I Need Your Help! November 18, 2008
Posted by keepbreathing in Uncategorized.trackback
Hi there readers. Not your usual madness today. No, I come to you instead with a request. I require your assistance. That’s right: you there, on the other end of the internet! Help!
I am currently enrolled in college, working towards my bachelor’s degree. As part of the curriculum this semester I am taking a course on nonfiction writing. The final project for the course involves picking an issue or a subject that interests you and writing a “feature length” article about it, 3,000 words or more.
I pitched my topic as follows:
“One of the less pleasant and more philosophically challenging aspects of working in respiratory care is the delivery of futile care. Often, when a person is very sick, their chances for survival drop almost to zero. However, modern medicine offers us a huge assortment of life-extending measures that we use almost indiscriminately. While that sounds great on the surface, it creates a lot of ethically hairy situations, and I often describe the dilemma as “just because we can doesn’t mean we should.” As a respiratory therapist, part of my job is to run mechanical ventilators that breathe for people who are unable to on their own, and I am exposed to a huge number of futile cases. A typical “futile” case would be a ninety-year old man with alzheimers dementia, diabetes, renal failure, colitis, and skin breakdown from nursing home neglect who presents to us with pneumonia. We can use our vast arsenal of drugs and treatments to keep this person alive, but should we? A lot of providers who end up providing care in situations like this are strongly, viscerally opposed to doing so, and yet we are legally and maybe ethically forced to do so. Listening to people talk about this is always fascinating and often thought-provoking.“
As part of my background for the story I’d love to get other people’s perspectives on the ethical issues involved with end of life care, intensive care, and so on. I’m interested in hearing from people with any perspective on this: if you’re strongly opposed to termination of care for any reason, why? If you’re strongly opposed to keeping people alive beyond certain conditions, why? Or if you have a middle-ground position, explain it to me. Are you a non-medical person? Your opinion is still interesting. I am very interested in what you have to say…I have my own reasons and opinions but I need to know other people’s reasons and opinions or else my article will be nothing but an angry screed. Heck, if you’d like, I could even post your opinions or reasons here as a guest post…just to throw an incentive in there.
It would be ideal if I could quote people using real names, but if for Internet Anonymity Reasons or any other reasons you’d prefer to be pseudonymed that is fine with me. Anybody who wants to weigh in on this and give a brother a hand with his writing, please drop me a comment or even better send me an email! I can be reached at anonymoustherapist at gmail dot com. Any feedback would be greatly appreciated!
Thanks for reading and thanks for your help.
That’s a great topic, but a very challenging one. I usually try to stay away from general ethical issues like that, because whatever statement you make, you can always find examples to undermine it, so I generally believe decisions should be made on a case by case basis.
I think ideally, the choice should ultimately belong to the patient. Maybe the old man doesn’t feel ready to die yet, and while nature will eventually have its way, if we can give him some more time to sort himself out, then we should. You could argue that dementia makes him incapable of deciding for himself, but I think that even people with dementia have desires and goals that are very real to them, and we shouldn’t discard them as nonsense.
I am having a hard time building an argument, because there are so many factors involved: understanding the process of death, the individual’s ability to let go, family’s ability to let go, the patient’s state of consciousness, the patient’s chances to recover, the time a patient might gain from the use of these methods, the economic impact of using these methods (both on the patient and his family and on the health care system), constraints when several patients with different survival chances compete for medical resources and time… there are just so many variables that reaching one, overarching general conclusion on the matter seems impossible.
Bottom line… I think putting the patient’s well being on the first place is very important. Whether he is going to live or die, he should feel that someone is looking after him and he is not dumped and discarded because his life is not worth maintaining anymore.
Why should it be up to you who lives or dies? You would make that decision because you believe the person to be useless, in very bad shape, and a drag on resources? Perhaps your assessment of the hopeless status of the patient is correct, perhaps it isn’t. Maybe the next patient you decide you won’t treat has a reason for living, that is invisible to you, but because you deem that person unworthy of maximum effort, they will never have a chance. Better they fail on their own, rather than you deciding for them.
What kind of time frame wil you have? Will you establish a cut-off date like “Don’t give any care to anyone who looks like they will die in 48 hours.”
You have a job to do. That job is to give everyone the best possible chance you can at survival. If you have reservations about who should get the best that you have to offer, you should find another career. People come to hospitals as portals of mercy.
I’ll give you a little grammar help.
One of the less pleasant and more philosophically challenging aspects of working in respiratory care is the delivery of futile care.
Often, when a person is very sick, their **his or her (A person)..singular, not plural** chances for survival drop almost to zero ** however is always used within the context of a comma or a semi-colon**; however, modern medicine offers us a huge assortment of life-extending measures that we use almost indiscriminately. While that sounds great on the surface, it creates a lot of ethically hairy situations, and I often describe the dilemma as “just because we can doesn’t mean we should.” As a respiratory therapist, part of my job is to run mechanical ventilators that breathe for people who are unable to on their own. **a little run-onney, thus the paragraph**.
I am exposed to a huge number of futile cases. A typical “futile” case would be a ninety-year old man from nursing home neglect who presents to us with pneumonia with **Alzheimer is capitalized and not punctuated per the AAMT BOS (medical transcription bible)** alzheimers dementia, diabetes, renal failure, colitis, and skin breakdown **I’d put that after man, not after…too confusing**
We can use our vast arsenal of drugs and treatments to keep this person alive, but should we? A lot of providers who end up providing care in situations like this are strongly, viscerally opposed to doing so, and yet we are legally and maybe ethically forced to do so. Listening to people talk about this is always fascinating and often thought-provoking.“
Nice work, KB.
**before** man, not after. Shit, I made that confusing too!
It’s such a complicated subject, KB. I”m of the opinion that as long as I do what I do (smoke) or whatever, the results of those actions should be on my shoulders. Of course, I work in the medical field, so I have a lot more knowledge than most (as do you). I’ll be a DNR till I die. Ha-ha.
I think it really goes deeper than just simple medical care; it delves into the fear of dying that we all have. Friends, family and patients get scared..bad, especially if they have no REAL true family support or social network. I think that’s why hospice is a super-wonderful, but under-utilized aspect of our society and healthcare milieu.
So, yah, it’s totally complicated. One argument I heard was, hey if we want to extend these preemies lives at any expense (financial, to the preemie’s health and future welfare, etc.), why won’t we do the same for our elders? Who is more “valuable,” so to speak? An interesting conundrum to be sure.
I agree with Karla. It is indeed a very interesting and contemporary topic that health care practitioners of all sorts (doctors, nurses, RTs, paramedics, and mid-levels such as PAs and NPs) deal with on a daily basis.
I’m not sure if this is off-topic, but I was once in a lengthy debate for school regarding euthanasia (physician assisted suicide). A large portion of the debate stems from the opening of the Hippocratic Oath which states, “First, do no harm….” Some food for thought would be: Is it more harmful to prescribe medications to keep a patient alive in true agony, or to “assist them to their death,” with a lethal dose of medication?
Of course, this may be too far off from what you are looking to accomplish with your paper, but English is definitely my strong point. If you need any help, just send me an e-mail to js0095001 AT gmail DOT com.
Hello,
I like ‘Pink’s’ statement, “I’ll Be a DNR Til I Die” which could also be the title of a country western song (but I’ll never know ‘cuz I don’t do country; currently listening to John Coltrane)!
Ah yes, the age old dilemma of how much to “do” and for whom. At the hospital I work at, we are developing a “Care and Comfort” order set that specifies that the family must be included in a care conference to determine the next steps. This will become automatic and will happen earlier than it has in the past, once it is up and running. This is really the key, I think, to getting everyone on the same page as well as taking into consideration the patient’s wishes (IF they are known – if not, you’re kinda screwed). But, at least the care conference gets the discussion going and sometimes (lordy be) the families realize that grandpa isn’t going to make it. We never say the words “withdraw care,” either, as over the years we’ve realized that many families balk at the thought. Instead, we preface the discussion around what we are going to do to “provide comfort.” I’ve seen that intervention with the family as early as possible saves many patients from days of “futile” care, which doesn’t help anybody.
“Death is a universal human experience, yet our response to it is shaped by the culture in which we live”. A quote from a book called The Last Dance- Encountering Death and Dying. I’m a student RT and read your blog often. In the course of my studies, I had to take a SOC class and that was the book we used. Very relevant to your current endeavor. It discusses quite a bit: the health care system (emergency & palliative care), living with life-threatening illness, end of life issues & decisions, etc. I think you’d get a lot of insight from the book, as well as statistics and historical perspective.
If you’re interested and can’t find it, email me and I can mail you my copy. I just want it back when you’re done. BTW, keep up the great writing!
Just a grammar note…
The use of “they,” “them,” and “their” for a singular but gender neutral pronoun has a long history, going back to Shakespeare. Especially now, in today’s political/social climate, it is gaining increasing popularity. I think it sounds WAY better than the clunky and overly PC “his or her.”
It’s an interesting topic, and I applaud you for bringing it up in a (I assume) non-medical arena. All I can say is, death comes to us all, and one of the most disturbing things I have ever seen (shadowing an ER doc) was the reinsertion of a feeding tube in an elderly, demented patient who had pulled his out. He was in obvious pain, and the reinsertion did not go well. I felt ashamed of being a part (even as an observer) of his suffering.
FYI, I put a post up on my blog linking to yours to try to drum up more business, so to speak.
A medical ethical problem, ..in need of many words? That should be no sweat.
Here’s a real life one.
Terminally brain injured person on mechanical ventilation in your ICU.
It’s been decided to stop support…but the patient recieved sedation and paralysis drugs just before “The Decision.”
The family is gathered ..it as an anguishing and poignant time, and the time seems right.
But…if our patient is still under the effect of a paralytic drug..isn’t that too close to euthinasia??
Would that bother you ethically or religiously?
AJC
I have been philosophically opposed to the amount of medical care that is allocated to the smallest of premature newborns and end of life care. It really sickens me the way that people have used such heroic efforts on individuals who have had limited brain function like the individuals born with anencephaly (without a brain). Although it should always be considered on a case by case basis. Perhaps brain functioning to me is a sign of having a soul? Although the human brain can be amazing. I am interning as a social worker at the acute rehab department of the regional trauma center. One of my family meetings yesterday was for a young man who was shot in the head. During the meeting he stared at us “pretty” ladies and wrote his name over and over. He is in the very beginning of his recovery. There is no doubt in my mind that he will recover to have a meaningful life.
I have also seen people who have had very long recoveries from being very very ill or who have been in serious trauma. I find it very rewarding to see people a new chance on life.
Yesterday, we had an “off service” patient (the hospital was full, as usual). It was an elderly man who lived at home. He was brought in for aortic dissection (He was sent to us by a rural hospital). The family mobilized and halted the surgery. Hospice was called. A DNR was written.
The family wanted the patient treated with medication, just not heroically. I thought that was pretty reasonable. So they were stuck in the limbo in many ways, with some people pushing for surgery, others for hospice.
Things can get complicated. But I thought this family was wonderful. They just “got it.” The patient was awake, oriented x2.
If you want my “real name” just comment here, I’ll email ya.
[...] 21, 2008 Posted by keepbreathing in Uncategorized. trackback I got an interesting response to my ethics post the other day. Here is the [...]
My field of pediatrics imposes an interesting twist on your ethical conundrum. Let’s face it – kids aren’t supposed to die before their parents do. Unfortunately, I witness that first-hand more often than I care to admit. Determining “futility” of care in pediatrics is difficult to do, as children are often expected to “bounce back” or eventually recover from illness. I can think of many instances where we probably kept someone alive far longer than the point of viability or recovery or painlessness because of the family. I can also think of many instances where the parents said enough is enough before the going got really bad.
The most important thing to do is to be honest. Don’t use flashy words when explaining the situation to families – give them the straight and plain truth. I’ve found that in doing that, families appreciate your honesty and are better informed to make decisions about the care of their loved one. Having the “Death Talk” is never easy but it has to be done and even as a resident, I feel like an integral part of that process.
I’ve been thinking a lot about your topic, and I feel that as patient advocate’s we need to not only advocate for the right of a patient to receive treatment, but for the the right of a patient to go “quietly into the night.” There have been many patient’s whom I have worked with that have not had family or the mental lucidity to determine whether or not treatment should continue. One gentleman in particular had been intubated 6 times in a 3 week period. It was harder and harder to extubate him; and each time he got extubated it was for such small increments of time that we to tube him again just to keep vital organ systems perfused. In addition to the ventilator, he had feeding tubes, a foley, ECG strips, an art line, and was restrained via soft restraints. He obtained mild treatment compared to the levels that we can go technologically and he suffered. He had so much trauma to has laryngotrach and esophogeal tracts (?) that he was bleeding from his nose ears and mouth. Had we not had him on a Propafol drip and other meds, he would have been in dire pain. His respiratory function was so poor that without the vent he would have passed away, which is what the patient eventually did. To tube him 5 times after the initial intubation was horrific! Had we provided comfort measures with this patient his passing would not have been so torturous. We kept this patient breathing because of the Hippocratic oath our Docs felt compelled to honor; as well as, fear of legal connundrums that would occur if we did not do everything in our power to save him. I was taught early on in my Health care training that you MUST always display empathy for the patient…it doesn’t seem that when we just routinely keep someone alive for the sake of legalities or because we have the technology to do so that we are displaying empathy.
You know, there will always be the question of what is right. I had an uncle DX’ed with pancreatic cancer. He wanted nothing extraordinary. He smoked and conducted his “business” until 2 days befoe he died. We took him to hospice because Gram couldn’t do it til the end. We kept him pain free, until the end.
As a health care person, there are too many situations that call for different protocol per situation. It is too hard to make a blanket call. We can always hope for miracles, but some are long gone, no hope. It is terrible to waste the resources that could be available to others who have a chance.