End Of Life Issues---The Good The Bad and the Ugly

What would happen if we made the POA spend 24hours with the patient before being eligible to make any decisions related to health care? If someone hasn't been physically with the patient they shouldn't have any weight in what happens.

Preaching to the choir, Viva.

Ditto SuesquatchRN. Doesn't sound the elder centered care,but unfortunately, these unrealistic,medically modeled beliefs have been reinforced by MDs to pts. and families for so long, that it's a long LONG push to turn this whole geriatric ship around. For some positive reinforcement, have you checked out the EDEN ALTERNATIVE? My facility has been certified for 5 yrs., and while the whole thing is an ongoing process, it starts c the elder in the center of care, and radiates outward,involving care providers,family, MD,and on up to the Board of the hospital.If the PERSON in the bed doesn't WANT IT(fluids, meds,PT, supper, whatever) and we've tried our darndest to give them the CARE they deserve,they reserve the right of refusal. We document DOCUMENT document the circumstances,notify appropriate parties,and move on. It's their life.Keep your chin up-we do sacred work.

Quote from SuesquatchRNPreaching to the choir, Viva.

Thankyou for your blog it was beautiful. I know Nursing is the direction I want to take in my life, I am a first semester student.

Amen!I work LTC and I, too, cringe at the things we are supposed to do to these poor souls who want nothing more than to be set free.I am of the thinking, that just because we CAN make people live longer and longer doesn't mean we SHOULD! I see no benefit of living to see 99 if my mind and body are just a shell that houses my being, with no quality of life, I'd rather be in the better place.I promise you, if my family EVER did to me what I see some families do to those they love, (tube feeds, full codes, treat at all costs, force feed meds/food etc) I will come back from the afterlife with a vengance and haunt them to the very end.The hospice nurses who come to my facility are always trying to get me to go work hospice for their company, I have the "knack" they say. Hospice has always been an area i'd love to try.

Great blog - lots of important questions Marla. And yes, I encourage you to look at hospice . . . . it is too bad one of the families isn't ready for hospice yet.One of the things I've found is that people has a false idea about what hospice actually is. We (hospice) need to do more education.steph

When I left work this morning my 94-year old uroseptic/respiratory failure patient looked like this:Vasopressin gttLevophed gttNeo gtt80% FiO2PEEP of 10just about every square inch of skin surface was weeping copiouslydistal extremities cool & dusky from the pressorsHR in 120sBP with those pressors 100/40skin breakdown around her mouth despite repositioning the ETT up to 4x/dayskin breakdown around the Foley & Flexisealunresponsive except to moan and shake when being turned or suctionedI drove home feeling almost ashamed of how I had spent the last 8 hours.

I agree whole heartedly...which is what makes me so mad when people talk about this health care legislation and "Death panels" I haven't read the bill...but the way I understand it, it would simple mean your Dr. needs to have "the talk" with you about what your wishes are....rather than waiting until it's your loved ones who have to decide. A quick "do you a living will?" and would you like information on that ? Is not a great discussion starter when you are already admitting someone who is ill, scared, and trying to remember when did they have their last flu shot, and what year did they have their gallbladder taken out.

This is an issue I hold very near and dear to my heart. Although I have only been a nurse for 1 year now (on med-surg floor) I find myself relating closest to the patients who come to our 3 "hospice suites" on my floor to die. These patients and families evoke in me the kind of compassionate nurse I know I have always wanted to be, and know I have it in me to be, but sometimes am not able to be due to patient load, crazy pt. families, etc. I would love nothing more to get into hospice nursing somehow, but am unsure of how to go that route (most places want nurses with hospice experience...I wonder if my care of dying hospice pts. on my floor would suffice?). At any rate, I applaud all nurses, MDs, families, and pts. who have the understanding and knowledge to accept death as a normal part of life and who work tirelessly to make hospice / palliative care the standard of care for all end-of-life people! I hope we as a society can get this to be the standard as opposed to the exception, although I know we have a long way to go...

I work in oncology and once had an 80-something yo man who came down with some type of cancer. (I can't remember which one.) He ended up in our hospital's ICU with a GI Bleed that turned into DIC. By the time he got to our floor he was hopeful that he could go home to his farm soon. He had been strong and healthy up to this point and had a POA who was not related to him. He stayed on our unit for a few weeks. His blood counts were never right and we kept having to give him blood and platelets. The POA kept insisting on the most aggressive cancer treatment because "My Godfather is precious to me." ALL the doctors adviced against it. They said it would make his life miserable and probably wouldn't even work. But he kept insisting.The patient, in the meantime, kept getting more and more depressed. He wanted to go home and sit on his porch and enjoy his farm. He didn't want to go through chemo and radiation. He was perfectly capable of making his own decisions, but the POA kept butting in, kept throwing his weight around, kept talking about money, and lawyers, etc. It was criminal. I really wonder what ever happened to that man.

Being a nurse yet having taken care of an Alzheimer parent I can see somewhat where people are coming from that I wouldn't have been able to see before. If not for the gentle encouragement of me and the other caretakers...my Mom would have never gotten washed, would have never eaten anything but ice cream (and I KNOW she would have refused any feeding tube), and would never have taken her Alzheimer medicine which totally prevented sundowner's and allowed more then five years with a good quality of life. If she was allowed the choice, my brother and I would have missed out on five wonderful years. I learned early not to call the "washing up" we did in the morning a "bath", to add sugar to foods that she would eat, to forget the typical breakfast/lunch/dinner and work on what she would and wouldn't eat, and to work on ONE pill at a time giving her some food after to make sure she swallowed it (as she hated to take any pills and wouldn't eat anything with them crushed). Refusing hospice for awhile because if agressive measures that wouldn't cause her pain or discomfort were needed we may want to do it...for instance she had kyphoplasty that helped her backpain tremendously. Hospice was finally called four days before she left us from her bed at home as she would have wanted...and even those short days was tremendously helpful with pain control alone. My point is no one actually can tell you what is going on with family dynamics...IMO the best we can do is show the family all that is being done and the quality of life their loved one is living right now. It is up to them to decide once they have all this information.I remember one group of nurses in ICU where I worked that despite hospital policy allowed the family to see the 10th code on a patient that the heart had given out a long time ago. Previously no amount of discussion from different professions helped in their decision process. After seeing the code the patient was quickly placed on hospice by the family.Our jobs as nurses is not to be judgemental but educate, inform and be a patient advocate and yes, this can extend to the family.