Tuesday, August 4, 2009

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.


Grandma Tillie's Bakery said...

Great minds think alike--I blogged about the health care issue today too. I feel especially strong about the end of life issue with what my mom is going through now.

I am afraid I have come to the place where I so strongly distrust our government that anything they are proposing I am automatically against.

I really feel like it has gotten so bad because there is a huge separation between "us" and "them" and the chasm is growing by leaps and bounds with this new administration. And I actually think they planned it this way...

farmlady said...

Oh Karen, this is a tough subject for most folks. I really think it has to be done on a case to case, family to family basis. We don't want dying regulated by the Government in any way, shape or form, but the government isn't responsible for most people's apathy in this country. Folks need to wake up and start looking at what they are loosing. They are always angry at someone and it's a whole lot easier to be angry than it is to solve problems. Enough said.

My Mom died two weeks ago and had a DNR and Hospice in place. This seemed to work very well and she had a death that was relatively free of pain. If she hadn't had both of those medical programs set up ahead of time, she would have died in a hospital, attached to a lot of tubes and they would have kept her alive much longer than she wanted. She was 90 years old and had Congestive Heart Failure, Diabetes,and other related problems. I can't tell you how important it is to have all of this thought out ahead of time. As hard as it was to talk to her about her death, it was worth every uncomfortable discussion we had with her so she could die in her own room without going to the hospital and being attached to breathing tubes, catheters and commotion all around her. She died peacefully and without pain. Hospice rocks...

We need to appreciate the things that work and change the things that don't.

Linda said...

That's right, sugar! No one dies in the OR! They may die in PACU or when they get back up to the unit, but not in the OR. ;)

I'm with you. You know that I've seen plenty of cruelty in the name of keeping Momma alive to salve a guilty conscience or frankly (and this is so sad, yet true) just so the family can get her check for the next month or two. I'm a big advocate of people making their own end of life decisions. And, please, people...don't just tell someone in your family. Put it on paper and make it legal so that doctors and nurses aren't legally bound to keep you here when they don't want to and you don't want them to. It makes it so much easier on everyone!

Farmgirl Paints said...

I definitely agree it is NOT the government's place to get involved in these scenarios.

I personally believe that death should be allowed to come naturally to those that are beyond saving.

It should be part of any nurses, doctor or medical professionals training to learn about this and to educate their patients and their families.

Schnitzel and the Trout said...

I agree with everyone so far. The problem is....what can we do to convince Obama that he is dead wrong about getting the government involved? He has become out of control and it does not look good for any of us.

Do you really want some people in government deciding if you need a procedure done? It is bad enough with the insurance companies going over the doctor's head and suggesting that procedures should not be done. Why did these doctors go to school? They and only they should be the deciding factor. I am afraid, if this passes, there will be fewer doctors in our world. Then, the waiting lines to see a doctor, etc. So, people will die while waiting and Obama's health care plan will work for him, won't it?

Annie said...

Hi Karen..just popping by to say hello...have been catching up here on your blog...thanks for visiting my Queensland doorway post!
Hope all goes well in the next few weeks for you.
Glad the renovations are sorting out and coming to a close for you..whew...what a time for you! We had to hang plastic sheeting in the doorways when our floors were being sanded...helped a bit, but too late for you now!

Chris H said...

I think this is an entirely personal choice, and everyone needs to discuss their own wishes with their family BEFORE it is necessary.

imbeingheldhostage said...

You've given me a lot to chew on. My Hubby and I were first approached about a DNR when we were preparing for our first baby-- young and invincible we thought, "Yeah, we'll look into this more, later". (I would've died after that delivery, if it weren't for some medical heroics so I do believe you that if we're healthy, our hineys are covered). So here we are, later, and have never touched the subject again. Thanks for prompting me to think.

Laura ~Peach~ said...

the very first thing that i did when granted guardianship of mother was to make her voice her wishes in front of witnesses so it could be documented and filed in her files. second thing was went to the funeral home of her choice and pre paid for her cremation and head stone and all other necessities... then worked on the mess with her stolen identity and subsequent conviction of said thief... now we live and work on the qualtity not quantity of her life. plans and such were made here with us and our kids many years ago as i have had to crush bones during cpr and and been at bedside with way too many dying people and their families who by the way are not thinking clearly in the moment.... like youdid not know that... good topic and i so think EVERYONE should have plans made and known to all who love them and care for them .... it is just easier... after all we went through with my mother in law who voiced her wants but never put them into writing.... and my in laws insanity wanting to change and go against her wants.... i was the one who had to sign her hospice papers and DNR they refused ... even after she begged them to... it was the most horrid thing to ever go through .... sigh... please people put it down make this part of life easier!

Ruth said...

Since you are a nurse. Do you have to have an attorney to fix up papers for a person to not DNR? Or put on life support? My hubby and I was talking about it at supper tonight. Since he has a niece that has had a stroke. Everything is beginning to shut down. Kidneys first.

Also we too, had fresh pinto beans yesterday. You are so right they smell so good cooking.

I enjoyed looking at your garden today. And kinda of laugh to myself and said, my goodness they have flowers and produce going every place. Sure looks good too!


Karen Deborah said...

Ruth, and anyone else that is interested. Your local hospital should have forms for advanced directives that is what you will fill out. An advanced directive does not need to be done by an attorney. It allows you to appoint someone to carry out your wishes if you cannot talk for your self. It also asks questions regarding different situations so you can think about it. For example I have indicated that I have an illness that would take my life I don't want heroics but I don't want food and water withheld; thank you very much don't starve me. Unless I am actively dying and don't want it then no tubes or IV's. I know such a mess.
Anyway you fill out the form have it notarized and witnessed by people who are not your family members.
An advanced directive indicates your wishes to health care providers. It is not a power of attorney.

Twisted Fencepost said...

Isn't that called Medical Power of Attorney?
My Mother stated that she wanted to be a DNR in her last days of renal failure.
Sometimes it's hard to swallow, but after my Father passed four weeks earlier, she gave up and denied all life saving treatment, such as dialysis.
Watching her give up was hard for my brother and I, but we had to respect her wishes.
I agree with you. Don't make someone suffer just because YOU aren't ready to lose them.

Karen Deborah said...

No this is an advanced directive. A medical power of attorney requires more legal involvement I think. I get mixed up about all the technicalities except for an advanced directive can be done simply and revoked simply. It is honored by health care providers, and it is the easiest way for people to make their wishes known.

Anonymous said...

This is a great post and the last one I read... although, I didn't comment. As always, what you write is very thought provoking.