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.
Specializes in UR/PA, Hematology/Oncology, Med Surg, Psych.
1 hour 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 want to know how you crawled in my brain and took the words right out of my mouth? You must be my soul sister/brother
Well I work oncology so we absolutely do have these conversations with our patients. Well our oncologist, palliative care, hospice, and life with cancer people do a lot of it but us nurses have our roles as well. Just recently all the nurses on my unit had to attend a class on advanced directives and having these end of life care discussions with our patients and their families. They hired actors to play the patient or family in simulation scenarios.
Then just a few weeks ago I had an end of life patient who was actively dying without an advanced directive and family refusing to change her code status from being FC. The entire care team including ethics talked for hours with the family in the days leading up to me being the nurse for this patient. They family finally agreed to allowing pain medication the day before I was their nurse. By about 5pm during my shift I had the family agreeing to change her to AND. The next day I got her on a morphine drip to help manage her pain and got the family to agree to switch her to hospice. She passed peacefully around 10pm after my second shift with her. I was so nervous about her coding that first morning before I got them to change her to AND. Doing CPR on a dying cancer patient like her is just cruel so I’m very happy we didn’t have to go in and do it.
"Old people" and I'm one of em, not so hard to decide what is best. My husband and I have had advance directives since our 40's. Updated every 15 to 20 years.
I don't think anyone has brought up children born with rare, not compatible with life, genetic anomalies, defects, etc. Their parents too often want everything done.
These are horrible situations with no easy answers.
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!
THIS!! Your first sentence took the exact words out of my mouth!! The ethical dilemmas are by far the “worst/hardest things I’ve seen” when I was an ICU nurse. I’ll take all the blood and guts and crap over being forced to torture people for a living any day.
That is one of the main reasons I got out of ICU too. It seemed like I was torturing the pt's instead of helping them to recover. So many cases where recovery was never even possible but the doctors back out of telling the family and leave it to the nurse. It's kind of heart-breaking to convince the families to take their loved ones off of life support.
I also found it very difficult to call a spouse to come to the hospital right away because the pt was very close to death. And even worse yet to call the spouse and say come to the hospital because your loved one is dead now.
But the straw that broke the camel's back was the gigantus pts with sepsis I would get. I have arthritis is my hands had seriously difficulties moving these pt's in bed or pulling them with sheets.
Good bye ICU environment, I don't miss you one bit.
On Allnurses....the News section is an article that over 80% of Americans want to die at home....and that more Americans ARE getting their wishes heard, they are dying at home.
On Allnurses....the News section is an article that over 80% of Americans want to die at home....and that more Americans ARE getting their wishes heard, they are dying at home.
I read that. That's great for those with terminal dx's. If there wishes are to remain at home, and that seems to be the best approach/most appropriate to end of life care, than that's great. However, over 50% of deaths are still occurring in facilities and are dependent on the most relevant dx.
Specializes in Mental Health, Gerontology, Palliative.
2 hours ago, brownbook said:
On Allnurses....the News section is an article that over 80% of Americans want to die at home....and that more Americans ARE getting their wishes heard, they are dying at home.
The crux of it is, make sure your family are aware of your wishes. Make sure its legally documented and easily avaliable eg with your doctors local hospital etc
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"
I have never seen one that says- "In the event that I recognize nobody, live a life focused around fear and pain, am susceptible to infections and get them frequently, have skin rotting off so the bone is visible, and require a team to roll me to clean the feces out of my skin folds, please keep me alive."
I have never seen or heard anybody express this, yet we do it all the time. Since nobody, ever, has expressed this as their will, we do it against the will of of the helpless elderly.
Like some others, it is a huge part of the reason I got out of ICU. While I do participate in this abuse periodically in the ER, my involvement is limited.
Specializes in Surgical Specialty Clinic - Ambulatory Care.
So I think this can only be answered by the people in the situation. Personally I have seen the many futile attempts of patients in attempt to ‘be there’ for their family allow their quality of life to be reduced to zero So they can “live”. I think this also happens a lot with severely disabled children, in attempt to not loose their children, who has a meaningless existence, all resources are used to “save them”. As the ‘professional’ in these situations I always support patient/family desires, but inside I feel disgusted.
With that said I have seen a few cases where I was sure the patient had outlived their quality and they shocked me by fighting back to a new and meaningful quality of existence. And as someone who watched a parent die slowly of a disease, as rational as I can be about patient progress or lack their of, it was way harder to see when I was advising my own father because my emotions of wanting him to be here clouded my judgment. Fortunately when the time came and he had a stroke after surgery, I was at least able to only keep him on life support for 2 days so people could fly in and say goodbye and then pull the plug. But even as I write this, was it really necessary to keep him in life support? In my nursing mind I know that his post op stroke was so massive he was gone the moment it happened, but I still let him stay on life support for two days.
I firmly believe that quality of life is more important than quantity, but if I could not follow my own beliefs in my personal time of crisis I don’t really know how I can expect others to be ‘reasonable’ about such a decision when it comes to their loved ones.
Specializes in Mental Health, Gerontology, Palliative.
18 hours ago, hherrn said:
I have never seen one that says- "In the event that I recognize nobody, live a life focused around fear and pain, am susceptible to infections and get them frequently, have skin rotting off so the bone is visible, and require a team to roll me to clean the feces out of my skin folds, please keep me alive."
I have never seen or heard anybody express this, yet we do it all the time. Since nobody, ever, has expressed this as their will, we do it against the will of of the helpless elderly.
Like some others, it is a huge part of the reason I got out of ICU. While I do participate in this abuse periodically in the ER, my involvement is limited.
Yea, but thats why an advanced directive is essential
And not to mention if someone was that bad, they would not be left in an ICU here they would be moved to a long term care facility with an active palliative care program
And i think unfortunately the litigious nature of the US also plays a roll in it. I've never had someone screaming at me that if I allow their loved one to die, they'll sue me for all I'm worth. Infact I've never had troublesome family members in that respect because when they do get a touch twitchy, I can take them back to what their mum/dad etc has expressed in their advanced care plan
I've also had arguments with doctors who cant understand why "uncle Jim" who has end stage COPD and multiple recent infections needing hospitalisation doesn't want to go to hospital for the fourth time in 3 weeks. "uncle jim" is a former medical professional who understands exactly what will happen if they dont go into hospital for IV antibiotics. The bigger issue I find here often doctors have an issue with letting people die. When they chart morphine for a terminally ill patient who is actively dying "Q2 if RR greater than 12".
dream'n, BSN, RN
1,162 Posts
I want to know how you crawled in my brain and took the words right out of my mouth? You must be my soul sister/brother