Withdrawl of care

oMerMero · Mar 13, 2007

If the power of attorney or next of kin want to continue treatment, that must be done...even if the doctors and nurses disagree with the decision. The family makes the decision, not the doctor.

hellonurse36 · Mar 13, 2007

We have a palliative care team (MD and several FNPs) that are consulted. They review the case, meet with the family and try to establish appropriate goals of care. Most families find this very beneficial as these experts know how to communicate about end of life issues very well. We are very lucky to have these experts as any health care providers don't communicate well when discussing end of life issues. For example

MD discussing code status of loved one: "If your mother's heart stops working do you want us to do everything to save her?"

What son/daughter would feel comfortable saying no to that questions?

vs. MD "If your mother's heart stops, do you want us to do CPR, (make sure they understand that this could result in broken ribs), shock her, give her drugs to try to start the heart again? Would she want to be on a ventilator? How does she feel about life support? What quality of life is acceptable/unacceptable to her?"

I have found it very useful to make sure the family understands their role. I tell them that they know the pt the best and know what they would/would not want. I make sure they know their job is not to make decisions for their loved one, but to communicate to us what that person would want. I have had several family members tell me they appreciated being told that as it felt like it took some of the burden off.

That being said, some families just can't let go. It is very hard to see the pt struggle, but all we can do is continue to provide education, support and care and hope that the family will make the best decision.

Terri Finney

allnurses Guide · Mar 16, 2007

If the power of attorney or next of kin want to continue treatment, that must be done...even if the doctors and nurses disagree with the decision. The family makes the decision, not the doctor.

This is very different in the UK, it is the doctor's decision made in collaboration with family but the medic has the final say. That is not to say the families opinion is not respected.

It would be phrased as, We have done everything possible for your relative and unfortunatey they have not responded to this treatment and there is very little else we can offer. We will not be able to escalate treatment further and should their heart stop it would be inappropriate for us to try to restart it. It is unlikely they are going to survive for much longer.

Obviously if they had real difficulty with this then more discussion takes place before withdrawl of treatment takes place but I cannot remember a situation when there has ever been a major problem in the 10 years I worked critical care

justme1972 · Mar 16, 2007

This is very different in the UK, it is the doctor's decision made in collaboration with family but the medic has the final say. That is not to say the families opinion is not respected.
It would be phrased as, We have done everything possible for your relative and unfortunatey they have not responded to this treatment and there is very little else we can offer. We will not be able to escalate treatment further and should their heart stop it would be inappropriate for us to try to restart it. It is unlikely they are going to survive for much longer.
Obviously if they had real difficulty with this then more discussion takes place before withdrawl of treatment takes place but I cannot remember a situation when there has ever been a major problem in the 10 years I worked critical care

Do you think that the decision in the UK, that is left up to the Doctor, has to do with the fact that there is Universal Healthcare in the UK and not here?

I would be curious if our Canadian friends, how their hospitals handle this.

This part of universal healthcare, scares me.

allnurses Guide · Mar 17, 2007

Do you think that the decision in the UK, that is left up to the Doctor, has to do with the fact that there is Universal Healthcare in the UK and not here?
I would be curious if our Canadian friends, how their hospitals handle this.
This part of universal healthcare, scares me.

I'm not quite sure how best to answer this. It is not just the Doctors's decision. The lead consultant (not sure what the equivelent in the US is but that is the most senior medic in charge of that patients care) would usually discuss the plan of care with the nurses and other healthcare professionals such as physiotherapists who are caring for the patient. I suppose it is something that I have been used to and is the culture here,

Whereas you find the medics making the desicion scary I find leaving the decision up to the family alien. I have had many ethical discussions about allowing family to make the decision and the feeling that I get is generally it is felt unfair to put this sort of pressure onto a family. Also there may be conflict of interests, it may be the family would be a benificiary should the patient not survive (although I have never seen this and find it a very far fetched argument)

Essentially I have always been taught to me that when faced with a frightened, grieving family whos loved one is deteriorating that it would be unkind to give them the responsibility of discontinuing treatment. IF they feel that the decision was not thiers to make then they cannot feel guilty in the years to come for that decision. We listen to thier wishes and sometimes delay the withdrawl of care to allow them to adapt, but ultimately the decision is not thiers. I suppose that this is something that you would find extrodinary because it is not your practice but I suppose that is the nature of cultural difference.

I suppose there are other perspectives, The cynic could wonder if there are other factors that may well influence who makes the decision, for example critical care resources in the UK are precious, often we have to cancel elective surgery that requires critical care because of a lack of beds. please don't interpret this as us being heartless with our calculators and fingers over the ventilator power supplies withdrawing care to save money because this is not what I mean but in the big scheme of things it is a consideration - and as I said that would be the cynical approach. Fortunatley our accountants do not have the power to make these decisions

Mayflye · Mar 21, 2007

Is "withdrawl" what they do in the South?

CHATSDALE · Mar 21, 2007

AIN'T FUNNY, MAYFLY

it can't be said too many times, make out a living will, make your desires known it relieves your family of wondering what you want

if the family has all the facts and they know them however they are presented then the decision should be honored

caroladybelle, BSN, RN · Mar 21, 2007

If the power of attorney or next of kin want to continue treatment, that must be done...even if the doctors and nurses disagree with the decision. The family makes the decision, not the doctor.

That actually is not true in the legal sense. Several states have legislation that permits facilities to withdraw treatment from cases where care is deemed "futile". The family has the option to find another facility - but in most cases, no other facility will take the patient.

George Bush actually signed some of this type legislation into Texas law when he was governor there. This came back to haunt him during the Terri Schiavo dust up.

Legally, if the patient wants "no code/dnr" and the family insists on having them coded, the patient can sue and will win. Laws have backed "battery charges" for unwelcome rescusitation and have vindicated those that refused to code patients with clearly indicated "no code" wishes.

But, realistically, in the USA, few MDs are going to go against family wishes. Who is more likely to sue and make the MDs life miserable, as well as garner bad press? The dying temporarily rescued patient (that will probably die before the case goes to court) or the healthy family members.

And any lawsuit, even one the gets eventually thrown out causes problems/cost/loss of time to those involved.