...are the ones that make the biggest difference

11.08.2005

The End of Life Debate: New Clarity & Confusion

As a little bit of background info, my facility specializes in long-term acute care for patients with significant complications. Many are on ventilators and we try to ween them off the machine because there are no nursing homes in this area that will accept patients on the vent. If they do not redevelop their ability to breathe on their own, they have very few options for continuing care. We have many patients with renal failure, diabetes related amputations or circulation problems and wounds. Wounds are probably the 2nd biggest reason our patients come to us, most developing from simple bedsores. What starts as a small little breakdown in the skin can quickly develop into a complete degradation of the skin.* This opens the person up to some bad infections and can exacerbate other conditions.

Since I started working at the hospital we've had several people die. Some of these deaths were expected; the patient's condition was so severe that their chances of survival were slim. One woman had a horrible wound on her leg that had developed from a bed sore and resulted in a systemic infection that left her in constant agony. Her skin was degrading and every movement was torture, so in many ways, her death was a blessing. There have been at least 2 cases wherein the family decided to "pull the plug." Contrary to what you tend to see in the movies or on TV, these "termainal weans" are generally not very quick. It can take hours, or even days, for the person's breathing to eventually stop. There was even one person who was perfectly conscious who decided to be removed from the vent - they lingered for several days before finally passing. We just had a person die yesterday evening whose death took me by surprise. When last I saw him, he seemed to be improving so it caught me off guard when his room was empty last night when I came in for work.

So far, this experience has brought both new clarity and new confusion for me as I think about end of life issues. In seeing the suffering of that woman with the wound & infection, I can see why people would think that alleviating that suffering through death (even high doses of narcotics did not appear to be helping in this poor woman's case) is a good option to consider, particularly if they have chosen it, either through a conscious decision at the time or through an advanced directive. I can even see where people could think its a good idea to eliminate their suffering even if such a patient has made their intentions clear. No one wants to see another person suffer needlessly and if pain management techniques aren't working, as they frequently don't, then the only remaining option is taking their life. Of course, one could argue that there is a profound difference between eliminating life support and actively euthanizing someone, and I agree that there is. However, I have noticed among some of my coworkers the intent of using terminal weans as euthanization - the person is in pain, there is very little chance of recovery or improvement, so why not just get it over with? They even berate the family, behind their backs of course, for not making the decision any sooner in the process. Case in Point: Last night, we (me and a couple of nurses) were discussing a patient who has been in our facility for a while - he is not only not improving, he's starting to slide a bit. But if this is the beginning of the end, its going to take a long time for him to die. One of the nurses opined that the "best thing for him would be to die." I pointed out that the man is alert & oriented. She basically said "yeah, that's rough." Here she is talking about a man, a human being made in the image of God, as if his life is worth absolutely nothing. Is his life very meaningful right now? No, its clearly not and he is just as clearly being a "drain on society" by gobbling up the resources necessary for his care, but does that mean that he should just die?! I'll grant that her view is not representative of all the nurses on staff, but its not uncommon.

It is precisely this compassionate impulse that makes clear and careful thinking about these end of life issues so incredibly important. When things become frought with emotion, or in some instances, a complete lack thereof, our feelings can easily override good moral thinking. We can lose our path quickly and easily. This is where the new clarity is coming into focus for me; we absolutely have to hold the line on these issues because, quite frankly, most of use aren't equipped for the hard thinking they require. And the confusion is that I know I'm not equipped for that yet and certainly am not in a position where I can influence any policy on this matter. Over the course of my education, I'm sure this is going to be something I need to learn a great deal more about.

* If you have family in the hospital for an extended period, probably one of the best things you can do is to make sure your loved one is getting turned at least every 2 hours.

5 comments:

Jeff Wright said...

Nathan,

I haven't been by in a while. You've got some intriguing posts up.

Anyway, on this issue - I'm a lot more comfortable with the process when the individual has stated their will on the issue.

Where I'm struggling is whether or not they should have the final decision on when their life ends. My thinking goes like this: "We don't determine when or even if we will have life, how then do we determine if we have the right to end something that was never under our control anyway."

Thinking through it with you...

The Scrivener said...

Reminds me of our old discussion back here:

http://xanthikos.blogspot.com/2005/03/engineered-immortality.html

Nathan said...

Jeff -

Ideally, everyone would leave clear records of their own wishes as it regards life support and extraordinary measures but its far too uncommon. The families are the ones who are forced to decide in most cases, and it goes from the extremes of those who are unwilling to give up no matter what they cost or duration of care, and those who wish their loved one had not lived through the initial cause of their condition and just want them to die. Emotion rules both of them.

I'm with you; I'm not sure our lives are really our own and even leaving advanced directives gives me a certain feeling of unsettledness.

Doug -

Thanks for reminding me of that discussion. I think it raises the same kind of questions, the only difference being a quality of life issue. If we truly could engineer immortality, would we do it for someone in a coma or for someone who would need to be on a ventilator for the rest of that "immortality"?

The Scrivener said...

Yes, you're right. My wife and I argue about quality of life issues and advance directives whenever something like this comes up in the media. She doesn't want to be kept alive artificially if she is unconscious and has to be kept alive through a feeding tube, with no medical hope of recovery. As her husband, I'm not sure I can promise to carry out her desire in that situation. I'm honestly just not sure how to see the issue or where to draw lines in these kinds of cases.

Nathan said...

The only problem with that is we really have a hard time determining if there really is "no medical hope of recovery." And what is recovery? Back to 100%? 75%? Besides, conditions can change pretty rapidly. We had one woman that seemed like she had already been knocking for a while was just waiting for death to get the locks figured out, but made a strong turn-around by the next morning.