Withholding Treatment Of Elderly Patients

leslie :-D · Nov 13, 2003

hi distraught,

there can be several factors involved: if the patient is alert and oriented and has requested to be a dni, then their wishes would override the family. if the patient has a healthcare proxy who wants a full code BUT even a demented pt. could indicate they don't want to be intubated, then there's an ethical issue of a patient's rights. if intubating could potentially cause more harm than good and impose higher risks for injury, then the doctors are within legal boundaries. but if it's a matter of costs only, then there could potentially be legal implications. i hope any of this information helps you and find some peace.

stressednurse · Nov 13, 2003

I have seen that the more futile, the more hands involved.

I have not seen a patients wishes ignored as far as being treated to the fullest. What I usually see is families overriding Living Wills and putting people through tortures they didn't ever want.

Intubations, CPR, tube feedings, antibiotics, testing out the whazoo.

All this on a person who continually pulls out lines, tubes and indicates that they don't want any of this.

I also see a lot of quarreling going on amongst siblings, girfriend vs ex, boyfriend vs kids etc.

Unresolved issues are usually the culprit, sometimes this can be resolved in an ethics committee meeting, sometimes nothing is resolvable and we just let GOD take care of it eventually. Many times the ill one was the leader of the family and no one is ready to take their place, so they continue to fill that post while near death in the hospital.

I have asked families more than once "What the hell did he/she do to you that you need to let this go on?" The first time it worked, I made them come in the room and watch a dressing change on a liver failure after a knicked artery during gallbladder surgery resulting in bad kidneys and after almost a month still had an open abdomen. The patient was swollen to plus 4 all over and was weeping a lot of serous stinky rotten fluid. We had always made him pretty and as non smelly as possible prior to visits. He was still alert and could communicate a bit, I couldn't give him enough pain meds to keep tears from rolling off his cheeks during the dressing change.

The family met with the docs and decided to withdraw most treatments and let him die as comfortably as possible the next day.

He gave me a "thanks", (unspoken but I can read lips a bit) after the family decision. I chat a lot with patients when I am in their rooms, it was his decision to not have them see what pain he was in at first. Finally he agreed to have them come in for the dressing change. I was at his bedside when he finally died. I cried.

ktwlpn, LPN · Nov 13, 2003

Originally posted by distraught
Is it common for doctors treating an elderly patient (90+) to have a tacit understanding amongst themselves that they won't do anything major (ie intubation or reintubation) even if the family requests that "everything be done" and the patient is full-code?

Have you ever witnessed doctors withholding such treatment when needed and then engaging in creative writing in the progress notes?

Curious to know how frequently, if ever, this kind of thing happens. I have a personal situation that I'm very troubled about.

Thanks

Not my crowd-the staff docs at my LTC are so into CYA that they throw all balls to the wall....2 of them are VERY into peg tubes(regardless of any advance directive-after all-if they never say the word"terminal" then the peg tube is not a violation of the directive...I wish this did happen more often-many families have issues preventing them from seeing the big picture and end up putting their loved one through TORTURE...there ought to be a law against it....We all will die someday-it's the last thing you can plan on and do well...

Long Term Care Columnist / Guide · Nov 13, 2003

Stressednurse.........love your signature line!!

I feel the same way you do about some of these so-called treatments: we are prolonging *suffering*, not life! I think it's absolutely sadistic to "save" the life of someone whose body, in its wisdom, has decided to shut down after suffering some massive insult or trauma. Who in their right mind would want to exist in a nursing facility, completely unable to walk, talk or ask for anything? Who would choose to be confined to a bed, year in and year out, being turned every 2 hours (if you're lucky) around the clock, unable to use the bathroom or even scratch an itch on your own?

To me, it really doesn't matter how old or young someone is; what matters most in my estimation is quality of life and potential for improvement. No, I don't think we should use limited health care resources to try to "rehabilitate" a 90-something dementia patient who suffers a massive stroke. Then again, neither would I want those resources wasted on a ventilator, feeding tubes, and so on for me, or anyone I loved, if one of us were in an accident that severed the spinal cord at C-2 or -3. But, that's just me.

allegator · Nov 14, 2003

Thanks for the candid replies. I see where you're all coming from and appreciate it. None of us want to see our loved ones in that kind of situation yet it happens all-too-frequently.

But what of the 90-something ambulatory dementia patient who suffers only a mild stroke or one who's family desires aggressive treatment of CAP?

Have you ever had a situation where your docs purposely let an elderly CAP patient slip into comaville - actually defying the family's plea to reintubate, because they believe the outcome was a forgone conclusion?

This is what I'm grappling with personally. How I wish I could have taken my dear father to a 'CYA' facility.

fergus51 · Nov 14, 2003

I have never seen a slow code, but I wish they were done. Too often the patient's wishes are pushed aside in favor of the family's. And unfortunately usually the family has unrealistic expectations of the chance of recovery... It's so sad to see.

Not being an adult nurse, I don't know what a mild stroke would do to a 90 year old man, but I hope you aren't feeling guilt about where you took your father. if I were you, I would just ask to talk to the doctor directing his care, or many hospitals have a family representative who deals with these issues.

mattsmom81 · Nov 14, 2003

Not as many docs are comfortable with this anymore due to lawsuits. That term is pretty much only whispered these days...by older team members who recall the term. Most of my code team and ER responders are on GO at all codes...sometimes the primary care doc will ask us to stop over the phone, and the ER doc respects this. Sometimes not.

I've been glad when a thoughtful doc in charge uses some common sense and makes a call to halt code proceedings on elderly, ill patients with declining quality of life. In my experience, too many docs will intubate elderly patients...and they spend the last months/years of their lives hooked up to machines, dying slowly of complication after complication...in my ICU or at a LTC center. Not my choice of how to go out of this world, for sure.

I've seen docs continue futile care against the patient's wishes....because family could not let go. The old saying there is "side with the live ones who can sue ya". :stone

ktwlpn, LPN · Nov 14, 2003

Originally posted by distraught
Thanks for the candid replies. I see where you're all coming from and appreciate it. None of us want to see our loved ones in that kind of situation yet it happens all-too-frequently.

But what of the 90-something ambulatory dementia patient who suffers only a mild stroke or one who's family desires aggressive treatment of CAP?

Have you ever had a situation where your docs purposely let an elderly CAP patient slip into comaville - actually defying the family's plea to reintubate, because they believe the outcome was a forgone conclusion?

This is what I'm grappling with personally. How I wish I could have taken my dear father to a 'CYA' facility.

Please forgive me-what is CAP? Is the ambulatory demented patient with a mild stroke the same person with CAP?

Speculating · Nov 15, 2003

Originally posted by distraught
Is it common for doctors treating an elderly patient (90+) to have a tacit understanding amongst themselves that they won't do anything major (ie intubation or reintubation) even if the family requests that "everything be done" and the patient is full-code?

Have you ever witnessed doctors withholding such treatment when needed and then engaging in creative writing in the progress notes?

Curious to know how frequently, if ever, this kind of thing happens. I have a personal situation that I'm very troubled about.

Thanks

I've seen that often enough. It's what we call a slow code which mean't we often were told to walk instead of run when the code got called.

allegator · Nov 15, 2003

Hi Ktwlpn, CAP is community aquired pneumonia.

My concern with my dad who "passed away" in March is that they didn't just do a slow code; they did a no code - despite my being in the room when the respiratory distress began and pleading for intubation. They gave him a 100% mask, then a 50%, telling me "we need to let his respiratory muscles work or they will atrophy."

The Death Summery indicates that I was informed intubation was necessary but instead opted for aggressive suctioning. I guess they figured I'll never request the records and even if I do it's the word of a distraught child against that of some pretty reputable doctors. Besides, you can't sue for the loss of a 91-year-old; he's past his book value.

And you know what? I could forgive all that if I'd believe that my father was doomed anyway and that intubation would have only prolonged the dying process. I fear that elementary mistakes were made in my dad's treatment due to age bias, and that if these mistakes were made in a 40-year-old he would have fared no better.

So my question is, have you guys ever had cases (few though they may be) where you felt the docs didn't give the elderly person enough of a chance and then covered it up?

Empress · Nov 16, 2003

If you requested intubuation, and they said "No, for such and such reasons." and then documented it as such, that is one thing. But if on the documentation they wrote that you requested suctioning instead of intubuation which is a lie, that ethically and morally wrong along with highly illegal. I would contact a lawyer about it, and hope you can seek some counseling to deal with your grief. I am very sorry to hear about this.

I can understand the reluctance to intubuate an elderly patient with an active stroke and advanced pneumonia, the outcome would be very poor getting the patient off the ventilator. Elderly have a very hard time with intubuation and can decompensate quicky even on a ventilator. But it doesn't excuse "creative documentation" and slip shod treatment of family's requests.