scigirl

case,

I enjoyed reading your scenarios - in fact I've used a similar contrast in a paper I wrote on euthanasia for medical ethics class. If my sister (young healthy teen) wanted to die, how would we treat her, versus an aged grandmother who expressed the same wishes?

scigirl

Dr Rick

Whoa, nurse; there's a distinct difference between euthanasia, which is actively killing someone, resuscitation, which is not letting someone die who otherwise would immediately, and support, which is prolonging life through intervention

Even the Catholic church sees a distinction

Christ Bioeth 1997 Dec;3(3):188-203

Decisions at the end of life: Catholic tradition.

Donovan GK.

"Medical decisions regarding end-of-life care have undergone significant changes in recent decades, driven by changes in both medicine and society. Catholic tradition in medical ethics offers clear guidance in many issues, and a moral framework accessible to those who do not share the same faith as well as to members of its faith community. In some areas, a Catholic perspective can be seen clearly and confidently, such as in teachings on the permissibility of suicide and euthanasia. In others, such as withdrawal of nutrition and hydration, the Church does not yet speak with one voice and has not closed out the discussion. Yet, it is not in the teaching on individual issues that a Catholic moral tradition offers the most help and comfort, but in its account of what it means to lead a life in Christ, and to prepare for a Christian death. As in the problem of pain and suffering, it is the spiritual support more than the ethical guidance that helps both patients and physicians bear the unbearable and fathom the unfathomable."

I would be very hesitant to direct the resuscitation of a terminally-ill person. The probability of such a person surviving to discharge from the hospital is negligible. More than likely, that person will die during their hospital stay after undergoing a prolonged and probably painful series of interventions.

Most people don't recognize the futility in attempting to resuscitate a terminally-ill person; when they do, they overwhelmingly choose not to be resuscitated under those circumstances:


NEJM Volume 330:545-549 February 24, 1994 Number 8

The Influence of the Probability of Survival on Patients' Preferences Regarding Cardiopulmonary Resuscitation

Donald J. Murphy, David Burrows, Sara Santilli, Anne W. Kemp, Scott Tenner, Barbara Kreling, and Joan Teno

"Studies suggest that a majority of elderly patients would want to undergo cardiopulmonary resuscitation (CPR) if they had a cardiac arrest. Yet few studies have examined their preferences after clinicians have informed them about the outcomes of CPR.

To study older patients' preferences regarding CPR, we interviewed as many ambulatory patients as possible in one geriatrics practice in Denver from August 1, 1991, through July 31, 1992.

A total of 371 patients at least 60 years of age were eligible; 287 completed the interview (mean age, 77 years; range, 60 to 99). When asked about their wishes if they had cardiac arrest during an acute illness, 41 percent opted for CPR before learning the probability of survival to discharge. After learning the probability of survival (10 to 17 percent), 22 percent opted for CPR. Only 6 percent of patients 86 years of age or older opted for CPR under these conditions. When asked about a chronic illness in which the life expectancy was less than one year, 11 percent of the 287 patients opted for CPR before learning the probability of survival to discharge. After learning the probability of survival (0 to 5 percent), 5 percent said they would want CPR.

Older patients readily understand prognostic information, which influences their preferences with respect to CPR. Most do not want to undergo CPR once a clinician explains the probability of survival after the procedure."

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As an example, I took one of my patients to see her physician recently. As she did not want to take a particular medication anylonger which had serious side effects, the physician told her " I want you to get a DNR order".... what gave the right to that doctor to pressure my patient into getting an order which will keep her from being ressuscitated?

That depends in large part on your patient. If she is terminally-ill, he may want to avoid inflicting futile and painful interventions on her. I disagree with him charging you with getting the order, though; he should have talked with her himself and explained his reasoning for wanting such a directive and then asked her what she wanted.

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I feel and fear that we may see an increase in pressuring terminal patients out of life support measures as the cost of medical care for such individuals is so high.

That may be appropriate in an era of sky-rocketing health care costs; resuscitating a terminally-ill person isn't usually just futile; it's damn expensive. That money could be better spent on vaccinations and prenatal care, where it could actually do some good.

Once again, there needs to be a distinction made between euthanasia, non-resuscitation, and withholding life-support, and I fear you are using the terms interchangeably.

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IMO the withdrawal of life support measures is justified only when the patient has no brain activity and is artificialy maintained "alive", that is on a ventilator.

I favor withholding life-support if that is what the patient wants and the prognosis is hopeless. That is not the same as euthanasia.

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The Clearwater case in Fla. is alarming in the sense that the patient was evaluated as having no chance of any recovery from the damages to her brain. She breathes on her own, is wide awake but is indeed severely mentaly handicaped. However she does have some cognition ( mostly sensorial). So do we have a breathing dead individual in her case? no.... But the court case was based on her no chance to recovery. Those medical reports are what prompted the judge to order the withdrawal of her G tube.

Not exactly; the judge based his decision on the evidence and testimonies that the patient would not want to be artificially supported under her current circumstances. If there was compelling evidence that she wanted to be maintained in her current state, the judge would have ruled differently. The whole case has centered on what the woman would want if she could speak for herself, not on her lack of fitness.

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I believe that a fully mentaly fit terminal patient has the right to ask for euthanasia granted he has recieved proper and informed counseling. But for the mentaly incapacitated patient who may not even be considered terminal, noone has the right to assume that they wish to die in absence of a living will.

The courts do have the right and responsibility to make those determinations in the absence of prior explicit directives from the patient.

Let me remind you once again that there is a distinction to be made between euthanasia and withholding artificial support.

Rick

Sabine Grant

Thanks for your reply Rick.....
are you evaluating as a physician that the woman in Fla. is then a candidate for euthanasia ( as the court declared that she would beyong the reasonable doubt want to die) or are we dealing with withdrawing life support measures?
The press and TV releases we recieved here localy indicated that the judgement was mostly based on the extensive brain damages which do not indicate any chance of recovery. In other words, until then she was not considered a terminal patient. She became terminal as her brain injuries were evaluated as no possible recovery. sort of like... she might as well be physicaly dead as her brain is never going to recover its full capacity.
Are you sure that is a solid and safe criteria to establish the validity of a court decision.
How did the case come about? one one hand hubby who wants to move on with his life and feels that his wife would not want to live in such conditions. I guess it would look sort of "bad" to divorce her. On the other hand, her parents who treat her as if she can percieve their care and love and respond. They probably have a hard time letting go of their beloved daughter. Mom talks to her, gets her attention with a colorful balloon which she follows with her eyes.... gosh, Rick... neither you or I would want to be in the judge's shoes... would we?

She is life supported in the sense that she is tube fed and would starve and dehydrate otherwise. So was that court order a "gallant way" to transpose withdrawing life support measures by claiming beyong the reasonable doubt that the woman would not want to live in such conditions and make it " euthanasia"?. So it is more acceptable. It is then a measure of mercy.

The fact remains that we do not know for sure what the patient wants right now. There is no way we can establish if she can feel any sense of the care and love mom and dad are giving her.

I could assume all kinds of scenarios where I would not want to live and be maintained by life support measures. But can I evaluate the degree of worth I could still represent to the one who would care for me and communicate to me with a touch of his hand how much I am still loved and wanted?

What if she has awareness of that touch? would she still want to die?
oh by the way... I am an HHA.. hoping to complete RN program in 2 years. For now I need more experience in Home Health Care and hospice.

About DNR orders, I find them posted mostly in my non terminaly ill patients 'homes. That is scary to me. Most of them are over 70 and somehow were convinced that being CPRed does not justify 10 more years of enjoying your grand children etc... A touch of " Soylent Green" where older folks volunteer to die......gives me a chill down my spine.

I am not letting go off my bone....am I ?

Dr Rick

The latter; euthanasia or killing someone is illegal in Florida, but withdrawing life-support is not.

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The press and TV releases we recieved here localy indicated that the judgement was mostly based on the extensive brain damages which do not indicate any chance of recovery. In other words, until then she was not considered a terminal patient. She became terminal as her brain injuries were evaluated as no possible recovery. sort of like... she might as well be physicaly dead as her brain is never going to recover its full capacity.

The press has a funny way of distorting complex issues. At the heart of the controversy is the question of what the lady would want for herself under these circumstances. Her husband's attorneys have successfully argued that she would not want to be subjected to artificial interventions or life-support under these conditions. The judge did not rule that she may be euthanized or killed, an active intervention, but that life support may be withdrawn, a passive intervention, because the evidence shows that is what she would want done. Whether she is terminally-ill or not isn't really germane; she is in fact not terminally-ill and could conceivably live for decades in her current state. At issue is her wishes; she can no longer express them, so the court has done it for her.

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Are you sure that is a solid and safe criteria to establish the validity of a court decision.

No, I'm not "sure," but I'm comfortable that the court is acting in accordance wsith the implicit wishes of the patient.

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How did the case come about? one one hand hubby who wants to move on with his life and feels that his wife would not want to live in such conditions. I guess it would look sort of "bad" to divorce her. On the other hand, her parents who treat her as if she can percieve their care and love and respond. They probably have a hard time letting go of their beloved daughter. Mom talks to her, gets her attention with a colorful balloon which she follows with her eyes.... gosh, Rick... neither you or I would want to be in the judge's shoes... would we?

I'm a gastroenterologist, Sabine; I'm the physician that puts feeding tubes into incapacitated patients. But I won't do it if it's not indicated or if it is clearly against the wishes of the patient.

Certain incapacitated people do warrant such artificial support; stroke victims, severe traumas, and certain ENT or digestive tract cancer patients can benefit from feeding tubes. But most terminally-ill patients do not, and the American College of Physicians has put out a position statement harshly condemning the practice of nutritional support beyond oral supplements in the terminally-ill. That's because the practice often creates complications and does not meaningfully improve the length or quality of life in the terminally-ill. I agree with this position and have talked several terminal patients and their families out of the procedure because it would not have been helpful to them.

But the lady in Clearwater is different; she's not terminal, but permenantly incapacitated and apparently would not want to be kept alive under these circumstances. If that is the case, and the court thinks it is, then I think it would be unethical to act against her wishes.

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She is life supported in the sense that she is tube fed and would starve and dehydrate otherwise. So was that court order a "gallant way" to transpose withdrawing life support measures by claiming beyong the reasonable doubt that the woman would not want to live in such conditions and make it " euthanasia"?.

Withdrawing medical intervention is not euthanasia; indeed, imposing such interventions where it is not wanted is technically a crime: assault.

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So it is more acceptable. It is then a measure of mercy.

Letting someone in a hopeless state die can be a merciful act.

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The fact remains that we do not know for sure what the patient wants right now. There is no way we can establish if she can feel any sense of the care and love mom and dad are giving her. I could assume all kinds of scenarios where I would not want to live and be maintained by life support measures. But can I evaluate the degree of worth I could still represent to the one who would care for me and communicate to me with a touch of his hand how much I am still loved and wanted? What if she has awareness of that touch? would she still want to die?

Your right; we can't be certain what the lady would want, but if the standard to take action was "certitude," you couldn't go to the store to buy a carton of milk (you couldn't be certain that you would return, afterall), much less make any kind of medical decision.

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oh by the way... I am an HHA.. hoping to complete RN program in 2 years. For now I need more experience in Home Health Care and hospice. About DNR orders, I find them posted mostly in my non terminaly ill patients 'homes. That is scary to me. Most of them are over 70 and somehow were convinced that being CPRed does not justify 10 more years of enjoying your grand children etc... A touch of " Soylent Green" where older folks volunteer to die......gives me a chill down my spine. I am not letting go off my bone....am I ?

The cruel, hard fact is that most elderly people that "code" do not have any meaningful chance of survival, so the decison to be a "DNR" seems reasonable to me. When I pass the age of 65, I'll designate myself that way.

Codes can be gruesome events; There are few things that give me the willies more than recalling the sensation of cracking an octenagarian's ribs as I performed chest compressions. Old people just don't survive that kind of trauma well.


Rick

Mad Kally

I was going to mention that earlier Rick, but it kind of makes me sick to remember that feeling of bones breaking. That was from before I was hospice. I don't recall any very old seniors who survived CPR. I can't remember what it's called right now, but once I saw what happens when the ambu bag is filling the skin area on the left side instead of the lung and it keeps swelling up like a balloon. It was so gross and of course the patient died anyway.

Good for you Sabine. Get that RN behind your name and you'll never have to worry about financial insecurity. Jobs? There are too many jobs! RN shortages are even happening in other countries..

Dr Rick

subcutaneous emphysema

Rick

Mad Kally

subcutaneous emphysema

eewwww that's it.

alek0

I don't find the idea of "abuse" of euthanasia particularly disturbing, probably because in such circumstances I would wish to die. I don't see a problem with courts making decisions in cases where patient's wishes are unknown. People to whom such matters are important usually take care that their wishes are known anyway.

I am curious though how is "age discrimination" going to be dealt with since it is definitely there. Not only concerning euthanasia and life support withdrawal, but also other serious issues. For example, why is it so hard, almost impossible, for a child free young adult to get a tubal. I've been trying unsuccessfully to do that since I was 18 till about 25, when I decided there wouldn't be much point in that anymore due to endometriosis damage already done. Why are people so often judged by ther age and not as individuals?

winstonjen

I must say that I disagree.

Say I have diabetes, and I need an insulin injection to survive. If I stop taking these injections, am I merely 'withholding life support'? Or am I commiting suicide, since I fully expect and intend to die?

wade-w

You mentioned in another thread that you consider age when making decisions about admissions to your university. Is that not judging people by their age and not as indiviuals?