Life Support - Thoughts?

[Firecat]

Left the title a little vague. Wanted to get your opinions on things like life support, do not ressuciate orders etc. Would you want to be kept on life support for an extended period of time? Side-topic....are you an organ donor?

I bring this up after reading two different stories recently....

http://news.yahoo.com/teen-ordered-off-life-support-family-appeal-223311842.html

A judge on Tuesday ordered that a 13-year-old Northern California girl declared brain dead after suffering complications following a tonsillectomy be taken off life support.

But Alameda County Superior Court Judge Evelio Grillo gave Jahi McMath's family until 5 p.m. Dec. 30 to file an appeal. She will stay on life support until then.

....

Children's Hospital of Oakland, where Jahi is hospitalized, has asked that the girl be taken off life support after doctors there also concluded she was brain dead.

Her family has said it believes she is still alive and that the hospital should not remove her from the ventilator without its permission.

Hospital lawyers disagree.

"Because Ms. McMath is dead, practically and legally, there is no course of medical treatment to continue or discontinue; there is nothing to which the family's consent is applicable," the hospital said

http://news.yahoo.com/texas-man-asks-pregnant-wife-removed-life-support-002159041.html;_ylt=A2KJ3CQPHbpSbWcA3KDQtDMD

A Texas man is seeking to have his pregnant wife removed from life support and may try to obtain a court injunction against a state law requiring her to be kept alive because she is with child, reports said.

Marlise Munoz was admitted to a hospital in Fort Worth on November 26 after suffering what her husband believes was a pulmonary embolism. She has been on a ventilator since then.

Her husband Erick wants her to be removed from life support, saying that he and his wife are both paramedics in the Fort Worth area and discussed what they wanted to do in such a situation.

"We both knew that we didn't want to be on life support," he told Dallas broadcaster WFAA.

He found his wife unconscious on the kitchen floor when she was 14 weeks pregnant and is worried the fetus may have been injured by a blood clot that cut off the flow of oxygen and nutrients in Marlise's body, he told WFAA.

"We've reached a point where you wish that your wife's body will stop," he said.

Marlise is now about 18 weeks pregnant and tests have shown the fetus has a normal heart beat, WFAA said.

Under Texas state law, a person may not withdraw or withhold life-sustaining treatment from a pregnant patient, even if there is a "do not resuscitate" request from the patient or the family of the patient seeks to end life support.

"The hospital is following the law," J.R. Labbe, a spokeswoman for the John Peter Smith Hospital in Fort Worth, told Reuters.

 

[Cobol74]

Nope the bloke is wrong I am afraid. Also who would discuss such a thing with their pregnant partner - weird?

 

[avanti]

Why not abort the child first then worry about the wife?

 

[Spectre]

Strictly from a legal standpoint, "we discussed it" is pretty much considered BS by the legal system anywhere in the US. As paramedics, they should *know* the law - and they should have filed the prerequisite DNR/living will documents ahead of time.

 

[Red_Bull]

INTENSIVE-CARE nurses know things you don't and wouldn't want to know. Kristen McConnell, an ICU nurse, writes for The New York Post explaining why they would never want to be admitted to hospital:

Last year I graduated from nursing school and began working in an intensive care unit in a large hospital. During an orientation class, a nurse who has worked on the unit for six years gave a presentation on the various kinds of strokes.

Noting the difference between supratentorial and infratentorial strokes - the latter having a severe effect on the body's basic functions - she said that if she were going to have a stroke, she knew which type she would prefer:
"I would want to have an infratentorial stroke. Because I don't even want to make it to the hospital."

She wasn't kidding, and after a couple months of work, I understood why. I also understood the nurses who voice their advocacy of natural death - and their fear of ending up like some of our patients - in regular discussions of plans for DNR tattoos. For example: "I am going to tattoo DO NOT RESUSCITATE across my chest. No, across my face, because they won't take my gown off. I am going to tattoo DO NOT INTUBATE above my lip."

Another nurse says that instead of DNR, she's going to be DNA, Do Not Admit. We know that such plainly stated wishes would never be honored. Medical personnel are bound by legal documents and orders, and the DNR tattoo is mostly a very dark joke.

But the oldest nurse on my unit has instructed her children never to call 911 for her, and readily discusses her suicide pact with her husband. You will not find a group less in favor of automatically aggressive, invasive medical care than intensive care nurses, because we see the pointless suffering it often causes in patients and families.

Intensive care is at best a temporary detour during which a patient's instability is monitored, analyzed and corrected, but it is at worst a high-tech torture chamber, a taste of hell during a person's last days on earth.

Choices you don't always have

I cared for a woman in her 90s whose family had considered making her a DNR but decided against it. After a relatively minor stroke that left her awake but not lucid, "Helen" went into kidney failure and started on continuous hemodialysis. Because she kept pulling out her IV lines and the feeding tube we had dropped into her nose and down to her stomach, we put boxing glove-like pillow mitts on her hands.

When I approached with her medicine, Helen batted at me with her boxing gloves, saying, "NO. STOP." She frowned, shook her head and then her fist at me. Her wishes were pretty clear, but technically she was "confused," because when asked her name, the date and her location, she failed to answer.

During the next shift, Helen's heart stopped beating. But despite talking with the doctors about her advanced age and the poor state of her health, her family had nonetheless decided that we should "do everything we can" for her, and so Helen died in a frenzy of nurses pumping her with vasopressors and doing chest compressions, probably cracking several ribs.

That was a situation in which a patient's family made a decision that probably caused Helen to suffer and did not help her. But there are circumstances where it is the health-care team that chooses to push on with intensive interventions. And there are circumstances where bureaucracy, miscommunication and the relatively low priority, among very busy physicians, of making decisions about how far to pursue medical care cause patients to linger in the ICU weeks past the point when any medical professional thought meaningful recovery was possible.

Consider another example, of a patient with advanced cancer, in this case an elderly woman with a well-informed husband who knew his wife was dying and that she didn't want to end her life with an extended ICU stay.

After her last tumor resection, this woman developed an infection, and during a meeting with her husband the attending physician explained that the main problem we were immediately dealing with was the infection, which was bad and could well be something she would not recover from.

The patient's husband explained that he knew that his wife didn't want to be there and that her underlying diagnosis plainly meant that her life was going to end, that they both understood this and didn't want to painfully draw things out. Then he asked if he had any decisions to make - in effect being as blunt as he could without simply insisting that they withdraw care then and there.

The doctor said no. She said that the patient needed to complete the course of antibiotics to see if the infection could be cured, after which they could approach the question of whether to continue with intensive medical care. I imagine the doctor saw some distinction between letting the patient die of her primary, terminal diagnosis and letting her die of a complication. So the husband's efforts to stick up for his wife went unheard, and she stayed in the ICU, comatose, for about two more weeks - quite the opposite of her stated wish - before everyone agreed to let her go.

On the other side of the spectrum are the poor forgotten patients, the ones who linger because nobody will speak up for them and the medical team is not legally allowed to decide to do anything short of maintaining life, day after day.

The terrible indignity of the ICU

These patients had different injuries and different circumstances. What was common to them was that they all suffered the bodily harm and indignity of being physically invaded in every sense, robbed of their integrity entirely and pinched and poked continuously during the last days and weeks of their lives. Since nobody at the time thought they were going to get better, the people doing this to them - myself and other nurses - had an overarching question: Why?

All of us love the opportunity to help save a life. That happens in intensive care, and it is exciting and miraculous. But in the instances I've described, and many, many others, nobody involved is under the delusion that a life is being saved.

The absurdity weighs me down, and so I want to describe it to you. Medical science can do incredible things. But you would not believe the type of life these life-sustaining treatments often allow.
People who are at the end of their life and are being kept alive artificially have a way of shutting down. Fighting this process is not a peaceful act.

Most of the patients I've described were on ventilators, with plastic tubes pushed into their mouths and down their tracheas in order to provide respiratory support. The tubes are taped to their faces, and patients who can move at all are usually both tied down by their arms and sedated when on a ventilator, because it is so physically uncomfortable that patients will use their last ounce of strength to pull the tube out of their mouth. These patients were already comatose due to their injuries, but other critically ill patients who were previously awake and responsive become unable to speak while on a ventilator.

Once intubated, patients are unable to clear their respiratory secretions - phlegm - and so we stick smaller rubber tubes connected to suction into the breathing tube, down their trachea and towards the entrance to the lungs themselves, in order to vacuum the secretions out of their lungs. You can imagine that this too is uncomfortable.

Patients obviously can't eat, so they will have had a feeding tube pushed up their nose or through their mouth and their esophagus, down into their stomach. This often takes a few tries, requiring us to pull up the bloody tube, re-lube it and push it back in at a different angle.

If a patient is ill long enough, these instruments will be replaced with a tracheostomy in the neck rather than a tube down the mouth and a feeding tube going directly into the stomach rather than down through the nose. These are for patients who aren't expected to be able to eat or breathe independently in the long term.

These patients often develop diarrhea, sometimes simply because of the liquid food they receive - cans of smelly, nutritionally balanced tan-colored slush - and sometimes because they've acquired a very hardy and aggressive bacteria, C. difficile, that is widespread in hospitals and causes profuse, foul stool. If they have diarrhea several times a day and their skin is exposed to it, the skin begins to break down, and so we place a rectal tube in their bottom, held in place beyond the rectum with a small water filled balloon.

The diarrhea drains into a clear bag that hangs on the side of the bed. Sometimes when a patient is very sick, as in the case of the man whose family avoided him for over a month after his stroke landed him on my unit, they lose their rectal tone and the tube falls out. This is how I found myself up to my elbows in diarrhea with another nurse, struggling to clean the crevasses of his body and tape an ostomy bag around his bottom, the last hope to contain the flow of stool so that the patient wouldn't sit in a continuous puddle of it while permission for his death was pending.

Only two ways to die

Breathing tubes, feeding tubes and rectal tubes are only part of it. The patients of course have urinary catheters and IVs, often larger IVs that are placed centrally - threaded straight toward the heart to allow us to push drugs in concentrations that would damage smaller veins.

Healthier hospitalized patients complain sometimes about their IVs and frequently about their urinary catheters - a rubber tube up your urethra isn't pleasant.

If the patients I'm describing could talk, though, I think the urinary catheter would be the least of their complaints. In addition to the invasion of tubes, ICU patients live in a world of bright lights and loud alarms, continuous stimulation. People pry open their eyes and shine flashlights into them, then pry open their mouths.

We treat most patients with small shots of heparin in their subcutaneous flesh, in order to prevent blood clots. This makes them bruise easily, and patients who have been with us for a while are often peppered with tiny bruises from the shots. Then there are the bigger bruises caused by painful stimulus given by doctors and nurses who are monitoring the arousability of the patient, the depth of their coma. If he doesn't wake up when you shout, or when you shake him, what about when you pinch and twist his trapezius muscle?

It's been said that dying is easy, and it's living that's painful. Not so in the world of intensive care. Patients who have a hope of recovering from their injury, genuinely surviving it, may be fighting to live. For them the torturous days as an ICU patient are required in order to surmount their injury. And there are always cases where nobody knows what the outcome may be, where the right thing to do is maintain physical function and give the body time to heal.

Many patients will survive with deficits, will not return to their former selves but will be able to leave the hospital, go to rehab, begin the hard work of adjusting to another kind of life.
But time and again we care for patients who are fighting to die, and having a very hard time of it, because in the ICU there are only two ways to die: with permission, too often not granted or granted too late, or in the last-ditch fury of a full code blue.

Forging a better end

We are not helping these people by providing intensive care. Instead, we are turning their bodies into grotesque containers, and reducing their lives to a set of numbers monitoring input and output, lab values and vital signs, which we tweak to keep within normal ranges by adjusting our treatments, during the weeks and days immediately preceding their death. This is the opposite of what should be prioritized when a person is known to be nearing the end of their life without the hope of getting well.

I want this to change. People who choose to do the work of caring for the gravely ill must concentrate on monitoring and responding to changes in their vital signs, administering their medications, examining all of their physical systems, coordinating their various tests and procedures, bathing them and cleaning up their bodily messes, dressing their wounds, keeping them comfortable and communicating with their families.

I don't think that we should also have to deal with feeling that our work is morally questionable and, at times, reprehensible.
Americans have a lot of work to do in developing a more sensible, fairer and less wasteful health-care system. That work needs to include taking a hard look at the conditions of patients whose lives may end in intensive care, both at the level of the entire health-care system and at the level of the individual - our wishes for ourselves and our family members whose health is failing or has already failed.
Our goal is to help these people, and assuming that prolonging their lives for the longest time possible is the only way to do this is a foolish and harmful mistake.

http://www.news.com.au/finance/work/diary-of-an-intensive-care-nurse/story-fnkgbb6w-1226786372897

I read this interesting article the other day on the subject and it was certainly an eye opener.

 

[LeVeL]

From a strictly personal and moral perspective, if the person has no chance of coming back, they should be taken off life support. That said, if the unborn child is healthy, then it should be up to the parent what to do, shouldn't it?

 

[Cobol74]

No, it is a viable possible life and should be brought to full term if at all possible. Just because the father now does not fancy paying for its upkeep is no reason to kill the photos. Normally I'd support a Womans right to choose to have the baby or not (Up to 28 weeks - we can argue about that time line) but as she is on life support she can not express herself (given that the legal documents have not been drafted) we must assume that she wanted the child and it should be born.

 

[LeVeL]

If one parent is physically and mentally unable to make that choice, shouldn't it be up to the other parent now?

 

[Spectre]

If one parent is physically and mentally unable to make that choice, shouldn't it be up to the other parent now?

When in doubt, one should err on the side of life. (When not in doubt is another matter.)

The problem here is that they had plenty of opportunity and knowledge to file DNR or No Heroic Measures paperwork and apparently she didn't. Therefore, legally, one MUST assume that she wanted to be maintained on support until and unless the judges decide otherwise. After all, there are many times when a spouse will agree with their partner in the interest of domestic tranquility yet disagree in private and refuse to follow through so they can claim they 'forgot.'

 

[awdrifter]

http://www.cnn.com/2014/01/06/health/jahi-mcmath-girl-brain-dead/

I just read about this yesterday. Apparently her mother got the court's permission to move her body out of the hospital. She's not saying where the body was moved to. Obviously the child is dead, they are just keeping her bodily functions going, but I can also see why the mother doesn't want to believe that fact, looking at her child still breathing and has a heartbeat.

As for the side question, I'm not an organ donor, but I will instruct my family to allow my organs to be donated after they declare me dead. Call me paranoid, but I don't want them to not save me just to harvest my organs.

 

[Viper007Bond]

As for the side question, I'm not an organ donor, but I will instruct my family to allow my organs to be donated after they declare me dead. Call me paranoid, but I don't want them to not save me just to harvest my organs.

Okay, I will -- you're paranoid.

 

[Misrabelle]

I know none of my family would want to be kept on life support if the doctors said there was no hope. We made the decision to turn off my Grandmother's life support after she had a heart attack 13 years ago, because we knew that was what she would have wanted. It wasn't a hard decision for us.

We're also all registered as organ donors. My mum got a kidney transplant when I was 12. We believe that it was from a young man killed in a motorbike accident in South Australia a day earlier.

Mum's cousin has a transplanted liver due to damage from haemochromatosis, and I have a friend who has two transplanted corneas, so I know how important it is. My uncle participates every year in the Kidney Kar Rally to raise money for charity, even though his own health is starting to fail. https://KKR2014.everydayhero.com/au/dirty-1s <-- that's his sponsorship page for 2014.

Sadly in Australia, we have one of the lowest rates of organ donation. Even if you consent to it on the Organ Donation Register, the doctors ask your family for final consent at the time of your death, meaning your wishes can be over-ruled by family who are grieving, and may not be able to consider that your donation could save up to a dozen lives.

I think it should be an opt-out scheme. If you feel that strongly about not donating, or it's against your religious/spiritual beliefs, then by all means opt out. It would put people on a more level playing field, especially those who are worried that doctors might not work so hard to save them because of the shortage of organs available. There are currently 1800+ people on the transplant waiting list here.
The average waiting time ranges from one year for a liver transplant to almost four years for a kidney transplant. At least one person dies every week while on the transplantation waiting list.
In 2010, 309 people donated their organs and gave 799 individuals a second chance at life.



One the morning of my mum's surgery, as she was taken to theatre, the nurse had to get the kidney from the fridge in it's styrofoam box, and put it on the trolley with her.
On closer inspection they realised it wasn't marked as a human organ, wasn't sealed as they would have expected, and that the box actually contained a staff member's ham sandwich. Oops.

 

[awdrifter]

Okay, I will -- you're paranoid.

There are documented cases where organ donors declared dead then they were able to recover before their organs got harvested. I wouldn't say the doctors did it deliberately in this case, but it certainly give them incentive to hastily declare you're dead even when you have a fighting chance if they know ahead of time you're an organ donor.

 

[wooflepoof]

No, it is a viable possible life and should be brought to full term if at all possible. Just because the father now does not fancy paying for its upkeep is no reason to kill the photos. Normally I'd support a Womans right to choose to have the baby or not (Up to 28 weeks - we can argue about that time line) but as she is on life support she can not express herself (given that the legal documents have not been drafted) we must assume that she wanted the child and it should be born.

Yes, It's her body and she asked to not be on life support. Both her and her husband (aka the next of kin) were/are paramedics; they know exactly what that entails. Who are you to get to decide you want to keep her body alive as an expensive incubator against her final wishes? The fetus, and no-one else else for that matter has the right to live at another's expense, and I'm including keeping her body alive against her final wishes part of that.

 

[argatoga]

I work around many in the medical field. One thing I've noticed is that nurses and doctors tend to be quite fit. Being around the sick seems to have the effect of "this is what can happen to me".

 

[Interrobang]

I work around many in the medical field. One thing I've noticed is that nurses and doctors tend to be quite fit. Being around the sick seems to have the effect of "this is what can happen to me".

That?s different here ... doctors aside, where most are really in great shape, even the older ones - nurses on the other hand, not so much. The young ones, yes. But once they get a bit older, they seem quite "average" when we?re talking about fitness ... (don?t mean to disrespect anyone, just my observation).

My conclusion has always been that it?s more salary related in general. People making more money tend to live healthier than those who make less.

 

[Spectre]

Yes, It's her body and she asked to not be on life support. Both her and her husband (aka the next of kin) were/are paramedics; they know exactly what that entails. Who are you to get to decide you want to keep her body alive as an expensive incubator against her final wishes? The fetus, and no-one else else for that matter has the right to live at another's expense, and I'm including keeping her body alive against her final wishes part of that.

Except we *don't* know for sure what she wanted. Since they were both paramedics, they knew that they were required to file living wills or have signed DNRs on hand to legally express their wishes. They had plenty of time to file or create either and she didn't - which can reasonably lead one to believe that she might not have actually agreed with her spouse and was just humoring him in their discussions.

 

[wooflepoof]

Yeah....very probably the husband isn't lying but everyone is just caught up about this fetus. I hope he wins this case and no longer has to be tormented by this B.S.

 

[Spectre]

Yeah....very probably the husband isn't lying but everyone is just caught up about this fetus. I hope he wins this case and no longer has to be tormented by this B.S.

I didn't say he was lying at all. I'm sure when they discussed it she said she agreed with him. However, she knew she had to create the paperwork (a matter of just a few minutes) to make her wishes known and she didn't do that despite many opportunities to do so. That generates more than reasonable doubt that termination was her intent.

If she had had a DNR, NHM (no heroic measures) or other such no-artificial-support document, we wouldn't be having this discussion. Not even in so-called 'Bible Belt' Texas - her wishes would be honored as she had clearly and legally stated them in that case. As is, we *don't* have clear evidence, only he-said-she-said testimony. In such cases, the system (correctly, IMHO) should err towards life barring clear and incontrovertible evidence of her wishes to the contrary. To do otherwise is one hell of a slippery slope.

 

[equiraptor]

If she had had a DNR, NHM (no heroic measures) or other such no-artificial-support document, we wouldn't be having this discussion. Not even in so-called 'Bible Belt' Texas - her wishes would be honored as she had clearly and legally stated them in that case.

Are you sure about that? From what I've been able to find, if a woman is pregnant, the law states her DNR would be irrelevant.

Please see: http://www.statutes.legis.state.tx.us/Docs/HS/htm/HS.166.htm. This quote is from the portion of the law that sets the DNR language:

I understand that under Texas law this directive has no effect if I have been diagnosed as pregnant.

From what I can see, and from what I can find to confirm with Google, this means if a woman is pregnant, is injured in a way that may require life saving measures, has a DNR, and is in Texas, her DNR is irrelevant.