursement or lack of family.

[KatieMI, BSN, MSN, RN]

1). It happens. Every single day, in pretty much every hospital of the USA, it happens. It might sound "shocking" only for someone incredibly naive.

2). It most commonly happens due to insistence of either families or nursing care facilities, and they both more frequently than it is comfortable to think of have very money-wise interest in continuing futile care. Many of those severely demented patients continue to receive SSI checks, pensions, rental revenues, they can still possess ownership of the houses which can be profitably rented by families or used for living there for free, etc. Nursing care facilities also receive Medicare/Medicaid $$ even while the patient is being moved along death loop of "ER>>ICI>>acute/LTACH>>ICU" for months in a row. Some of them even somehow manage to keep another patient in bed which otherwise would be empty and not generating revenue. All those parties wanna their $$$ - that's it, plain and simple, in clear English.

When I was working in LTACH, the comprehensive financial check was run by feds for complicated process of making patients eligible for potentially life-long high-requirements care. In like 70% of cases there were what was politically correctly named "misuses of funds" - in other words, someone was stealing money from the patient. Couple of times some inconsolable but full of hope family members who were camping in rooms constantly requesting "everything to be done, even if for just another day" of their Mother Dear' earthly existence were one beautiful day led out of there in handcuffs.

3). Ethical committee decision has ZERO executive power. They can recommend whatever but it is totally up to "current medical service" providing direct care at that moment to have that talk. The people who have guts to speak up and tell things as they are, without medical language of "might help" and such, are rare breed. Those who do not afraid of possible legal actions, repercussions from hospital administration, etc. are even rarer.

4). In cases like described in the article, in many ICUs there will be an action of "soft code". It can be named "code azure" or "code bluish" and has all components of the typical code blue, only delivered slower and with less vigor, as everybody in the team understands that the patient is dying anyway. Also, specialists always may, under some sort of premise like "the patient is a very poor candidate due to..." refuse to take potentially life-prolonging actions like dialysis, ECMO, TPN, advanced vascular access, tracheostomy, prolonged courses of IV antibiotics, etc. Or they can "recommend", for one example, very liberal regiment of "as needed" for pain and "agitation" controlled meds. The circumstances of such cases are freely discussed between providers and there can be decision made and verbally accepted by every involved provider not to accelerate care. Docs who will do whatever "family wants" or "suggested (by whoever)" under any circumstances so "not to rob them of hope" got nicknames like "eater of the dead" and universally despised by their peers and are first to be thrown under bus should case become legal.

[egg122 NP, MSN, APRN]

11 minutes ago, KatieMI said:

1). It happens. Every single day, in pretty much every hospital of the USA, it happens. It might sound "shocking" only for someone incredibly naive.

2). It most commonly happens due to insistence of either families or nursing care facilities, and they both more frequently than it is comfortable to think of have very money-wise interest in continuing futile care. Many of those severely demented patients continue to receive SSI checks, pensions, rental revenues, they can still possess ownership of the houses which can be profitably rented by families or used for living there for free, etc. Nursing care facilities also may receive Medicare/Medicaid $$ even while the patient is being moved along death loop of "ER>>ICI>>acute/LTACH>>ICU" for months in a row.

3). Ethical committee decision has ZERO executive power. They can recommend whatever but it is totally up to "current medical service" providing direct care at that moment to have that talk. The people who have guts to speak up and tell things as they are, without medical language of "might help" and such, are rare breed. Those who do not afraid of possible legal actions, repercussions from hospital administration, etc. are even rarer.

4). In cases like described in the article, in many ICUs there will be an action of "soft code". It can be named "code azure" or "code bluish" and has all components of the typucal code blue delivered slower and with less vigor, as everybody in the team understands that the patient is dying anyway. Also, specialists always may, under some sort of premise like "the patient is a very poor candidate due to..." refuse to take potentially life-prolonging actions like dialysis, ECMO, TPN, advanced vascular access, tracheostomy, prolonged courses of IV antibiotics, etc. Or they can "recommend", for one example, very liberal regiment of "as needed" for pain and "agitation" controlled meds. That usually helps to solve the problem quicker and without additional sufferings.

Yes. I have had very heated encounters with nursing home administrators who have undermined putting a patient on hospice in order to continue billing under Medicare Part A. Not to mention the number of providers who advise that they do not want to order wound treatments that speed wound healing since it will decrease the number of times they can bill for debridement. Healthcare is big business and unscrupulous behavior is quite pervasive...

[LibraNurse27, BSN, RN]

I have definitely seen the family members benefitting from a demented or brain dead patient's pension, SSI checks, etc. I always wonder if they had a bad relationship with the person before they were unresponsive, but even then I can't imagine treating someone like that =/

[KatieMI, BSN, MSN, RN]

12 minutes ago, LibraNurse27 said:

I have definitely seen the family members benefitting from a demented or brain dead patient's pension, SSI checks, etc. I always wonder if they had a bad relationship with the person before they were unresponsive, but even then I can't imagine treating someone like that =/

Usually, nope. The family just see the opportunity and then, as one Fed guy explained us, "they just got used to get ting that check, and they want it to be coming as long as possible - after all, they pay nothing for the care".

I saw tens of thousands of dollars being literally thrown by the wind because of $200 SSI check which was spent primarily on buying drugs from a street.

[LibraNurse27, BSN, RN]

5 minutes ago, KatieMI said:

Usually, nope. The family just see the opportunity and then, as one Fed guy explained us, "they just got used to get ting that check, and they want it to be coming as long as possible - after all, they pay nothing for the care".

I saw tens of thousands of dollars being literally thrown by the wind because of $200 SSI check which was spent primarily on buying drugs from a street.

WOW! ? That is so depressing. I don't usually think about the amount of money spent on the futile and painful care but now I realize that money could be much better spent on preventative care to prevent people from getting so sick that the ER and ICU become their primary care. It would be a win win for the patient who is being kept alive unnecessarily and the patients who lack access to care but still have a chance for some more healthy years of life. Good point!

[Wuzzie]

We had a baby in the NICU once who was just horribly brain damaged, absolutely no quality of life. Trached, vented and g-tube with almost constant seizure activity and frequent "death spells". The mother refused to sign a DNR. She visited about once a month for 10 minutes. On one of her last visits she asked us if we would write a letter stating the baby was blind. When we asked her why she told us that if the baby was blind she would get more money for her. Needless to say the very next day we petitioned the courts to put her in state custody. It took awhile but custody was finally transferred and we were able to let that poor little girl pass.