I'm not proposing rationing or coercion. I don't want to make decisions for pts or families. What I DO want is someone objective, to honestly and compassionately provide hard truths about what death and dying looks like.
Doctors, for the most part, are not objective. Some I work with want to keep the pt alive as long as possible because it means a paying customer. End of life is when most of the health care dollars are spent, and that's where MDs and hospitals make the most money.
Death panel? Call it what you want, but our society is sorely lacking in honest accepting discourse about death.
Some people want to live forever and will submit themselves to any test, drug or procedure for that end. I respect that decision.
Some people want to live as long as possible, with quality of life determining how much intervention they want.
Shouldn't these people be given hard, basic information to guide them in these decisions?
Consider the possible case scenario. 80 y/o man with stage IV osteosarcoma comes in with a major heart attack, asystole for 10 mins before being shocked back to "life" now he's on a ventilator. Doctor #1: "There's no chance of survival. Nothing we do will change his outcome. We should withdraw care" Doctor #2: "He will probably not survive this but we dont know whats going to happen yet. We can do X, Y, and Z if you want but it may not help." I propose to you that Doctor #2 scenario is FAR more likely than doctor #1, because it is very uncomfortable to speak in absolutes. Would you nurses agree with the assessment of doctor #1 if it was your father? Or you would you think to yourself "hey I've seen guys in worse shape than this survive before, this doctor doesnt know what he's talking about."
There are thousands of doctor #2 for every doctor #1 out there, because it is virtually impossible to speak in absolute terms about imminent death and survival odds. Given that, its easy to see why the "default" path is to just keep doing stuff for as long as possible. There's a lot of uncertainty in medicine, and that carries across into end of life discussions. Its not as easy to convince a family to give up life support as you guys think it is (that is unless you are willing to use absolutes)
i'll agree that very few can handle the burden of such decision-making...
even when pt wishes are known and spelled out.
no one wants to be "THE" person that caused the death of a loved one.
still, while no one can speak in absolutes, speaking in probabilities is the next best prognosis.
and with an 80yo man w/stage iv cancer, WHY would we want to sustain him for maybe, a few more months, with invasive and painful intervention?
a good death holds far more value than a bad, end of life.
I'm sincerely impressed that this conversation is happening, and as it should! Even 10 years ago, I believe this would have been heresy by most accounts.
If one considers that modern medical science is around one hundred years old (depends on your measurement), it is amazing how far we have come. The rate at which advances in medical treatment has occurred is astonishing. This has created a sense of superiority, entitlement, and power. Death has become an enemy to be conquered and sneered at. In a relatively short period of time, we have all assumed a sense of entitlement and are in awe of the seemingly infinite power of medicine. In a bizarre way, our technology has removed from us part of our humanity.
Yes, we need to talk.......more and more. Somehow, we need to regain touch with being human near the time of death, and not detached by the influence of technology. Keep talking
It's not just the elderly in the ICU's either. As much as no one wants to think of it, we deal with these situations every day in the NICU, babies who are just devastated for whatever reason and doctors just won't have the conversation. It makes it very difficult for the nurses who have to care for these babies, and the families who insist that baby "Heaven" will lead a normal life, go to school, get married etc despite her Grade 4 IVH, hydrocephalus, renal failure, liver failure, respiratory failure and on and on. And it's the nurses who have to take care of that baby, inflicting pain with every diaper change and then put up with the full code that goes down when that time comes. Nurses bring these situations to doctors attention but the doctors act like we are accusing them of something, or like we just should give up on the patient, there are times even when parents occasionally question the life of the baby and the doctors still want to "try one more thing". It's awful :-(
My dear grandmother is 95 years old and mentally "all there." She walks the halls of her nursing home with a walker and chats with everyone. She goes out with friends and family occasionally. Aside from outliving her siblings, cousins, husband, and and both of her children, she still has a good quality of life. If her eyesight weren't so bad, she'd probably still be living on her own in an "elder residence."
Despite her "good heath" I find it appalling that doctors are treating her like she's 75 years old. She still gets an annual mammogram and NUMEROUS other tests that I consider ridiculous for someone her age. Where is the line between "rationing" healthcare for the elderly and "wasting" healthcare for the elderly?
I love her dearly and want her to have a good quality of life, but will spending thousands of dollars a year provide her with more quality of life or reasonably extend her life?
We are definitely going to have some serious discussions in this country about healthcare.
These discussions should be had when people are young, before they are decrepit and ve;ry ill. There can be pressure to just "let nature take its course" at a time when people are most vulnerable.
I don't feel it's the government's job to regulate when/if/how we have those conversations, and to be encouraging it to perfectly healthy people.
Just my $0.02
Perfectly healthy people have catastrophic diseases and accidents all the time. Why shouldn't they talk to someone ahead of time, have a living will/POA/etc? My family knows what I do and don't want done because if I don't tell them when I'm healthy, I might not have the chance when I'm ill.
the new medicare benefit simply provides physician reimbursement for "voluntary" end-of-life counseling (advance care planning). it gives the medicare beneficiary the opportunity to decide their own end of life care. it isn't a death panel or rationing of care.
you've got it right!! the cynics who coined the term "death panel" ( tea party/sarah palin/glenn beck et al) were only trying to create hysteria and panic as they lobbied against health care reform.
"A lot of hot air, cyber material, and ink go into bemoaning the supposed lack of respect patients receive in the medical system for their advance medical decisions. Usually, criticism involves the purported reluctance of doctors to honor a patients “right to die”–usually accompanied by allegations that such willful disobedience is financially motivated.
But those days are long gone. Today, Medicare (diagnosis related group) and most health insurance pay hospitals on a capitated basis, which has turned ICUs from profit centers into money losers when patients require longer than average stays. So now, the problem isn’t so much as receiving care you don’t want, but obtaining intensive treatment you do, e.g., futile care theory and rationing.
But this post isn’t about that. It is about how “living wills” often don’t anticipate events . . . "
Perfectly healthy people have catastrophic diseases and accidents all the time. Why shouldn't they talk to someone ahead of time, have a living will/POA/etc? My family knows what I do and don't want done because if I don't tell them when I'm healthy, I might not have the chance when I'm ill.
That is a very good point. It should not just be medicare paying for these talks to be had with elderly patients. These talks should become common place between a PCP/nurse at PCP office FAR earlier in life. It is just that death has become so unacceptable in our society as if health care should be able to save every one from every illness. Everyone is in denial that we all die sometime, even looking at someone that is 70/80/90, and even more so at 20/30. But anyone of us could be in a serious accident, leaving us unable to answer for our selfs and our wishes as to what extent we want healthcare to go to in trying to keep us alive.
As for Drs that push for more procedures/trying anything they can to save a patient, yes some may be due to income those procedures provide, but I would bet that far more it is because they see any death as a failure on their part, and feel like they should be able to save the life, and feel success in saving/extending the life that they fail to see if they are increasing quantity of of life, at the cost of quality of life. I think the Drs that do see the loss of quality of life to increase quantity of life are the ones that are more likely to sit down and give a full picture of what each option is, and what the costs with each one would be (like the first Dr that talked with tralalaRN's mother) Also if there is no advanced directive when a patient can not speek for themselfs, the Drs must err on the side of life (ie, you do not have a DNR a Dr MUST attempt to resussitate, even if it means doing it over and over again)......which is why advanced directives really should be in place far earlier then hitting older ages.
Advanced directives should not be just for patients with terminal conditions or the elderly. They should become commonplace in heathcare.
(But one thing, just having family know is not always good enough. Have it in writing, an actual living will stating your wishes and/or dictating POA should you be unable to make your own decisions. Sometimes the Drs have to err on side of life even if your family is saying "she/he wouldnt want this" because they have no proof that is your wishes or their beliefs)
I don't have one yet, but I plan on putting one together very soon (Im 28....just took psych of Death and Dying....very eye opening course).
There is absolutely nothing wrong in discussing end of life care with patients. I think it is our duty to educate our patients and allow them the dignity they so deserve. The problem is when the government steps in and "pays" doctors for this service. Like many other things, the government should mind their own business.
As a hospice nurse I do have qualms about how these end-of-life issues are presented by some on the right.
But I do understand their fears.
With health care rationing there is a slippery slope to quality of life-based health care rationing, and that doesn't look good for the elderly, disabled, and otherwise expensive for whom to care.
Euthanasia looms.
I think that is where the concern comes in. And, if you do any research, it is a legit concern.
i would like to add that 10.5 years ago, i was pregnant with my daughter, jasmine. i was told that she had trisomy 18 and that she would not survive past her 1st year of life. up until the time i had her, my doctors, nurses and i talked about my options. i was given the option of having an abortion. i said, "no!" or continuing the pregnancy. i continued my pregnancy.
the day that i was in labor, i was given two choices: 1) do all they can to sustain her life 2) do nothing & let nature take its course. before i could give my answer, my meddling mother chimed in and made the decision. i wanted option number 1. my mother wanted option number 2. but because i was only 19 and wasn't "there" mentally, i went along with my mother's choice. to make a long story short, my now ex-husband, put jasmine & i through hell and back and i went through some major depression. i literally detached myself from society. i locked myself in my room for weeks, eating only chocolate chip cookies. seriously!!!!
the point is, my doctors, whom were military doctors, gave me options. they weren't afraid of talking about death. in fact, while i was "hoping" for a miracle, they were basically saying, "lady, there is nothing we can do. she is going to die. it's not a matter of if, it's just a matter of when."
physicians seem to be in the biggest denial. 89 yrs old, ca with mets, life expectancy is nil, but we force the person back to life after a normal physiological process, and make them die over and over, as if they were a toy. where's the compassion in that? not to mention the logic?
my children know that, if i'm terminal, they had best not make me die repeatedly, or i will haunt them and all my caregivers to the ends of their lives.
i :lol2::lol2:after reading this. then i started imagining you doing it. :yeah:
.thumb.jpg.1730911fbf00f611ba1c99c44f0b92b3.jpg){kind=small}
:lol2:
:yeah:
leslie :-D
11,191 Posts
i'll agree that very few can handle the burden of such decision-making...
even when pt wishes are known and spelled out.
no one wants to be "THE" person that caused the death of a loved one.
still, while no one can speak in absolutes, speaking in probabilities is the next best prognosis.
and with an 80yo man w/stage iv cancer, WHY would we want to sustain him for maybe, a few more months, with invasive and painful intervention?
a good death holds far more value than a bad, end of life.
leslie