Futile Care. Dead is dead.

sharann, BSN, RN · Nov 4, 2004

I really understand what you mean. I know it is not my "place" to question what the family wishes are, but then again if not me then who will see to it that the patient is allowed to die with dignity. It's quality that counts in my book. It's lovely to hear how grandpa lived to be 108, but no one mentions that he was a vegetable with bedsores and tubes for 7 months! We see this in surgeries. You know those surgeons who see someone with private insurance and the family is begging them to "save mom". So they open up the belly, Trach them, PEG tube, colostomy....

Yep, I am traumatized as well by being involved.

Trauma-tizedRN · Nov 4, 2004

I really understand what you mean. I know it is not my "place" to question what the family wishes are, but then again if not me then who will see to it that the patient is allowed to die with dignity. It's quality that counts in my book. It's lovely to hear how grandpa lived to be 108, but no one mentions that he was a vegetable with bedsores and tubes for 7 months! We see this in surgeries. You know those surgeons who see someone with private insurance and the family is begging them to "save mom". So they open up the belly, Trach them, PEG tube, colostomy....
Yep, I am traumatized as well by being involved.

It's not my place either to question what the family wishes are, but it IS my place to question families knowledge, motivations and coping skills, and to intervene when it is unrealistic or misguided in any way. Most families are unrealisitic for a period of time due to shock and denial....perfectly normal....and we can treat the patient and the family through this period, while therapeutically helping families to grasp the realities. It's the ones that get stuck in this denial that become problematic. And grandpa is LITERALLY rotting away on the vent and families want that 3rd opinion....EWWW....hate this.

TEACH TEACH TEACH! Comes to play here....but often falls on deaf ears...

dazzle256 · Nov 4, 2004

One of the most challenging ethical dilemmas for me. I just HATE participating in it. We get so many patients in the ICU setting that prove to us in so many ways that it is JUST TIME TO DIE! But no, for whatever reasons ie: Doc is a super god..saves everyone, doc is too wimpy to call it to a stop, families running the show and docs letting them...and other various reasons, we get to come to work everyday and poke and prod these poor souls. Costs the system alot of money too. I don't go home feeling like a good nurse when having to do this. In fact I feel really bad. I am pretty aggressive about it and corner these docs and families for a "chat" to help bring some reality to play, but sometimes have to get ethics involved to make any headway....docs don't appreciate it either. But geez people...we are maintaining dead or dying people with all the bells and whistles, for weeks on end. Can't we just let people die when they ARE. Treat pain and suffering....not cause more. Never a good day when you get to work and the buzz phrase on the unit is "I see dead people"
:angryfire

What about the ones the families say do everything possible.........and never come to visit them. As far as costs to the system I find this usually to be the case of people with no insurance and no way of paying. Just let their family member vegetate on a vent. I just hope these people don't feel pain.

Antikigirl, ASN, RN · Nov 4, 2004

I run into this all the time working with the elderly. I rather insist on having folks have POLSTS or Advanced directives before they can move into our facility. That way I know what it is they wish before I send them out (or in some cases...don't send them out). But there still are grey areas even with that!

Most people outside medical think do not resusitate means don't do anything! I am very sorry, but if you have to be pulseless or apnec for me not to do anything or it is called neglect or murder. Unless you are on hospice or have direct orders NOT to go to the hospital or call 911 under a very clear line of circumstances. I had one family yell at me for sending their mom in when she was having chest pain..."you resusitated her"..no I didn't, I called 911 and they put O2 on her, no IV, and had her evaluated!!! Sheesh!

And I hear you about the "do everything possible" and the family doesn't see them! I think it is a comfort to them and a crutch...well, we medics will keep them alive, so the pressure is off them so no guilt for them for sending them to a home or hospital. At least that seems to be a common thread where I come from. Sign grandma off to a facility, and the pressure is off! Uhhhhhggggggg!

Thanks to me complaining so much we do have POLSTS and advanced directives for about 60% of the residents! YEAH! only 40% more to go! And I think it is now standard to have one filled out before being admitted to our facility! Good thing!

But to me..it isn't up to the family (unless the patient can not express thier wishes) but the patient themselves. I will honor those wishes..that is my job, and I haven't had a probelm yet doing so...even with some religions that don't believe in medicine...I still honor their wishes! It is not my place to change that...if I wanted to change that I would have picked another field...

Antikigirl, ASN, RN · Nov 4, 2004

Oh and the cost!!!!!! OH brother! I think us lovely tax payers have paid for lots of extras with the elderly especially that the patient may not have wanted or needed!

I had a >100 year old get radiation tx 3X, carpal tunnel surgeries for people >90yrs, masectomies for >80, heart surgeries for folks in their 100's, and on and on...I get concerned that their bodies will not handle the recovery and I am pretty on the nose about that...most often they are never the same, much weaker then they were and aren't healing as well, wind up on insulin, and very depressed (they thought the surgeries will help, and find out it does little or recoveries too much!). And Medicare pays for all of this!

I will never tell someone they are too old to get what surgeries they want, but someone really needs to paint a picture for them about recovery and potential bad outcomes of surgeries when you are >80! But they don't really...and I wonder at times is it a money deal, liablity deal, or what??? Guess I would have to be a surgeon to get it...

Pediatric Critical Care Columnist · Nov 4, 2004

you think it's bad in geriatrics, you should try peds! omg!! because they're children and have so much potential we should keep them all breathing. ri-i-i-i-i-i-ght! lately we've had a series of teenagers with neurodegenerative disorders who are dearly loved by their families, therefore cannot be allowed to die peacefully, as god and their bodies intended. no, instead we have to intubate and sedate them, put in a bunch of lines, take them for interminable numbers of tests, run q2h abgs, peg them, treat a variety of nosocomial infections (multi-drug resistant, of course!) and go through half a dozen trial extubations. then after several weeks of no progress, someone finally finds the gumption to talk to the family and we eventually get a dnr. our most recent teenaged patient, a boy with dmd who came in with respiratory failure, told us in no uncertain terms that he did not want to be intubated, he did not want a trach; he'd put up with bipap but he did not want his wishes ignored. well, didn't he flatline while watching the price is right and have compressions and epi. no tube... his wishes were "respected"... until he said, "why did you do that? no more!!" family were upset, but accepting. so he's now in heaven. i wish there were more families like that. i won't even get into the whole ball o' wax we have with babies... they practicaly have to be rotting on the bed before we even broach the subject. sheesh.

Cherybaby · Nov 4, 2004

It is so important to have the wishes of the patient known. My hubby and I had a LONG talk about this, in light of the Terry Schiavo case here in Florida. But you are right, it is frustrating to resuscitate, time and again, someone who is obviously ready to leave this earth. I have seen more than my share of families who bring in their parents for treatments of decubs...after they have become so severe, they will require surgical debridement. They are cancer ridden, or very sick with diabetes or COPD...

It's incredible how many patients I hear say...I wish my kids would just let me die already. It's heartbreaking...

On a lighter note about patients in their 80's/90's having surgery? We recently had an 82 year old woman, in GREAT health (I should have her energy NOW...let alone at 82! And her figure! Oy! We should all be so lucky!) come in for breast implants! *L* She respected her husbands wishes...not to alter her body for years and years...despite the fact that she always longed for larger breasts. Well, her husband passed a year ago...and she said she is ready to have "the boobs of a 20 year old!" Good for her, I say!!! :chuckle

She said, after the surgery..."won't he be surprised when I meet him in heaven!"

She's a hoot.

Elenaster · Nov 4, 2004

Oh ladies, you're preaching to the choir here. I'm really contemplating leaving ICU because of so many of the reasons you've stated. I'm so tired of taking care of "corpses," coding dead people for hours, avoiding brain-death testing just because no one wants to tell the family the truth, administering unholy amounts of pressors and watching their limbs turn black.....Futile care is one of the most stressful parts of my job, it's so draining to deal with the families when you have nothing but bad news.

You gotta love those DNI codes :rolleyes: Personally, I don't know who decided that was acceptable, but I've never seen anyone come back without a freakin' airway - the patient is completely purple, but we'll go ahead and dose her up with epi and atropine, in the meantime, jack that levophed up to 500 mcgs

There was actually an article in the American Journal of CC about perceived futility in care r/t job stress in the ICU. There was quite a correlation between the two (I know you're shocked). I think it contributes heavily to ICU burnout as well.

Jo Dirt · Nov 4, 2004

You shouldn't blame the family. It can be very hard to let a loved one go, to the point of the family not thinking rationally. Their main care is to keep their love one alive at any expense because they are just not ready to let go. It's not like they are wanting all the bells and whistles for their family members just to annoy you. They are hurting and under a great deal of stress.

Trauma-tizedRN · Nov 4, 2004

Oh ladies, you're preaching to the choir here. I'm really contemplating leaving ICU because of so many of the reasons you've stated. I'm so tired of taking care of "corpses," coding dead people for hours, avoiding brain-death testing just because no one wants to tell the family the truth, administering unholy amounts of pressors and watching their limbs turn black.....Futile care is one of the most stressful parts of my job, it's so draining to deal with the families when you have nothing but bad news.
You gotta love those DNI codes Personally, I don't know who decided that was acceptable, but I've never seen anyone come back without a freakin' airway - the patient is completely purple, but we'll go ahead and dose her up with epi and atropine, in the meantime, jack that levophed up to 500 mcgs
There was actually an article in the American Journal of CC about perceived futility in care r/t job stress in the ICU. There was quite a correlation between the two (I know you're shocked). I think it contributes heavily to ICU burnout as well.

My exact experiences and sentiments....worst part of ICU

Elenaster · Nov 4, 2004

I can count the number of times on one hand that I've actually had a family that has the good judgement to say that their loved one has had a good life and he/she wouldn't want to be like this. It's pathetic how few people realize that humans were not designed to live forever. It's even more pathetic when we do everything possible and then some, and then the hospital gets sued anyway because of some unforseen complication (i.e. MRSA, sepsis, etc) in a patient that had an extremely poor prognosis to begin with.