the other day, a group of us ex-nursing students were discussing end of life issues. after being in clinical and seeing the sickest of the sick in our icu observations, i made a decision that should anything go south, i want my family to let me go for the following reason:
-if my quality of life after the event should be worse and i am kept alive by machines,with no hope of getting better, i do not want that for myself or my family.
i know that some people make dnr decisions and then rescind them when death looms in the shadows..
my question is, as a nurse in your day to day activities, do you believe some of your patients changed the way you looked at dnr, cc, full code status?
(for example the 92yr old lol emaciated and stage 4 ca, decubs up to the bone, who kept saying she wanted to go and join her long deceased husband, yet her family insisted that everything be done-full code status. a bunch of broken ribs later, she died a traumatic unnecessary death)
*** what decisions have you made personally about your code status that were influenced by what you see on a day to day basis as a nurse.
I agree! Its harder to let go when one is a family member and one cannot be too sure that their wishes will be carried out when their are not in a position to make it so.
You have to realize that people who insist everything be done for their family member who clearly wants to be let go often do not care about the big picture, they do not consider suffering of the patient, they can only see their own intense despair at being without mom/dad/sister/brother/etc and cling relentlessly to the patient; they would rather have the patient physically there, even if comatose, than let go. Sometimes they come to peace with this and finally allow us and them to let the patient go. Sometimes they don't.
This is very true. Have been witness to this time and time again. Some just can't face living in a world without Momma. This can be sooooo frustrating at times but I try to remind myself that fortunately I have never had to say the words "It's OK to let my mom die". Maybe as much as I think (know) it's the right thing, maybe it won't be so easy when I am faced with that day.
Two years ago, my grandmother became unresponsive due to sepsis and had to be moved to ICU. The intensivist was all, well she has a living will that states DNR, another Dr, the Neurologist was like, well I'm on the ethics committee and I think it would be ok to put her on a vent for a few days to get her over this hump. Funny thing, though was that my grandmother was fine just a few hours before she crumped and was to be discharged the next day.
Anyway, me being the ICU nurse, my aunt, the POA was looking to me to make the decision whether or not to intubate Grandma. I told her, Grandma wouldn't want to live the rest of her life on a vent. In fact she had just told my other cousin that she was ready to go to Heaven to be with my Grandpa. .
We honored her living will and let her pass quietly later that night. It was the hardest thing ever but I still feel good as I know we made the correct decision. It's not up to me to try to play God.
re: a pt with both a living will and MPOA--The language in most LWs says something like "in the event of a terminal illness or persistent vegatative state" I want /do not want.... In my work place, MDs still pretty much believe that terminal illness only pertains to very metastatic cancer. Also, by definition, a vegatative state takes a few weeks to months to become persistent. Because of this language, LWs are pretty much worthless in my opinion, other than serving as a limited guide on a pts thoughts about end of life care. If the terms of the LW do not apply, the MPOA gets to make any decision they want. They are supposed to be giving the directions that they believe the pt would make in this circumstance. However, many rely soley on emotions to make decisions, or may have never even discussed EOL issues with the pt. There can also be major issues when a pt has named 2 MPOAs to serve jointly--if they don't agree on a plan of care, the effort of the pt in making an advanced directive is worthless.
Yes, I see things all the time that introduces me to a new boundary of my own ethics. and I think to myself "If my family did that to me, I would haunt them after I'm gone!!"
there are times that I have serious moral issues with what we're doing to a patient, mostly it's when I feel like the doctors haven't painted a very accurate picture of the prognosis and the family is now "hoping against the odds". One thing that has always bothered me is when a nurse/doctor views a DNR as a "do not treat". You'll hear them say "oh well, that patient is a DNR." and I'm thinking "yes, I know, but we're not talking about CPR right now...we're talking about antibiotics or parenteral nutrition." It's strange to me how highly educated people seem to get caught by this sometimes.
The thing that probably bothers me the most about this subject are the full codes when there is no point at all. An earlier post had mentioned futile care, we had a patient die from mets (everywhere: bones, pancreas, liver, etc). He was like the poster had mentioned, emaciated skin stretched over bone, pathologic fractures everywhere. He was a full code until several hours before his merciful death. We were genuinely afraid we may have had to do CPR on him.
so here's a question and it doesn't have to be answered here: In a case like that, if a patient dies as a full code....are you tempted to make it a "slow" code? I understand that's against patient's rights for self-determination and I'm not advocating it at all, but it's a discussion I've had many times over the course of my career and there are more sides to it than I imagined.
I think I will have a will drawn up that states my children will lose their inheritance if they do not honor my living will. lol Seriously, everytime I work in the ICU (float there sometimes) I threaten my family with all manners of hauntings. Let me die peacefully or I will NOT let you live peacefully.
I recently had 'The Talk' (advanced directives etc), with my boyfriend.... he thinks i'm crazy! I think its important to plan ahead for such a time when someone else will have to make important medical decisions for you.
Yeah i've definitely made my wishes to be DNR well known. I have no desire to "live" on machines and never recover just to drain my family and the healthcare system of resources.
This is a very difficult topic for many people. I have seen patients with feeding tubes that do not talk or respond to us, and in pain.The patient has no quality of life, and no one comes to visit the patient. It is extremely sad. I would never wish that on anyone. It is truly sad. I do not want this for myself or my family.
With all that being said I had a really hard time when my Grandmother passed away. I know it was the right thing for the family to do. She had pneumonia, and the doctors wanted to put her on a ventilator. My family was split on what they wanted done. We decided to take a night while she was on a BiPAP machine, and think about things. We did not want to rush into anything as this would be a life changing decision. She was 93 years old with CHF, and possible colon CA. Her 02 sat levels would desaturate as soon as they tried to wean her off the BiPAP. I knew deep down it was best for her to discontinue the BiPAP, so she would not suffer. It is easier said than done. It was one of the hardest decisions our family had to make. None of us was ready to let her go. It took my Grandma saying she was mad, and this is what she wanted for my Mom to respect my Grandmothers decision. It was very hard for her. She was still holding out hope that with being intubated that she would recover. In the end all of her family was in the room with her until she passed away. We all got private time with her to say our goodbyes while she was still responding earlier in the day. She was surrounded by love, and comfort in her final moments.
It is so easy for us to judge our patients family for hanging on, and trying everything. It is a very difficult place to be put in. The nurses my Grandmother had were awful. They were insensitive. They tried to scare my Mom into her decision, and intimitate her. The nurse actually was yelling at my Mom, and my Grandmother's doctor. It was very unprofessional. When what my Mom needed was support. She would have come to the same decision, but it would have been a little bit easier. The nurse that came in when my Grandmother passed away actually had the nerve to say "so is she still breathing ? ".
I am the first nurse on my floor to get a family member a box of tissue, or be a shoulder to cry on. I learned what kind of nurse I do not want to be from my Grandmother's nurses. We may not understand our patients or their families decision, but we need to be supportive. That moment of hesitation, removing life support, or make a loved one DNR is something that should be given a moments thought. You know that these family members are doing what they think is out of love. They may not understand the pitfalls of thier decisions. I know probably most of us have had a patient were we cannot understand the families decision to keep a patient full code, or on life support. I have however always been compassionate to these families in their time of need. Please do not become so jaded that you cannot be there for these families at a hard time. It has become a pet peeve for me.
I had a pt come in and decide to be comfort measures only. He was ready to die, done with all the treatment and just wanted to go peacefully. The dr. continued to order consults, etc thinking the pt would change their mind. I had to go up against the dr and fight for the pt right to discontinue tx. He was alert and of sound mind and his family all supported his decision. He died the next day a peaceful death with family around him. On the other hand, I have had people full codes that we have had to involve the ethics committee because the family kept saying be aggressive and do this, do that, etc. It was horrible. So many things wrong with them with no hope and the family kept pushing. The only thing you say on those days is "please don't code on me!"
I also have had very blunt, open discussions with my my parents about their wishes based on things I have seen during my career. I think I have a very good undertanding of what they would like or not. Hopefully we will never be in the position to make that decision.
Before I was a nurse, my parents discussed what they wanted. They don't want any extreme measures taken, and at first I thought to myself who cares, I will do everything in my power to make sure everything is done. Now though, I feel completely different. I've been the advocate for the patient that wants to be an AND or DNR. Now I know that should anything happen to my parents, I will follow their wishes. It will be hard but I will stand up for them. They are aware of my wishes as well. (Plus its all written.)
I know that when that time comes, I will be there, holding their hand as they go toward their eternal slumber.
I have had a living will for a very long time. I had the talk with my husband and mother many years ago and made it clear what I wanted and did not want. My mom said "I don't care what you say, there is always hope and I will do everything in my power to keep you alive." Therefore, my husband and best friend are listed as decision makers on my living will. I do not, under any circumstance, want to live if I can't LIVE. There are things in this world that are far worse than dying. I have already had many talks with my children about this as well and told them that if mommy ever has a peg tube put in I will haunt them, lol. I feel very strongly about this. Far too many times I have see tube feeds not absorb and people have aspiration pneumonia or horrid diarrhea from it. IV fluids that the kidneys can't process and people swell up like balloons until their skin cracks and oozes fluids, or it puts them into CHF. Cancer patients who are completely emaciated despite artificial nutrition, where is the calories going? To the tumor, ofcourse. If I can't eat, its because I am not suppose to be eating. You body knows how to die.
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OhioCCRN, MSN, NP
572 Posts
I agree! Its harder to let go when one is a family member and one cannot be too sure that their wishes will be carried out when their are not in a position to make it so.