Withholding Treatment Of Elderly Patients

[allegator]

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

[ktwlpn, LPN]

Originally posted by distraught

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?

If it were allowed I would post a link to my website where I have a lot of the records and solicit your opinions on my specific case.

Thanks for the clarification-could you link your web site to your profile? We could check it out....Is your mom living? Was there a DPOA?Did your dad have an advance directive?....Pneumonia as known as the friend to the old and infirm back in the day before heroic measures and the use of feeding tubes was so common -it was a considered an easy way to go...I have really never seen any favorable outcomes in the type of situation you describe-I have never seen someone of that age weaned and have anywhere near the quality of life they had before their crisis....

[fergus51]

Inaccurate documentation is always unethical and should be adressed.....

But, and I may be completely off base in this, I wonder if it is easier to focus on this than accept that nothing could have been done to save your father. By the time he needed intubation, his death was probably already unavoidable, wasn't it? Speaking from my own experience, anger is a safer emotion than sadness and grief and that clouded how I felt after a loss. Again, I may be completely wrong, and I hope I haven't offended you by saying this.

[canoehead, BSN, RN]

We've had a doc who likes to treat until the angels are practically in the room singing- our problem is not having the docs let people go more than too many slow codes. But even so I have never seen anyone over 80 wean from the vent and survive to discharge.

Distraught-even though I wouldn't have chosen to intubate my family member in this situation I think they were wrong not to respect your wishes UNLESS your grandfather had written that he didn't want to be tubed and the docs were following his wishes. I don't see any reason to go from 100% oxygen to 50% if his condition was deteriorating, atrophying respiratory muscles happen over time, not minutes which is what I assume you were talking about.

Usually our physicians consider the patient incompetent when they get so sick they can't breathe and defer to family wishes. I don't think it's right, but it happens. Even if they chose not to resuscitate they would discuss their decision with family before a crisis occured. I'm sorry you have that memory to deal with, but I hope his death was peaceful. He was lucky to have you at his side.

[BarbPick]

My Living will spells out my exact wishes. Hydration and Morphine, and I have chosen 2 surrigates who promise they will not allow the fighting that is going on in my Home State of Florida over the pulling of a feeding tube. My feeding tube will have water and Morphine. My attorney thought I was just being anal the way I had it written, till he saw the feeding tube fight in Florida.

Today the husband got the Governor's intervention overturned and the state has appealed. What a mess.

[allegator]

Fergus51 you have certainly not offended me. Sadness and grief is what I felt the first six months. Anger is what I feel now. I've gone through the records very carefully and I think my anger is appropriate.

As I've said, the problem is that I feel my father could have survived based on everything I saw during his 2.5 week hospitalization. My analysis of the records only confirms this to me.

He was an extraordinarily healthy man with the appetite of a horse. I believe he simply contracted an infectious disease which was never adequately treated. The doctors saw the results they expected, and one particularly arrogant one decided to play god.

When a man is suddenly in the fight of his life, seems to me you'd wanna give him as much antibiotics as his kidneys will tolerate. I can't help but believe that if I had walked with him out of the ER with a handful of Levaquin 750's he'd still be with me.

Ethical outragiousness aside, the question is indeed whether my father's prognosis was as bad from the getgo as the doctors depicted. Maybe I just can't see it because he was the only person I had in this world and I miss him dearly.

[Speculating]

No disrespect intended Distraught, but I have to feel as though there is more going on here than we are all seeing. Were there other family members involved, if so cold they have been whispering something in the Dr.'s ear that was beyond ears reach of you? Is there someone who could have been communicating with the Dr. by phone? I just can't see a Dr. under treating a pt. against the families wishes then covering it up. The Dr. in this type of situation has everything to lose and absolutely nothing to gain. 95% of the time a Dr. will say that treatment won't work, but we have nothing to lose at this point and if you wish to give it a shot then that's what we will do. Either way Distraught unfortunately what as happened has happened and nothing can change that. You need to discover how healthy it is for you to keep going over and over this. I'm sorry for your loss. All we can do is take it day by day.

[New CCU RN]

I would like to express my deep sympathy for your loss. It does sound as though it was quite a sudden decline in your father's condition. I have spent a great deal of time reading over what you posted in your bio from your father's hospitalization. I can't really draw a conclusion nor answer your questions specifically. However, I agree with your sentiments that perhaps there was some bias in your father's care. If it is at all feasible for you perhaps you ought to have a lawyer review the charts you have presented us. Even if it can help answer some of your questions and give you some relief. I wish you the best.

Added:

I think that the simple fact that you still have a lot of unanswered questions and uneasiness about your father's care is a sign that perhaps there are some questionable things that occured. It is difficult for me to say, but I think that following up with this is deifnitely a good idea. Do not be frightened or think that you are doing something wrong. If you have a gut feeling about this then by all means, pursue it. Do not feel guilty or question yourself. Best luck to you. I hope that you will be able to seek some closure.

[VivaLasViejas, ASN, RN]

Originally posted by Speculating

No disrespect intended Distraught, but I have to feel as though there is more going on here than we are all seeing.

Distraught unfortunately what as happened has happened and nothing can change that. You need to discover how healthy it is for you to keep going over and over this. I'm sorry for your loss. All we can do is take it day by day.

OUCH.

I can all too easily identify with Distraught, as my mother, a COPD pt., suffered a massive MI and died in a way that was entirely preventable. She's been gone for almost 15 years now, but I still have the list of meds she was on at the time, which included Proventil 4 mg. tablets 3-4 times/day, albuterol inhalers every 2 hours, albuterol nebulizers every 4 hours, theophylline 300 mg. 3 times/day, and pseudoephedrine tablets 60 mg. every 4-6 hours. Her heart rate must have been around 200 most of the time. If only I'd known then what I know now, I'd have sued the pants off her doctors for giving her all that crap and never checking with each other. But by the time I learned about these meds in pharmacology class, it was far too late to do anything about it.

Knowing this, however, does NOT stop me from being angry at a system which not only allowed, but encouraged, a lonely elderly woman to medicate herself literally to death. And the above poster seems to think that such anger is unproductive, that one should just get over it and move on with one's life. Well, I'm here to tell you that this experience is one of the reasons I became a nurse in the first place, and why I will ALWAYS speak out for the rights of the elderly. Distraught's father deserved better than what he received, as did my mother. While I agree that a 90-something patient---no matter how healthy---generally doesn't do well in situations like she describes, it is a well-documented fact that the elderly are far too often undertreated for illnesses such as heart disease, cancer, and respiratory problems. (It can also be said that they are OVERtreated in some cases, such as feeding-tube placement in patients with severe dementia because the family "can't bear to part with Grandma"....or have some financial interest in keeping her alive as long as possible.)

Distraught will, in time, be able to put away her anger at her father's treatment (or lack thereof) or turn it into something useful. It's only been a few months, for crying out loud.....give her a break already!

[New CCU RN]

Originally posted by mjlrn97

OUCH.

I can all too easily identify with Distraught, as my mother, a COPD pt., suffered a massive MI and died in a way that was entirely preventable. She's been gone for almost 15 years now, but I still have the list of meds she was on at the time, which included Proventil 4 mg. tablets 3-4 times/day, albuterol inhalers every 2 hours, albuterol nebulizers every 4 hours, theophylline 300 mg. 3 times/day, and pseudoephedrine tablets 60 mg. every 4-6 hours. Her heart rate must have been around 200 most of the time. If only I'd known then what I know now, I'd have sued the pants off her doctors for giving her all that crap and never checking with each other. But by the time I learned about these meds in pharmacology class, it was far too late to do anything about it.

Knowing this, however, does NOT stop me from being angry at a system which not only allowed, but encouraged, a lonely elderly woman to medicate herself literally to death. And the above poster seems to think that such anger is unproductive, that one should just get over it and move on with one's life. Well, I'm here to tell you that this experience is one of the reasons I became a nurse in the first place, and why I will ALWAYS speak out for the rights of the elderly. Distraught's father deserved better than what he received, as did my mother. While I agree that a 90-something patient---no matter how healthy---generally doesn't do well in situations like she describes, it is a well-documented fact that the elderly are far too often undertreated for illnesses such as heart disease, cancer, and respiratory problems. (It can also be said that they are OVERtreated in some cases, such as feeding-tube placement in patients with severe dementia because the family "can't bear to part with Grandma"....or have some financial interest in keeping her alive as long as possible.)

Distraught will, in time, be able to put away her anger at her father's treatment (or lack thereof) or turn it into something useful. It's only been a few months, for crying out loud.....give her a break already!

I fully agree with you. First of all what was posted by the member you quoted was quite harsh as you said, how about a little sympathy?????? Geez.

Hospitals do make mistakes. Because they are run by people who unfortunately sometimes let either personal belief's or whatever get in the way of doing 100 percent for the patient, there are mistakes. People are also human. We are all doomed to unfortunately make some sort of mistake with a patient;s care. Scary considering how many people are in health care.... huh?

Somedays, it seems like patients for whatever reason are shafted from recieving adequate care. IT does happen and anyone that denies it is naive!!

BTW I am so sorry for the loss of your mother

Anyhow, I just wanted to let you know I agreed with what you wrote.

[VivaLasViejas, ASN, RN]

Thanks, CCU!:kiss

To be honest, it surprises me to discover that my anger over my mother's death hasn't totally resolved 15 years after the fact, but Distraught's post (not to mention the response from Speculating) brought it all back. I mean, I know there's NOTHING I can do about it now, and I couldn't have done anything then because I wasn't even thinking about becoming a nurse at that time and didn't know squat about what she was taking. I don't blame myself, my sister, or even my mother for what happened........the poor woman was just scared to pieces of not being able to breathe, and she put her trust in these doctors, who all worked in the same practice and NEVER ONCE checked with one another as to what the others were prescribing before giving her yet another nebulizer tx or MDI or pill.

OK, enough about that, I've already hijacked Distraught's thread as it is, and we need to get back to the subject at hand. I hope she is able to get some answers so she can make peace with her father's passing and begin the long healing process. While we all expect our parents to go before us, sometimes they do so in such a way that we end up with more questions than answers, and when that happens, it can take years to come to terms with our loss. If we ever do.

[allegator]

Mjlrn97, I too am very sorry to hear of your loss. I think it would be inappropriate for your anger to ever totally "resolve." Were the clueless doctors who "treated" your mother by looking in her chart for 10 seconds and overlaying yet another med ever held accountable?

CCU thanks for your time and your good wishes, I'll try to follow your advice. I think "closure" will ensue when and if the doctors in question are held accountable for their actions. This will turn a horrible and meaningless death into a positive deterrent. The question is how I get from here to there when the deck is heavily stacked in their favor. (ie. lawyers don't defend dead elderly, hospital and doctors are friends and colleagues, heavy bias throughout the medical community.)

[ktwlpn, LPN]

Originally posted by fergus51

Inaccurate documentation is always unethical and should be adressed.....

But, and I may be completely off base in this, I wonder if it is easier to focus on this than accept that nothing could have been done to save your father.]

You are right-this is one of those stages of grieving we all learned about in nursing school...It;s such a shame to see anyone stuck on any one stage but everyone goes through the stages at a different pace.....