Scheduling Death??

[icyounurse, BSN, RN]

It seems like lately I have been running into end of life issues every time I walk into the ICU that I work in lately. Here is my latest dilemma:

I get report on 81 year old pt with aggressive lung cancer post right middle and lower lobectomy 6 months ago, cancer has since spread to other lung. There are other co-morbidities and the patient is very sick. Has been in our ICU for one month on the edge of death, intubated and extubated 3 times I believe. NOw he is extubated x 2 days on BIPAP and VERY anxious, this pt is on the call light literally non stop. He called 6 times during report. I am told that family is very much in denial and refusing hospice and palliative care. They say that 5 months ago he was out on his tractor baling hay and if we can just fix all these little problems one by one, he can be back on that tractor in no time.

OK so I walk into pt's room and he is breathing 42 times a minute with eyes bulging out, ekg has been in a very wide crappy brady for days now, also kidneys are shutting down and there is bad 3rd spacing. He is on Precedex at .1mcg/min. He tells me he wants the bipap off. Respiratory is in the room and looks very anxious about this, his CO2 was 90 this am she tells me. I take it all in, and proceed to have a very frank conversation with the patient and tell him if we take off the BIPAP he will probably get into further distress and the way orders are right now I will have to intubate him and we probably will not be able to get him off the vent this time, and did he want to die on the ventilator? Or did he want "regular" O2 mask and we could give him alot of medicine for pain/anxiety and every comfort/dignity measure possible? Pt, who is very alert and oriented, states clearly to me and RT that he did not want to be put back on the vent or any other heroic measures. Great I tell him, I will call your doctor. Then I turn precedex up to .4 mcg to help him calm down and call his doc, who is very for a DNR order and tells me to write it if its ok with him and his family. So I talk to his daughter who is very quiet when I explain what is going on and she says she is on her way in with his wife. They arrive and I encourage them to go talk with the patient about his wishes and tell them after they talk, I want to call back the doc and officially put the pt's wishes on the chart.

Well long story short, family balks, refuses to talk with the patient about what he wishes, tells me they just cant talk to him about dying and what he wants because they cant bear it. Which I know is very hard. But here is the kicker: They ask me if I can just force the BIPAP on him for a couple more days so they can get some affairs in order and wait until other people are off of work and they can get things organized. The daughter told me that with today's modern technology they felt like they could plan his death and tonight just wasnt a good time. I was very blunt, and I told them (nicely because I am honest but I am sympathetic) that we will do what we can but at a certain point keeping BIPAP on against someone's will becomes assault. And I told them that putting him on o2 instead on intubating him if he declines is not making a decision to kill him(the cancer is doing that), but just respecting his wishes and making him comfortable as the vent will not cure him, also that he will not necessarily die as soon as they decide not to intubate, he could live for days or even weeks. They said they know all this. I said if you want him to stay a full code tonight, you want me to place an ET tube down his throat, even though that IS NOT what the pt wants. They wont look me in the eye, and they are crying at this point, and they tell me yes thats what they want. I said OK. They left and I called the doc and he said do what the family wants.

NOw its me who couldnt look the pt in the eye. With the precedex turned up, he rested comfortably with the bipap, so I just left it going all night. It made him very drowsy, but I figured his comfort was key at this point and I didn't want him wide awake and anxious. When I go back to work tomorrow night I will find out what happened to him, I hope his family managed to "schedule" a time to respect his wishes.

[RN1989]

It is time that our society quit hiding from this issue. For years docs and hospitals have touted all the latest gadgets that are destined to save people. But they won't educate people that you can't save everyone no matter how much technology you have. Docs don't like to admit that they are not God.

I do what is best for my patient first, then the family. If those two collide - the patient gets preference and the family will just have to be mad at me.

[scribblerpnp]

How awful. That poor man. I hope he stays comfortable.

Please update this thread. I am going to have him on my mind now. I wish I hadn't even read this.

[racing-mom4, BSN, RN]

what a heart wrenching story--i too have exp similiar events, family wanting the loved one to stay on the vent till other family can arrive, or to keep raising the leveophed till other family can arrive etc etc etc. it puts us in an awful situation, and correct me if i am wrong, even though the patient alert and oriented gives wishes, as soon as patient is not alert/oreiented family can change thier wishes?? it makes no sence to me, and why even have living wills?>??

my favorite line you wrote was " and i told them that putting him on o2 instead on intubating him if he declines is not making a decision to kill him(the cancer is doing that), but just respecting his wishes and making him comfortable as the vent will not cure him, "

i plan on using that myself next time the occasion arrises.

good luck, it is frustrating i know, but your doing the best you can for everyone involved...get some rest..

[mpccrn, BSN, RN]

it's usually at this point that i become very frank with the family often telling them that sometimes they have to LOVE the patient enough to let him go, free him of his suffering. placed in those terms their own selfish needs are brought to light and they are reminded what's really important......dear old dad's wants and needs. i hope his suffering ends quickly and quietly......for his sake.

[nessajune21]

How sad that his condition is such a burden that they can't schedule time in for him to die. I bet it is more inconvenient for him that he is passing than it is for them to have to take a couple days off of work.

[SDS_RN, RN]

I think that is a bunch of BS the doctor should have honored the pt's wishes not the families. Unfortunatly like stated before after his LOC decreases family is in charge. It's very sad that they are keeping him alive for their own benefit. Why would you want some one you love to suffer any more than they already have especially knowing that that is not what they want. :confused:It just makes me soooooo mad. I just can't even comprehend how selfish and disrespectful that family is being towards the pt. It sounds like you did a great job explaining to them what HE wanted but they did not want to hear it.

I realize that it's very hard for them and they are more than likely in denial but someone needs to give them a hardcore reality check perhaps the doctor should have spoke to the family. I guess by the sounds of it it probably wouldn't have detered them from prolonging his life as that would interfere w/ their plans and arrangements.

Please let us know what happens.

[Pedi-Gree, BSN, RN]

I see situations like this in pediatrics often enough to know it's not an easy path. We sometimes see young adults who have had cardiac conditions, CP or other life-long issues who keep being referred back to peds because the adult service is "uncomfortable". These young people often have parents just can't let them be adults and make their own health care choices. I feel that if they're mentally competent and cognitively normal, their wishes should matter!! We have a case like this right now where the poor patient's wishes have been ignored, and now he's not conscious or able to make his desires known. It's hard and creates so much moral distress for us.

[Ahhphoey]

That situation seems horrible and selfish to let someone suffer while the family gets their "affairs in order." Unfortunately, I have seen this same thing play out many many times in ICU. I once had a 50 something year old lady who arrested in the nursing home she was living in. They were able to get her back and she was intubated in the ICU for several days by the time I was assigned to her. No one knew how long she was down at the nursing home, but she was not breathing above the vent at all. Her only living relative was a cousin who lived out of state. She was consenting to everything we needed, but would not make her a DNR though until she came down to the hospital. However, she was not willing to take off work to do that, so she wanted everyone, including her poor cousin, to wait until a week later when she had some time off to come down and make a decision. A neurologist was actually going to pronounce her brain dead because her EEG was flat (I believe), but when doing an apnea test, she had one agonal breath after 2 minutes. The patient did eventually die when the cousin made time to come down and withdraw treatment; the good thing is that due to her age she was still a good organ donor candidate and her cousin was willing to donate.

[Batman24]

How come the family can override the patient here?! The man seemed very clear in what he wanted and his doctor seemed okay with it as well. Keeping someone alive because it doesn't fit their schedule is absurd.

Can you call in a social worker or clergy?! I would ASAP because this man clearly doesn't want a vent and it's time for him to die in peace. Perhaps sitting down with them along with the doctor and a social worker and whoever else you need to bring in is in order here immediately. Is there an ethics committee at your hospital?! Perhaps they can help too.

This BOILS my blood.

[Katnip, RN]

Does your hospital have an ethics committee? They will often sit down with the patient, then the family

It's a sad world when a patient's wishes is overridden by family because the doc is afraid of lawsuits.

[leslie :-D]

i'm soooo not understanding why this family was even given a choice re their preferences?

once the pt stated his wishes, i know i would have gently but firmly told the family the plan of care, PER PT WISHES.

his life, his death, his choice.

i pray he dies before he wakes...

leslie