Unbelievable family

AJPV · Jul 17, 2011

The way you describe this patient makes me wonder if it was truly accurate to find him incompetent. He is clearly verbalizing his wishes to die. When he is unrestrained, he is making purposeful, goal-oriented body movements designed to carry out the intentions that he has been consistently verbalizing. To me, that is evidence of clear cognition, logical functioning that enables him to connect cause-and-effect (ie, his attempted arm movements consistent with the outcome of ending supportive meaures), verbal processing, consistent wishes, and a memory that is at least somewhat intact. I have to wonder if the compentency hearing was a little manipulated?

gettingbsn2msn, MSN, RN · Jul 17, 2011

Why are you suprised? This is going on all the time. We kept a patient that had a stroke who was vented, tube fed, ect alive for 8 months because daughter could not accept that this had happened to her mother. Thing is, daughter never came to see her mother (I saw her once). She told people that she could not handle it. Finally ethics committee got involved. They moved the patient to a nursing home that could take that kind of patient. This was very difficult because no one wanted the responsibility for this. I never heard how it ended as I no longer work there. Unbelievable really. I fully expect this will become more the norm. The baby boomer generation believes that everything can be fixed. I do not know how this will all play out in our society??

iwanna · Jul 17, 2011

I hope the result of court is to let this man go in peace. I don't believe in euthanasia, but I truly believe in DNR. Really what good is life, if their is no good quality to it. As much as I love my elderly mom, I would let her go, if she was suffering. Clearly, this man is suffering. Also, he is verbalizing a wish to die. I think that it sounds like he is mentally competent to express his wishes.

leslie :-D · Jul 17, 2011

i'm not assuming, but am wondering if this pt has wernicke-korsakoff syndrom...

having liver failure and all.

advanced alcoholism (IF this is what he has), could definitely result in ms changes, profoundly.

yes, this happens all too often and that is why advance directives aren't as useful as they should be...

because they are OFTEN violated...

yes, even with dr's.

perhaps you can ask the dr. for an order 'to get this pt to stop crying'.

or even ask the 2 dtrs this question.

sometimes guilt works.

leslie

nurseprnRN, BSN, RN · Jul 17, 2011

this is a very important point: a hospital, nurse, or physician cannot declare incompetence. (repeat as necessary)

"incompetence" is a defined legal term. in the absence of a valid advance directive from the (adult) patient, if a relative wants to be declared the guardian for purposes of directing care, this requires a hearing before a judge.

while hospitals routinely ask for consents to be signed by wives, siblings, or parents of adults, they have no-- no-- legal force without a signed health care proxy. common law assumes that the average reasonable person would want treatment to save life or limb, and for this no consent signed by a third person is required. however, the court will hear evidence regarding the patient's opinions from poeple judged to be in a position to know.

this sort of situation is common, alas. i have seen it in my own family, where a terminally ill elder with severe pain and increasing dementia was denied hospice care because one of four siblings opposed it, even though before he became demented he told anyone who would listen that he wanted to die at home; when he was found apneic, pulseless, and grossly cyanotic after eating a bottle of narcotics, 911 was called and there was the 24-hour drama in the icu. fortunately by then he never regained consciousness or made a drop of urine, so he did die; if he had known about all this he'd have spit in yer eye.

in the situation you describe, the hospital should have an ethics committee. they should review all this and speak to all concerned; if there is no consensus amongst the family after that consultative process, the ones in favor of treatment cessation can get an emergency competency hearing and request guardianship; alternatively, the court can appoint a guardian ad litem (a neutral, unrelated person with training in this sort of situation) to make health decisions.

there is a great deal of case law in things like this. a famous one is candura-- mrs. candura expressed her wish to die; when her diabetic gangrene became progressive she refused amputation even though they told her it would result in her death. she completely understood. as the gangrene progressed and she became less and less lucid her daughter, who had fought to have "everything" done to "save her mother's life" went to court to get power of attorney to compel the amputation. fortunately, the court ruled that since mrs. candura had made it very clear to everyone what her wishes were, it would be (paraphrasing here) a pretty lousy trick to go against her wishes when she began to fail as a result of her choice, as she knew she would. she was allowed to die in peace.

if people can be found to explain to the judge that this man had expressed his wish not to be resuscitated, live with "tubes," and so forth, and was suffering as a result of this "treatment" with no hope of meaningful recovery or quality of life, the judge may very well listen. people do have the right to be left alone.

good luck, and let us know how it works out.

nurseprnRN, BSN, RN · Jul 17, 2011

oh, and another thing: someone can have no idea of time, place, or who's the president, but have a perfectly clear idea of what he wants done c his treatment. this man may have a lot of reasons to be disoriented (including wernicke's) but that doesn't mean he can't know what he means when he says "no more."

Double-Helix, BSN, RN · Jul 17, 2011

Is this wrong? Probably, but legally it is not up to doctors or nurses to decide when care should be withdrawn. Legally that is the right of the patient, or the power of attorney (if the patient cannot make decisions). Most hospitals have ethics committees to help mediate situations like these, but since the matter is in court, it's obviously gone beyond the jurisdiction of the ethics committee. Doctors and nurses have to honor the wishes of the medical proxy, or wait until one is designated, or face a possible lawsuit.

Our health system is designed to give the patient and the family the choice to receive or continue with medical care. There isn't much the hospital, doctors or nurses can do if the family wants the patient to continue receiving care.

Should the doctors and nurses refuse to care for this patient? Why on earth would they do that? The patient still deserves the best care he can get, even if it is a bad situation. In my opinion, simply refusing to care for the patient would be quite unethical.

Please remember that there is always more than one side of the story. Since you haven't actually witnessed this, but are hearing about it secondhand, the actual situation may be quite different. It's very easy for stories like these to get exaggerated.

SaraStrong · Jul 17, 2011

He isn't "competent," as we define it, but he's competent enough to know what is happening to him.

I just had a related talk with my parents yesterday, because I have seen for the first time at work a patient and a family in this situation. There is nothing that the hospital can do. Medical intervention is essential of course, and it is amazing what we can do to help people. We have also decided (even though this isn't my personal view) that it is appropriate to extend life for as long as possible by any means necessary. For me, what it comes down to is personal choice. I know I do not want this for myself. It's important to decide early enough in life, SPECIFICALLY what you want for yourself, and to tell your family and sit down with a lawyer and work it all out. Because it is heartbreaking when that doesn't happen.

lrobinson5 · Jul 17, 2011

See this is something I was curious about in my first semester. I could SWEAR my instructor said you couldn't just leave restraints on... Not only did you have to check circulation and all that every 15 minutes, don't you have to take them off at some point? I know that a Dr. has to keep he ordering them, but I thought even then they had to come off so they weren't on 24/7. I live in California, so I don't know if it varies by state or what, just something I always thought about.

rn/writer, RN · Jul 17, 2011

Even though this situation is now going to court, you can still get the hospital ethics committee involved. In fact, they may have something to contribute to the court hearing/case.

I also highly recommend that the siblings who want the patient to be allowed to die with dignity ask for the appointment of a guardian ad litem--a disinterested third party who will represent the patient and try to determine what's best for him.

I also suggest that someone videotape the patient when he is crying out and asking for someone to kill him or let him die. As others have pointed out, you don't have to know the date to know that you don't want the nightmare of futile treatment to continue. And what could be more powerful than the patient's own anguished words.

Such a sad scenario. I hope, for the sake of this elderly man, that his family can come to terms with his dying and see their way clear to letting him go.

caroladybelle, BSN, RN · Jul 17, 2011

Legally, if the care is determined to be "futile", the hospital and/MDs in the case can refuse to continue to provide it.

The issue, few facilities/MDs wish to have"murderer", "death panel", and "euthanasia" bandied about in association with their name.

Recently dealt with a futile care case. Thankfully, I suggested an ethics committee consult and the MD actually went for it, which made things easier later. When we had every distant relative coming out of the woodwork, screaming about "making us" give the pt chemo, we already had the appropriate legal data.

My unit frequently has pts that come long distances for treatment, often having been given a very dire prognosis. It becomes quite problematic when, after examining all the data, they get told that there IS NO Appropriate treatment available. Often the chemo would do so much damage with no chance of success even slowing othe disease.

They won't take no for an answer. They would rather have others pay 100s of thousands of dollars to destroy themselves uselessly and painfully, just to say that something was done.

Thankfully, we have the ability to weather the publicity.