QOL vs Preservation of Life

[MBar1, RN]

I am always curious to hear others thoughts and opinions related to a topic that is on everyone's minds, in private conversation with colleges, and sometimes inferred in conversation with patients and families, however, that is never really explored head on, for what it truly is.

How do you reconcile preserving life if it is not one of quality? Is it that preserving life is easier to justify ethically because attempting to create parameters for a quality life & describe what that should entail is far more difficult? The answer is probably yes. But what do you think?

Do we attempt to rationalize certain things in medicine that perhaps aren't rationale by themselves, at there core? Topics such as mortality, suffering, and self-determination? Who says these problems are based solely in medicine? I see philosophical, ethical, and sociological dilemmas here. Also, anthropological and theological implications.

The human condition is so characteristically subjective. To each of there own, our experiences are simply different from one another. The way we think, learn, believe. On the contrary, medicine is predominately objective (with a few exceptions of course) in nature. How do we reconcile tackling both realities and spitting out a universal truth that is applicable to both. I believe the answer is, you don't. And this is where the messy grey areas begin to infest. A reality that most ignore, but should come to recognize as chief importance to the quality of individual and collective life.

Comment below ?

[ruby_jane, BSN, RN]

This is why I no longer work in the ICU. Because we could prolong life but it was without quality. That was my opinion. But I grew tired of carrying out the wishes of the family (who maybe hadn't seen the patient in years) and were yelling at us to DO EVERYTHING for grandpa.

Only one time did I see ethics and palliative care get involved and that was because the patient was able to communicate her wishes (which were not the same as her parent's wishes). She passed peacefully but the parents were anything but peaceful.

It bothered me but then that's my middle class white lady opinion. Not everybody shares that.

So I left!

[Jedrnurse, BSN, RN]

I'm rather hardcore about this subject. In fact, I consider myself a "rationist" (if that's a word) i.e. one who believes in a sensible allocation of healthcare resources.

I believe in the wisdom of nature. When major body systems are failing, I think it's time to go.

And from an equity perspective, I think that people near the end of their lifespans shouldn't be using extreme amounts of healthcare resources when there are people in the beginning of their lives that don't have access to basic healthcare.

[brownbook]

Your post is theoretical. These difficult decisions, whether to preserve a life regardless of what that quality of life will be. Every case, every situation, is different. What the family wants vs objective facts.

The age of the patient makes a huge difference.

It's called the art of medicine. "We are to use the evidence based algorithms solely as guidelines. Each and every patient has to be treated as an individual."

[JadedCPN, BSN, RN]

I think my opinion on quality of life versus preservation of life is simply that - my opinion - and shouldn't be pushed into my practice because not everyone may share the same opinion that I do. Ultimately, every individual's wishes should be respected to the best of our ability. The problem is that nobody has these crucial conversations with their loved ones when they are healthy to ask them what they would want in these situations, and many people do not have it spelled out in writing.

My entire family and my husband know what my wishes are if I were ever in a situation like that. I legally have it on paper as well. They thought I was crazy when I had that discussion with them as a 30-something year old generally healthy woman, but its a discussion that everyone should have sooner rather than later.

[MBar1, RN]

@brownbook

Of course my post is theoretical. Each concept or idea I mentioned has some sort of theoretical basis based upon the derivation of its knowledge. Whether it be through the scientific method or story telling.

Whether it’s been applied into practice or not is the concern here. The “messiness” of the above topics is part of the reason why there is no clear-cut solution as for an approach or philosophy to guide practice.

[brownbook]

You write so eloquently. I feel like a cro-magnon, that would be me, having a discussion with a savant, that would be you.

I'm too practical, yes there's no clear cut solution, yes it's messy, is all I can come up with. ?

[Jedrnurse, BSN, RN]

48 minutes ago, JadedCPN said:

Ultimately, every individual's wishes should be respected to the best of our ability.

I think this idea tends towards a too carte blanche entitlement to limited societal healthcare resources. It's much easier to say (or demand) "do everything possible" when you're shifting the burden onto other people.

[Tenebrae, BSN, RN]

This is why I am a big fan of advanced directives or living wills. They outline a patients wishes in the event they are unable to speak for themselves. When I worked in aged care, I made a point of ensuring each patient had one done when they were well in conjunction with NOK EPOA

It meant that if I had another family member demanding we do everything to save their loved one I could take it back to the advanced directive and say "this is what your mum/dad wanted to have happen in the event of this situation"

[JadedCPN, BSN, RN]

16 minutes ago, Jedrnurse said:

I think this idea tends towards a too carte blanche entitlement to limited societal healthcare resources. It's much easier to say (or demand) "do everything possible" when you're shifting the burden onto other people.

I don't necessarily disagree with that either, which in part is what I meant/was including when I said to our ability. That is where there is the blurred line of where to draw the line, what is too much, who decides, etc.

[MunoRN, RN]

I don't think assessing the balance between quality of life and duration of life is necessarily all that abstract. A relative value can be assigned to quality of life, and that value can be positive to varying extents, or also negative to varying extents. Extended life where a the quality of life is a positive number multiplies that positive number, extending life where the quality of life is a negative number just multiplies a negative value, which makes it clearly non-beneficial. It's because of this same premise that I support someone's right to decide they're done living, and that further life is more harmful than less.

I think we do far too much extending of life for only that purpose, not recognizing that doing so can be abusive. This is predominately driven by families who refuse to recognize someone's quality of life, instead focusing on their own needs to avoid the grief of losing a family member, so they decide to subject them to further misery.

[K+MgSO4, BSN]

There is a term I discovered in my studies. QALY Quality Adjusted Life Years, and its inverse DALY Disability Adjusted Life Years. While it is used for population health I think it can be used in individual cases as well. If you were to score your life pre injury/stroke/metastatic cancer vs after it. Would you want to live for 10 years bed bound following a major trauma or never be able to communicate with your family due to a stoke or never eat food?

I do think I am in a better position living in Australia where medical staff seem to more closely follow with not providing treatment that has no long or short term benefit e.g. an 18 year old with severe CP who is full care, non verbal, VP shunt. Hadan emergency laporotomy for a bowel obstruction. Complex post op recovery. During that recovery he had a CT of his chest / abdo / pelvis. It showed a suspicious lesion on his chest. Treating team referred to oncology for advice- told probably need major thoracic surgery which the surgeons were reluctant to do, then suggested chemo. Family meeting with mum and medical staff. All in agreement not to treat.