End of Life Issues

21 Oct

I am not sure what is going on lately but it seems that I have been having “more than usual” for my experiences so far of end of life issues. (If that makes any sense)~

I have LOTS of questions and few opinions already. In the not so distant past I have s few experiences of elderly patients that are curled up in the fetal position, contracted. It is not even possible to move their limbs. I wonder how they get like that? They are not eating, not communicating and appear to be in no pain or distress and yet their kidneys are failing, or some other acute or chronic illness is ravaging the body for them to be in the hospital right?

Or what about nutrional status? One nurse while giving report said about one of the above stated patients, “We are just startving the patient? How cruel!”  Well is there something wrong with me that I feel that it is cruel to stick an NGT (nasogastric tube) into a person who ultimately will need a PEG tube that the family already stated they do not want to do. What is the point of putting in an NGT into a patient that does not wake up and put them at a risk of aspirating? Do they feel hungry while they are in the natural process of dying? What is the natural process of death?

The answers sometimes come to late. I had a patient once with severe chronic congestive heart failure as well as pulmonary failure. The patient had an advance directive with DNR wishes. On the 3rd day of the patients hospital stay it was clear that the patient was near the end with no gas exchange as revealed by the arterial blood gas analysis. What was to happen? The patient needed to be intubated to sustain life, but that was clearly against the patient and family wishes. Hospice was finally arranged, although late in the day and the patient died on the stretcher in route to the hospice care center.

Another patient that I had recently encountered was actually at a nursing home that provided hospice care, the patient had clear “Do not send to the hospital orders.” On the medical record. Someone from the nursing home had the brilliant idea of calling the family when the patient started to breath “heavy and funny” “not breathing right” or something of that nature, and asked the family, “Would you like us to send your Mom to the hospital?”  My opinion is this: The family already went through this!Why are you asking the family that and confusing them?  What happens? The patient is sent to the hospital and gets, 6 consulting MD specialists, antibiotics, poked with needles, tubes everywhere. The patient is not conscious, has not been for months! Then the family looks at the nurse appalled: ” we did not really want to put Mom through this.” Of course not, and I understand that none of this would of happened if the nursing home would of never called asking in that “way”.

i mean when is enough enough? Clearly that is not up to me, but I do have my opnions and I do not think that I am cruel. Sometimes I think it is cruel what we do!

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2 Responses to “End of Life Issues”

  1. a modern hell October 22, 2008 at 02:04 #

    I suppose it would be easier if there were a clear line between time to live and time to die. It’s a shame — medicine is in the business of keeping people alive, and I think it sometimes it loses sight of human dignity in the process.

  2. Christian Sinclair November 16, 2008 at 18:09 #

    Does your hospital have a palliative care team? That would be a good resource for these families & patients. A good palliative care team can also help gradually change the culture of medicine to see a patient as a list of diseases to be treated and medicines to be given. Talking about life and death issues can be daunting at first given all the uncertainty about outcomes, but if it is an ongoing conversation and a process, instead of just a one time discussion, it is much easier to react to the day to day changes in a patient’s condition.

    The bedside nurse can be a great stimulus to patients and families in probing some of these deeper issues, if only they had the time (which is monopolized by charting and passing meds and getting paperwork ready, and tracking down docs.)

    Feel free to stop by Pallimed anytime to get some more info on end of life care.

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