Do Not Resuscitate - An Inconvenient Truth About Our Healthcare System

scribblz, BSN, CNA, LPN · Mar 6, 2020

On 2/26/2020 at 2:37 PM, Wuzzie said:
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.

This is one of the most horrific things I've heard of...

KatieMI, BSN, MSN, RN · Mar 8, 2020

On 3/2/2020 at 11:01 AM, LPN Retired said:
It's hard for me to believe that actually is happening on a wide scale.

It does.

Only one way to avoid it, should one becomes an object of heroic efforts from either medical staff (who might have their own vested interests in a "case" for research, teaching or purely $-wise causes) or loving relatives is correctly written living will with clear stipulations like, for example, no feeding tubes or TPN in case of being on vent for more than full 14 24-h periods in a row, no trache, no insertion of any device which can be potentially used for prolonging life, etc. Also, preventing relatives from inheritance and automatically giving up everything for charity if any of the above will be done even if suggested by medical professional, preventing some or all of them from becoming DPOA if they are not completely trusted and many other things.

Unfortunately, one needs lawyer and close to $1000 to get this very important paper done right. Not everyone can afford this. Plus, there should be certain resolution and knowledge to willfully impact such "unthinkable" actions upon oneself or loved and dear ones.

Nascar nurse, ASN, RN · Mar 8, 2020

On 3/6/2020 at 11:52 AM, Hoosier_RN said:
It happens more often than not. I saw it so often in LTC that I no longer cringed about it. Now that I'm no longer in that environment, it saddens me to the core

Previous SNF/LTC Director of nursing and previous hospice nurse here: There’s 2 sides to this financial story that you all may not be familiar with.

Example: Pt returns from acute care with orders for hospice (but could possibly meet SNF guidelines as well d/t medical condition). We’ll assume pt meets hospice guidelines as well but not actively passing within the next week or two.

-If pt admits under SNF all their needs are included in the lump sum payment the facility gets. This includes ALL meds, room & board, therapy costs. Assuming there’s been no previous SNF days used in past 60 days, this is covered 100% for the first 20 days.

-Now assume that hospice provides services upon readmit. The pt/family is now required to pay room and board (usually upfront for a month $5,000-8,000/month). Pt/family has to pay for all non-hospice meds that family might want to continue.

In each case, DNR measures are preserved. It’s VERY common that once a family finds they’ll be paying $200-300/ DAY vs nothing they ask to go with as many SNF days as possible. This often leaves the administrator (or DON) saying “Don’t worry we’ll take care of this for you” and thereby making the call to cancel hospice for the meantime (and hence making it look like they’re the bad guy if you don’t know the entire picture).

This from a DON/hospice nurse that 100% believes in the hospice philosophy of care but knows are Medicare system is highly flawed when it comes to this.

Hoosier_RN, MSN · Mar 8, 2020

3 minutes ago, Nascar nurse said:
Previous SNF/LTC Director of nursing and previous hospice nurse here: There’s 2 sides to this financial story that you all may not be familiar with.
Example: Pt returns from acute care with orders for hospice (but could possibly meet SNF guidelines as well d/t medical condition). We’ll assume pt meets hospice guidelines as well but not actively passing within the next week or two.
-If pt admits under SNF all their needs are included in the lump sum payment the facility gets. This includes ALL meds, room & board, therapy costs. Assuming there’s been no previous SNF days used in past 60 days, this is covered 100% for the first 20 days.
-Now assume that hospice provides services upon readmit. The pt/family is now required to pay room and board (usually upfront for a month $5,000-8,000/month). Pt/family has to pay for all non-hospice meds that family might want to continue.
In each case, DNR measures are preserved. It’s VERY common that once a family finds they’ll be paying $200-300/ DAY vs nothing they ask to go with as many SNF days as possible. This often leaves the administrator (or DON) saying “Don’t worry we’ll take care of this for you” and thereby making the call to cancel hospice for the meantime (and hence making it look like they’re the bad guy if you don’t know the entire picture).

This from a DON/hospice nurse that 100% believes in the hospice philosophy of care but knows are Medicare system is highly flawed when it comes to this.

I've been a DoN and was a hospice nurse as well, and the 2 LTCs where I was had Medicaid in the mix. With hospice, they were still at same payor level at facility, with hospice, they ended up getting extra services. Many times, because of the decline, they had no skilled days, or very minimal, remaining. We got hospice involved to get that extra level of care, once we got the family on board

NurseBlaq · Mar 9, 2020

I caught an attitude reading this. ?

chopwood carrywater · Mar 22, 2020

On 2/26/2020 at 1:54 PM, LibraNurse27 said:
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.

As a NP I used to work with in hospice said “sometimes we are just prolonging their death”.

gonzo1, ASN, RN · Mar 25, 2020

Have seen this many times, although it seems to be occurring less often. The only way I can get through caring for these pts is by reminding myself that it is in the hands of God. We assign the pt to a different nurse every day if desired in order to keep anyone of us from suffering too much mental anquish. Once had a pt on vent without sedation per family orders. Pt laid in bed all day with tears running down her face. No nurse can take this kind of pt without suffering extreme mental anguish.

eakirlin · Jun 16, 2020

Just now getting the thread on catholic healthcare institutions encouraging futile care. Was the person encouraging an actual nun, priest, brother... because if so, they are going against very clear church teaching, which I am posting below:

Catholic Medical Association April 19, 2007 A. General Principles First, the DOE explicitly affirms and explains the traditional Christian rejection of suicide and euthanasia. Even in difficult medical cases, no one is permitted to seek death as an end in itself or as a means to ending suffering. On the other hand, the DOE clearly teaches that the decision to forgo extraordinary treatment (see below) “is not the equivalent of suicide; on the contrary, it should be considered as an acceptance of the human condition, or a wish to avoid the application of a medical procedure disproportionate to the results that can be expected, or a desire not to impose excessive expense on the family or the community.” Second, the DOE briefly recalls and reaffirms the traditional teaching on ordinary and extraordinary means. People are ethically obligated to use ordinary means to conserve their lives (and the lives of those for whom they are responsible) since human life is a gift of God and a fundamental good. Ordinary means are medicines, treatments and operations that provide some benefit, and/or do not involve excessive burden, pain, or expense. Extraordinary means are medicines, treatments and operations that do not provide a benefit, and/or involve excessive burden, pain, or expense. While people may use extraordinary means, they are not morally obligated to do so since earthly life for humans is not an absolute good and because, at some point, medical interventions are no longer effective and/or because the costs and burdens of medical interventions are out of proportion to the good of earthly life that they are intended to serve. The DOE teaches that no one can impose on a patient a need to accept extraordinary means, or even ordinary means, when there is no efficacy.

KatieMI, BSN, MSN, RN · Jun 16, 2020

10 minutes ago, eakirlin said:
Just now getting the thread on catholic healthcare institutions encouraging futile care. Was the person encouraging an actual nun, priest, brother... because if so, they are going against very clear church teaching, which I am posting below:
Catholic Medical Association April 19, 2007 A. General Principles First, the DOE explicitly affirms and explains the traditional Christian rejection of suicide and euthanasia. Even in difficult medical cases, no one is permitted to seek death as an end in itself or as a means to ending suffering. On the other hand, the DOE clearly teaches that the decision to forgo extraordinary treatment (see below) “is not the equivalent of suicide; on the contrary, it should be considered as an acceptance of the human condition, or a wish to avoid the application of a medical procedure disproportionate to the results that can be expected, or a desire not to impose excessive expense on the family or the community.” Second, the DOE briefly recalls and reaffirms the traditional teaching on ordinary and extraordinary means. People are ethically obligated to use ordinary means to conserve their lives (and the lives of those for whom they are responsible) since human life is a gift of God and a fundamental good. Ordinary means are medicines, treatments and operations that provide some benefit, and/or do not involve excessive burden, pain, or expense. Extraordinary means are medicines, treatments and operations that do not provide a benefit, and/or involve excessive burden, pain, or expense. While people may use extraordinary means, they are not morally obligated to do so since earthly life for humans is not an absolute good and because, at some point, medical interventions are no longer effective and/or because the costs and burdens of medical interventions are out of proportion to the good of earthly life that they are intended to serve. The DOE teaches that no one can impose on a patient a need to accept extraordinary means, or even ordinary means, when there is no efficacy.

Just so you know - they were administrators of that SNF.

I met with several priests who work in a Catholic health system when I had to present cases for ethical committee. Most of them, incidentally, had solid medical background and all had very rational point of view and attitude toward things. It was a pleasure speaking with each of them, unlike some other members of treatment team including phtsicians and a few nurses.