I've a been a nurse for two years, however it is not until recently that my mind has bee thrusted into a world of philosophical and moral questions.
Yesterday I realized to the extents that chemicals and machines keep people alive. Are they really keep people alive though? Are they keeping bodies alive? Organisms alive? These are the questions that have come to my mind.
Yesterday I was instructed per the wishes of the family to turn off all vasoactive drips. I felt guilty for feeling relief that the family had chosen this path. I felt guilty because I saw a body being kept alive by chemicals and machines, as a nurse I knew there was nothing more to do. I knew this was it and that there was nothing more to do.
However after I came home I began to think, maybe if I had more finely titrated those drips down. Maybe if I had more quickly caught the acidosis. Maybe if we had treated this quicker or that quicker or more aggressively. After about maybe an hour I dismissed these thoughts and remembered that first of all, I know well no amount of treatment can reverse this extent of damage. Secondly, as a nurse I respect the wishes of the family.
I've been left however with questions such as:
Is there a soul? When does it pass on? If so, where does it go? What is death? Is there an afterlife? Is the soul still there when there are 15 drips, a ventilator, CRRT, and ECMO keeping the body "alive"?
I suppose more than anything this was a reflective post. There's one thing that is certain is that the transition to the ICU has made me more philosophical.
Wow... I could not have read a more fitting post for my week... Started off the week with an elderly woman with dementia in LTC speaking to me one minute and gone the next... Spent days questioning if I missed something, if I could have done something, or if it was just her time... Followed up by picking up a shift on an unfamiliar floor, again LTC, with a Woman actively dying on hospice , a million family members asking to highly medicate the resident, an old school nursing partner upset that I called hospice for an increase in her meds stating "they just want to kill her" (??? Huh) then me just trying to make sure the woman passes in peace. Great post! Great conversations! Thank you
Steven Hawking has a rare early-onset, slow-progressing form of amyotrophic lateral sclerosis (ALS), commonly known as motor neuron disease in the UK, that has gradually paralyzed him over the decades.[21][22] He now communicates using a single cheek muscle attached to a speech-generating device. Hawking married twice and has three children.
I got this from Wikipedia. Yes, he does communicate, but he also is almost completely immobile, able to use one cheek muscle, subject to muscle cramps, itches, and everything in-between.
My point is that end of life care is personal; it should be decided by the patient.
We - in private duty home care - have been instructed to not call 911, as full treatment will then commence. Is ER required to treat a patient - brought in by family - who has a no-code order? Should the no-code be filed at the hospital?
I don't see euthanasia in a bad light. If euthanasia were legal and within nursing scope of practice and my patients wishes and discussed with physicians and legally documented and ordered by a physician, I don't think I would hesitate in the facilitation of euthanizing the patient.
I do not see the D/C'ing of life supporting machines or chemicals as murder, given the patients family has the legal authority to make such decisions. When a patient is so sick that they are on 15 drips and their mind is far gone to obtain any verbal consent, someone has to make a decision.
I see it a lot more murderous to trap someone on 15 drips and 3 machines. You have to understand that these people would be dead without those 15 drips. Those drips are also what are causing necrosis of every toe and finger and even member. I
Even when I turned off the levophed/norepinephrine the results were immediately reflected in the MAP. They could not and would not be alive if it weren't for all the drips and machines.
It's a fine line we tap dance around all the time in this case - what benefit are we providing to the pt when there clearly is no hope of recovery? Who are we servicing anyway in this instance? The family, whom for whatever reason are not ready or able to face this fact … some wanting the annuity checks to keep coming, others who can't imagine the hell of being in the bed themselves attached to a vent, swan-gantz catheter, art line, vassopressors, dubhoff feeding tube, foley, rectal bag, et al … Maybe the MD's whom feel compelled to do everything possible to protect their own licenses - or just don't know when to advise the family no more? Certainly not the pt in this case …
The morale and ethical dilemmas are enough to keep one from having a good night's sleep ever again when you delve down that rabbit hole.
Is there a soul? I like to think so. I don't want mine hooked up to every device known to modern medicine when my ticket is up … I want some diginity to pass comfortably, and NOT in a hospital or nursing home. If my family ever overrides my living will, as I've seen many do - clearly against the pt's wishes, I will haunt them mercilessly when I finally do escape.
I know that a number of people may not agree with what I wrote. That is understandable, however, just because someone does not believe or agree with something does not mean that it does not exist.
Parakeet,
I'm not here to argue religion with you, just to point out that the opposite of your statement is also true. Just because someone believes something,does not mean it exists. Yes, this is related to the OP's post. As nurses we are required to provide culturally sensitive care. Nurses are part of a team of professionals who revolve around and serve the patient. The patient's needs and belief system are primary. Every person has the right to their religious beliefs, but no person has the right to force their religious beliefs onto a patient who might not share them.
I was raised within a major, non-Christian religion that does not have a concept of heaven and hell. In my religion the dead live on in the memory of those who loved them. That is enough for me. I certainly hope you would not try to convince a member of my religion otherwise as they lay on their death bed. That would be rude and upsetting.
Every single patient deserves sensitive, culturally competent care. Every single patient deserves autonomy and the right to make their own decisions whether or not their nurses support those decisions does not matter a bit. If a patient or family in the ICU chooses a terminal wean, it is not up to any provider to try to influence their decision.
Death is like a dirty word to a lot of people. To me it is the natural ending of life. I am in the dialysis field. You want to talk about abuse of the system? We are dialyzing people with terminal cancer; with severe Alzheimer's, with severe heart disease; people in their 90's. We would not let our animal companions suffer like this, and believe me they are suffering.
My mother became gravely ill at 86 years old. I will not go into details, but she said to me, can they help me die? I don't know how. I told her that hospice would make her comfortable and that she could die on her own terms. She called the doctor and told him to put her on hospice and let her go. My brother and I respected her wishes. Yes, I miss her every single day of my life, but I would rather miss her than to see her go through what she was going through.
In conclusion, celebrate their decision and learn how to encourage other families to make that decision. Learn how to advocate for your patient, and that sometimes means to let them go.
I work in NICU, and when a baby is not going to make it home alive, we know it and try to break it slowly to the family. But in the end, the baby dies, but that family has to live on, and if they are comforted by having done everything possible done, then who am I to say they are wrong. We frequently negotiate end of life contracts with parents. A good death is as important as a good birth.
Death and dying is my job.... palliative/hospice nurse.
Oftentimes it is the family that has problems with the pat decision to focus on comfort or even physicians.
There are physicians who still believe that palliative care "kills" the patient (don't want to know what they think about hospice if they already think this about palliative care). There are physicians who will try to talk the family into feeding tube for end stage dementia patients "because the pat is starving", though not eating and drinking is the natural decline for those patients.
Some physicians are more prone to tell patient "to try everything" because they want the pat to keep fighting regardless of the quality of life and take it personal when the pat decides otherwise.
I set up meetings in which the patient/family/different physicians come together and explain the diagnosis and prognosis to the pat and family so they can understand and ask questions about implications. After that we talk about the different choices in advanced care planning.
I need to say that to get a better overall understanding of why a patient makes a certain decision it is important to understand how the pat has lived and what is important to them. If somebody had an active life, traveled, hobbies, friends, and they are suddenly faced with an illness that will decrease their quality of life they are less likely to accept that trade off. Let's say a person who was very active, good quality of life has now cancer and the prognosis is not good. Let's say it would mean to get stronger first, get surgery that would not be curative (debulking), after that chemo with uncertain outcome - those patients if they are in their 80s are less likely to agree to this. They do not wish to spend the time left in facilities/surgery/suffering.
Iheartnursing, ASN
22 Posts
Wow... I could not have read a more fitting post for my week... Started off the week with an elderly woman with dementia in LTC speaking to me one minute and gone the next... Spent days questioning if I missed something, if I could have done something, or if it was just her time... Followed up by picking up a shift on an unfamiliar floor, again LTC, with a Woman actively dying on hospice , a million family members asking to highly medicate the resident, an old school nursing partner upset that I called hospice for an increase in her meds stating "they just want to kill her" (??? Huh) then me just trying to make sure the woman passes in peace. Great post! Great conversations! Thank you