Mercy or Murder? Who Decides?

As I have mentioned in the past, whenever I work in Preop Holding, something strange or confusing seems to happen. One night last week it involved a hip repair on a 90 year old. Hip repairs or pinnings are something we see everyday, typically in elderly patients after a fall. However, this particular situation brought some very strong opinions out into the open.

Anyway, a couple hours before the scheduled surgery, I called the patient's floor nurse for a report.  Instead of reciting the usual vital signs and statistics, the nurse stated that she was unable to give me report. She told me that the patient's daughter refused to give consent for the operation and had just left to go home.  The floor nurse explained to me that the patient had advanced Alzheimer's and was therefore unable to give informed consent and all that legality nonsense. 

So, since I've been in Surgical Services awhile now, I immediately understood what was the most pressing concern here. Thus I let the OR charge nurse know the situation, so that the surgeon would not be kept waiting. Surgeons, I have learned through various tirades, really, really do not like to be kept waiting.  So now that I had my priorities straight, I could move on to other things, such as maybe finally getting to pee nine hours into my shift. But that was not to be. The orthopedic surgeon in question, with resident in tow, came storming into the unit, demanding answers that I did not have. I had gotten the daughter's phone number from the floor nurse, so I handed it to him and suggested he call her. Before he made the call, he ranted for a while about how the patient was being sentenced to death by her daughter, the patient would be dead within a week without the surgery, that this was the most ridiculous situation he'd ever encountered in his twenty years as a surgeon, etc, etc. His face beet red with fury, the surgeon stomped out of the room to call the patient's daughter.

The resident, left behind by his leader, was muttering about euthanasia being illegal while he checked his Facebook. I went into the OR office for an update. The OR team for the hip repair was enjoying their unexpected leisure time in the office, along with another team in between cases. All were loudly vocalizing their opinions on the daughter's decision, which had ignited a fiery debate on the meaning of suffering and end of life care.

"It's murder" said one nurse "I heard someone was gonna call the police and have the daughter arrested"
"She just doesn't want her Mom to suffer more" said a scrub tech "we all talk about people being kept alive for too long. The daughter is doing the right thing"
"She'll suffer more if she doesn't get her hip fixed" chimed in the resident, who had gotten lonely and wandered into the office, still looking at his Facebook.
"I'm with the daughter. I wouldn't want to live if I was bedridden with Alzheimer's" asserted the charge nurse, a twenty year OR veteran "I put my dog to sleep when he was eleven years old and needed a second knee replacement. I didn't want him to go through that. Why don't humans get that right?"
"This is not a dog. It's a human being. Hellooo! I think the daughter is no better than a murderer. She's cold" said a scrub tech.
"Check it out" said a nurse "this is how healthcare rationing is going to start. You know...the death panels. The elderly won't be able to get surgery anymore. They'll just have to die"

 At this point I went back to my little area of the hospital and started preparing the charts for the next day...no paperless system here yet! Soon the orthopedic surgeon came back, and the resident stopped playing on his iPhone and started paying attention.  The surgeon explained that he had managed to make the daughter feel guilty enough that she okayed the operation for her Mom. He told me to get the patient downstairs ASAP and "Chop, chop". Yes, he actually said chop, chop.

We sent for the patient. I called the daughter to obtain a telephone consent. When I spoke with her, she impressed me as a caring, kind person. She was friendly and cooperative on the phone. Another nurse and I witnessed the consent. Then the daughter spoke with the anesthesiologist to agree to rescind the DNR order during the surgery. It was done in less than ten minutes. The patient was prepped and whisked off to the OR within twenty.

The patient had been unable to speak, but groaned and lashed out with her arms when I got her vital signs and hooked her up to some fluids. She got extremely agitated when I pulled TED hose onto her nonoperative leg. She did not seem oriented in any way.

I had mixed feelings about the whole situation. It is too rare that a family has actually discussed the patient's wishes before illness either creeps up slowly or slices into their lives with devastating suddenness. I have witnessed these talks only a couple of times, but felt privileged to see them. It takes courage and love to bring this stuff up. It is so much easier to live in denial, not wanting to think about our loved one being weak or ill, much less close to death. Declining a vent or feeding tube strikes me as a very common sense option when a loved one is terminally ill and unaware of their own identity or situation. Declining a hip repair, I'm not as sure. On a 90 year old with advanced dementia, maybe that's reasonable. But love and fear of loss can make it hard to think logically. I don't know what I would do if that were my parent. What would you do?

I'm sure as budgets are cut and healthcare costs continue to rise, money will also become more of an issue in these decisons. Studies have shown that a huge proportion of healthcare dollars are spent on end of life care, often prolonging lives by only days, and not happy days either. I think there are certainly many times that hospice is a better option than aggressive, invasive medicine. Often these patients are vented in the ICU  while their families are hoping the next, newest miracle drug or treatment will fix them. A 90 year old is one matter. What if the dying patient is a child?  It is heartbreaking for all concerned. I know it is incredibly hard to let go, but unfortunately as the money dries up, the healthcare systems may start making that choice for us.

We see patients on a daily basis with tubes in every orifice, decubitus ulcers, and a grim prognosis. We meet families who want everything done, rib fracturing chest compressions, tube feedings, rectal tubes, endless blood and platelet transfusions, every antibiotic under the sun, painful, but futile treatments to add a little more time to a life whose quality has declined to almost nothing. We grumble about how we want DNR tattooed on our bodies and sigh as we carry out the family's wishes.

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.”

Read more http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande?currentPage=2#ixzz0yxLtNH1R
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???