Memo:

[Veneficus]

Sorry,

rant on...

If the ICU will not take your patient and you determined "she needs a vent" please remember that one of the admission criteria is "potentially reversable."

Please recall palliative care principles and do not try to "ICU" them up yourself on your ward and then complain about anesthesia...

Thank you.

(I swear, is letting a terminal patient die really that hard?)

Rant off.

 

[JakeEMTP]

Not all patients who "need a vent are terminal.

Any DNR patient can also be placed on a ventilator if deemed to be a reversible situation.

All patients (or people in general) are terminal.

You also have to consider the families wishes.

If the patient is already with a "terminal" illness this should not be an issue.

If you are just wanting to make the patient go away for your convenience then that brings into the reasons why 2 physicians are usually required in these cases or why an Ethics committee and peer oversight boards are active.

 

[VFlutter]

(I swear, is letting a terminal patient die really that hard?)

For a lot of people (both family and healthcare providers) it really is hard. There are any number of reasons why.

Maybe when people spend half their life going to school to learn how to "save people" it makes it hard to let them go, to admit defeat. They want to know it wasn't not all for nothing.

It is my opinion that we keep terminal patients around too long for our own selfish reasons. Respecting and valuing life means recognizing there is a time to let it go not the fairlyland notion that keeping someone alive at all costs is the same as respecting life.

 

[Veneficus]

For a lot of people (both family and healthcare providers) it really is hard. There are any number of reasons why.

Maybe when people spend half their life going to school to learn how to "save people" it makes it hard to let them go, to admit defeat. They want to know it wasn't not all for nothing.

It is my opinion that we keep terminal patients around too long for our own selfish reasons. Respecting and valuing life means recognizing there is a time to let it go not the fairlyland notion that keeping someone alive at all costs is the same as respecting life.

I think this was a simple case of trying to turf the pt to the ICU.

 

[VFlutter]

I think this was a simple case of trying to turf the pt to the ICU.

Well in that case rant away...

 

[JakeEMTP]

I think this was a simple case of trying to turf the pt to the ICU.

Without knowing any details, no one can side with you. Just not wanting to admit another patient is reason enough for some and turfing the patient to pallative care seems easy. Actually it is not always that easy. The physicians must be properly consulted since "pallative services" is not a call for STAT. They discuss with the family and the patient if possible a plan of care. Sometimes outside services may also need to be considered if the patient is not going to die quickly.

In the meantime, immediate care must be considered while the pissing contests continue and the "I don't want another patient" bullcrap without taking anything else into consideration. Poor attitudes bring on poor patient care. The patient suffers by being pulled from one service to another and left in limbo while egos rant.

 

[VFlutter]

When ICU beds are limited then the CCP has every right to deny turfs that should not be there. Why admit a terminal lung CA patient which could potentially result in a more viable patient being kept on a floor while they try to shuffle for a bed in the ICU?

This can cause a huge problem on regular floors when a should be ICU patient is left waiting. It eats up resources on the floor and results in poor quality care for the nurse's other patients.

 

[JakeEMTP]

When ICU beds are limited then the CCP has every right to deny turfs that should not be there. Why admit a terminal lung CA patient which could potentially result in a more viable patient being kept on a floor while they try to shuffle for a bed in the ICU?

This can cause a huge problem on regular floors when a should be ICU patient is left waiting. It eats up resources on the floor and results in poor quality care for the nurse's other patients.

It depends upon the reason for the ventilator. Someone with a lung CA may not die today or even 3 years from today. If they had a hospital caused fluid overload, do you not treat?

You are going to find these decisions are not as easy as you think. To allow a patient who might have many more months or years left with their family die is not good care. To turf a patient to pallative just in case you get another admission is also not acceptable. That is like EMS saying they don't want to take a routine call because something more exciting might happen in the next 24 hours.

If this was your loved one like maybe your wife who has breast cancer which may end up being terminal. Would you shorten your time with her just because it is an inconvenience?

If somebody "needs a ventilator" that means "somebody" did not have a talk with the patient or the family about the "terminal" part.

Some doctor may still be actively treating this patient for this "terminal" illness and may not have seen it reasonable to request end of life protocols to be placed.

Again without knowing all the details, it is hard to just not know the issues surrounding the patient and why now all of a sudden the patient must be put into pallative care if there was not even as much as a DNI order. Was this a line placement or some surgery for comfort which might take a little while for sedation to wear off?

 

[VFlutter]

It depends upon the reason for the ventilator. Someone with a lung CA may not die today or even 3 years from today. If they had a hospital caused fluid overload, do you not treat?

You are going to find these decisions are not as easy as you think. To allow a patient who might have many more months or years left with their family die is not good care. To turf a patient to pallative just in case you get another admission is also not acceptable. That is like EMS saying they don't want to take a routine call because something more exciting might happen in the next 24 hours.

If this was your loved one like maybe your wife who has breast cancer which may end up being terminal. Would you shorten your time with her just because it is an inconvenience?

I think that would fall under the "potentially reversible" issue. Fluid overload would take priority over the lung CA.

Like this is all situational and dependent on various factors which make situations like this very difficult.

 

[JakeEMTP]

I have seen cases where one day the doctors are going all out giving the family lots of hope and then the next day a more exciting patient is awaiting transfer so it is a quick change in attitude and the patient is made comfort care with a very confused family kicked out of the unit. As the bedside RN, what BS are you going to tell the family when you know the real reason behind the push?

 

[VFlutter]

I have seen cases where one day the doctors are going all out giving the family lots of hope and then the next day a more exciting patient is awaiting transfer so it is a quick change in attitude and the patient is made comfort care with a very confused family kicked out of the unit. As the bedside RN, what BS are you going to tell the family when you know the real reason behind the push?

That is a very difficult situation for a nurse to be in but unfortunately it does happen. However as a nurse it is my responsibility to be an advocate for that patient regardless of my personal feelings on that matter. This would be a situation that would probably require the house supervisor, social work, attending, etc to get involved. But there can be middle ground between ICU and comfort measures.

That being said, I am not there to do the dirty work for the physician. If he wants to make that call then he needs to have that discussion with the family and be very clear with them. If I feel that they are being mislead then I may step in but the responsibility should not fall solely on the nurse.

 

[Veneficus]

When ICU beds are limited then the CCP has every right to deny turfs that should not be there. Why admit a terminal lung CA patient which could potentially result in a more viable patient being kept on a floor while they try to shuffle for a bed in the ICU?

This can cause a huge problem on regular floors when a should be ICU patient is left waiting. It eats up resources on the floor and results in poor quality care for the nurse's other patients.

How did you know it was a lung Ca pt? That is amazing.

Anyway...

When I left ICU admit was denied and a strongly suspect that the pt will be discharged to the ECU by morning.

 

[NomadicMedic]

While I appreciate this discussion, it's not an EMS discussion.

 

[Veneficus]

That is a very difficult situation for a nurse to be in but unfortunately it does happen. However as a nurse it is my responsibility to be an advocate for that patient regardless of my personal feelings on that matter. This would be a situation that would probably require the house supervisor, social work, attending, etc to get involved. But there can be middle ground between ICU and comfort measures.

That being said, I am not there to do the dirty work for the physician. If he wants to make that call then he needs to have that discussion with the family and be very clear with them. If I feel that they are being mislead then I may step in but the responsibility should not fall solely on the nurse.

I strongly advocate that the nurse should never be in that position.

It is the sole responsibility of the physician and if said physician is untrue to her responsibility, it should be sent up the chain immediately.

It's a personal responsibility thing. When you make the call you have responsibility.

Don't get me started on that...

 

[Veneficus]

While I appreciate this discussion, it's not an EMS discussion.

That is why I put it in advanced medical

I was debating on the directionless thread.

I was pissed about it, sorry.

Patients die. Getting mad and talking bad about the ICU because a they will not do the paperwork and deal with the family for an actively dying cancer patient is not what the unit is for and sometimes the ward doctors need to step up and do their job.

 

[JakeEMTP]

Patients die. Getting mad and talking bad about the ICU because a they will not do the paperwork and deal with the family for an actively dying cancer patient is not what the unit is for and sometimes the ward doctors need to step up and do their job.

Cancer is not always a death sentence and there are other reasons for a ventilator. Sometimes doctors also have to get over their stigma about certain patients and treat. Some just have to hear the word cancer and immediately write the patient off before hearing the rest of the story. Having cancer does not always make them a second rate patient not deserving of a higher level of care.

To get accepted to a ward a patient may have to have all level of care decreased which includes pain management until a pallative protocol is in place. This is also not fair to a patient or their family.

If the patient's terminal condition had not been addressed by the primary or the specialists with a predetermined code status, the patient should also not just be dumped to a ward. A ward would also not be an appropriate place for this patient if they are going to be pallative care. Some arrangement should be made to put this patient into a private or at the very least a semi-private room if end of life protcol is initiated.

 

[Smash]

While I appreciate this discussion, it's not an EMS discussion.

I disagree. I regularly make decisions regarding the appropriateness of the interventions I can carry out, as opposed to what I should carry out. What I choose to do in the field will have a run on effect in the hospital, setting in play a course of action that may or may not be a sensible one.
I turn up to the Aged Containment Facility for the liver Ca patient with mets in the lungs, spine and left big toe who is bed bound, cachectic, non-communicative following multiple strokes and who now presents with aspiration pneumonitis, hypoxia and decreased conscious state and no signed NFR.

I can intubate them and put them on a vent and so on. Or I can provide some basic care, make them comfortable, have a discussion with the family, and if need be, transport them to hospital for the doctors to continue that discussion and palliate if that is the decision reached.

This sort of scenario is something that I come across in various iterations pretty much every week. As part of the health system I have a responsibility to consider not just an individual patient, but the ability of the system as a whole to commit the resources to that patient.

 

[VFlutter]

I can intubate them and put them on a vent and so on. Or I can provide some basic care, make them comfortable, have a discussion with the family, and if need be, transport them to hospital for the doctors to continue that discussion and palliate if that is the decision reached.

That is an important consideration that I wish more people actually considered.

In my experience it is much harder for a family to decide to extubate a patient then it is for them to make the decision to not intubate in the first place. Once it's done it makes for a very difficult decision.

 

[JakeEMTP]

That is an important consideration that I wish more people actually considered.

In my experience it is much harder for a family to decide to extubate a patient then it is for them to make the decision to not intubate in the first place. Once it's done it makes for a very difficult decision.

True. And if the patient can get to the hospital comfortably with only minimal interventions, I'm all for that.

The scenario Smash gave was in a controlled environment with what seemed to be an obvious end of life presentation. Many won't be and some patients look really sick but will live for many more months or even years. HIV/AIDS has taught us alot about this with those who have turned around and have gone on to live for several years even with the AIDS dx.

But the discussion should be initiated by the primary physician and not a med resident who happens to have that rotation for the day or the Paramedic who is seeing the patient for the first time and is annoyed by being awakened on a 24 or 48 hour shift. Unless the patient is very end stage with hospice or in some facility, you might come across as callous since they know you don't know anything about their loved one

Unfortunately there are also some patients and their families who aren't given the inevitable straight on because of the fragmentation in American health care for the uninsured or those who might be on a state or Federal insurance. If a patient is not in a system like Kaiser which has a great network for patient information, it is hard for an ED doctor to obtain all the records and make a truly informed decision.

 

[Veneficus]

In closing

I am reminded of The Wizard of OZ:

Barrister
Is morally, ethic'lly
Father No.1
Spiritually, physically
Father No. 2
Positively, absolutely
Munchkins
Undeniably and reliably Dead
Coroner
As Coroner I must aver, I thoroughly examined her.
And she's not only merely dead, she's really most sincerely dead.