A Frank Discussion

My husband and I were discussing the health care problem and the proposed reforms. Aside from the problem of illegal immigrations added expense to the system, which we are all aware of, there are serious issues about end of life decisions. Please stay with me, because I may go in a different direction than you might expect.

The majority of health care dollars are spent on the very elderly and the outcomes are very poor. We can prove that, statistics show it. Most of the frail seniors that fall and break a hip usually succumb to some other problem even if they survive the surgery. So does that mean they shouldn't have it? Who is elderly? Is a 59 year old person elderly?

I think the real problem with this is recognizing when the end of life is happening naturally. While I was working in the ICU I educated the other nurses there about the signs of dying. You would think that ICU doctors and nurses would know that, but not all of them are familiar with the signs of impending death. We can see signs from 6 months, a few months, weeks, days, and hours.
Just as we know the signs of labor and delivery and imminent birth; so are the signs of dying.

No one wants to perform CPR on a frail elderly person and hear the sound of bones breaking with every compression. If they don't have a DNR order on the chart we have to do it, it's the law. It's gross. The first time I actually had to give a patient chest compressions this was the case and Icould feel and hear the bones breaking, it was awful. This little lady had already "coded" once and since she was in her late nineties she did not have a successful resuscitation. Her family let us know later that she didn't want one. She had expressed her wishes to the family but it wasn't on the chart. That happens all the time.

Are you picking up on the problems as we go along?

What about when you know the outcome is going to be bad, say a person who has never been ill but presents with life threatening illness and a whole host of problems all inoperable and most likely fatal; but the patient and the family need time to absorb all of this. What do you do?

Your patient is a young person in their late thirties they are in end stage alcohol disease and they have AIDS, they have no family that you can locate. They are in denial of their impending death and are basically in your ICU for pain drugs. They have been in hospice and discharged themselves out. They are too sick for the floor so they must stay in the ICU until they die which can be weeks. What do you do?

These are real scenarios. I can write up hundreds of them. My point is that THESE are not the issues of government. Legal intervention and government intervention have made the nightmare we are in right now. The doctors and nurses DO have ideas about the right way to solve these problems but it is so cloudy between malpractice and RIGHTS that it is usually the last thing that can be done if ever.

How do we solve it?

One thing we need to do is educate everyone about natural death. I am very comfortable with helping a family accept that a person they love is leaving this world. I am in a place in my own practice where I can see what is going on and when to call it quits. I am very pro life. I do not believe in withholding treatment. BUT there are times when the treatment becomes cruel. There are times when the best treatment is to comfort and to relieve pain. It takes a tremendous amount of teaching for families and also for staff.

My husband asked me if I wanted the job.

I just looked at him.

It isn't a job for the government that is to be sure. They have already made a big mess of it. We can't mandate who gets what. If you knew the mess that medicare laws are, you'd see how that is ALREADY happening. If you don't meet medicare criteria you need to go home. Your sick? Sorry you don't qualify, can you private pay? No, well then you have to leave.
I am dead serious about that too.

What would you do faced with these ethical dilemmas? Have you had discussions with your loved ones about end of life issues? Have you really investigated this beyond table talk? Do you have it in writing? Does your doctor have a copy? Are there people in your family who oppose your thinking? If you don't want heroics when do you want them stopped? If you could be on a ventilator for a short period of time and then recover do you want your DNR in effect or not?
Just for the record if your going to the OR you are not a DNR.(do not resuscitate) You really have to be at the end of your life to have a DNR. If your healthy we are going to save your hiney, you can count on it.

Do you want to talk about this for a bit? I have time. Bring your questions to the blog table and lets talk about them.