Monday, September 20, 2010

How to End a Life

These are the words of Dr. Atul Gawande, a general surgeon and writer.
“Recently, while seeing a patient in an intensive-care unit at my hospital, I stopped to talk with the critical-care physician on duty, someone I’d known since college. “I’m running a warehouse for the dying,” she said bleakly. Out of the ten patients in her unit, she said, only two were likely to leave the hospital for any length of time. More typical was an almost eighty-year-old woman at the end of her life, with irreversible congestive heart failure, who was in the I.C.U. for the second time in three weeks, drugged to oblivion and tubed in most natural orifices and a few artificial ones. Or the seventy-year-old with a cancer that had metastasized to her lungs and bone, and a fungal pneumonia that arises only in the final phase of the illness. She had chosen to forgo treatment, but her oncologist pushed her to change her mind, and she was put on a ventilator and antibiotics. Another woman, in her eighties, with end-stage respiratory and kidney failure, had been in the unit for two weeks. Her husband had died after a long illness, with a feeding tube and a tracheotomy, and she had mentioned that she didn’t want to die that way. But her children couldn’t let her go, and asked to proceed with the placement of various devices: a permanent tracheotomy, a feeding tube, and a dialysis catheter. So now she just lay there tethered to her pumps, drifting in and out of consciousness.”

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This is an excellent article that I would encourage anyone to read. Most nurses are confronted with dying patients and their families. Every day we see patients come into our operating rooms at the last part of their lives. I was very saddened last week to see a 95 year old patient no longer able to take food by mouth, with advanced Alzheimer’s, come in for debridement of pressure ulcers on the backs of both ankles and on her tailbone area. She is in constant pain due to osteoarthritis and has emphysema. Her family has kept her at a full code rather than DNR status and insisted on feeding tube placement. The pressure ulcers are from not being able to move herself in the bed. Even with excellent nursing care, pressure ulcers can eventually occur. Now don’t freak out. I am not advocating euthanizing the elderly. We give our end of life patients loving and respectful care no matter their code status or the attitudes of their family. But where do you stop adding treatments? I don’t know what the answer is.
Dr. Gawande advocates early hospice care in his article as well as educating the patient and family on end of life care EARLY in the disease process. He questions the excessive costs of extraordinary measures to keep terminal patients alive. I would be interested to hear the opinions of those not in the medical field, so I can understand some different perspectives. After years in the ER and surgical areas, jaded is a kind adjective to describe us sometimes. What do you think???

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