End of life health care

[Brat]

The only solution is to stay out of the hospital!

If you go to the hospital the staff believes that you are there for their best efforts to send you out alive. If palliative care is appropriate use hospice and absolutely tell your family that you are not to leave your abode. Maybe tell them that your will/trust provides for their dis-inheritance it your wishes are not respected.

That doesn't do much for mom's who deliver prematurely.

 

[Khan]

My wife says DNR's are routinely ignored at her hospital...sometimes unintentionally (patient is crashing, lets do something...good...they're alive again...what does the DNR say?) and sometimes the doctor or nurse does it because they want to and feel its the right thing from their perspective.

Good luck...

I feel that at some level there is a total denial of reality.

If we can just keep Granny breathing for another week, we have accomplished something wonderful; even if Granny is a a total vegetable.

 

[Rich_by_the_Bay]

Rich, I honor your efforts but I still think that our culture has a problem with futile treatments. The FL Governor performance is a prime example.

Appreciated and I fully agree. I just don't think that this particular issue is money-driven, for once.

My gut reaction is that it reflects malpractice fears, perhaps understaffing and insufficient time to know the patient's desires til it's too late, some cultural bias, and a defensive posture when there is any ambiguity whatsoever. Families can complicate things despite individually good intentions.

That said, when the patient's wishes are clear and made in a lucid time, that is what is right. Trying to do that in the face of a tearful, distraught spouse/POA who is begging you not to is a moral dilemma that few outside the profession can appreciate. This doctor does not think he is God.

Best defense: get all your ducks in a row: family (all of them), patient, surrogates and medical team in advance; make it explicit at the moment of admission (not when a code is called) and gently but unequivocally insist that the attending physician (not one of the consulting physicians) write the order to that effect. Might not be a bad idea to clarify that even if the impending cause of death is unrelated to the disease of concern, the wishes should be honored. That should work. Leave any hint of ambivalence or family disagreement on the issue and the outcome is anyone's guess.

 

[sgeeeee]

When my mother was losing her struggle with colon cancer, she and my father chose hospice care for the last several weeks of her life. She eventually went into a coma and died a few days later at home. We all knew the decision was the correct one, but it didn't make it any easier to experience. I think my younger brother would have wanted to try any heroics available. He had more trouble dealing with her death than the rest of us. He suffered. If she had been in a hospital where other treatments were available, he would have tried hard to explore those treatments. It would have been difficult to resist him since he was suffering too, and you can't really aleviate that kind of suffering by trying to reason with him.

 

[DangerMouse]

That said, when the patient's wishes are clear and made in a lucid time, that is what is right. Trying to do that in the face of a tearful, distraught spouse/POA who is begging you not to is a moral dilemma that few outside the profession can appreciate. This doctor does not think he is God.

Rich, that is so true. Luckily for us, my Dad was in and out of a hospice for respite care, and while he was still in fairly good condition, they went over what his wishes were. He was quite clear that he was DNR. However, when it came to the crunch, if my mother had of been there at the time he passed, you could guarantee she would have been calling for the crash cart. The stupid thing is it wouldn't have been about keeping him alive because he wanted to be, it would have been because she was only thinking of her needs and wants. Rational was not a word that could be used for my mother at that time (or any other for that matter).

 

[spideyrdpd]

Your discussion making a rational decision about something people are unrational about.

If someones in the Er they havent likely reviewed the DNR or paperwork in the life directives. They are going to work on you . They might stop sooner but they arent going to say. I think this guy might be a dnr.
If your in the room and you code the nurse they will have a copy of the dnr in the chart and we make everyone do an advance life directive.
Ok so now your in the hospital and your bp drops. You dont quite code . They are going to move you to icu. You cant eat . They will likely put you on nutrition via an iv. They may run many tests. Put you on very expensive antibiotics. etc etc. Its not too dificult to run up and big bill before you reach the code blue stage.


Personally I thought that minorities and low wage earners was what skewed our life expectancies. Babies dying and the such ?

 

[Moemg]

Rich,I'm sorry to disagree with you but I do think some of it is about money .The difference in treatment of non-paying patients and ones with good health insurance is staggering .I've seen it time and again in my 39 years of nursing .Also isn't it true that two physicians have to agree the patient is terminal in order to apply the DNR.

 

[Rich_by_the_Bay]

Rich,I'm sorry to disagree with you but I do think some of it is about money .The difference in treatment of non-paying patients and ones with good health insurance is staggering .I've seen it time and again in my 39 years of nursing .Also isn't it true that two physicians have to agree the patient is terminal in order to apply the DNR.

In my state and hospital, you only need 2 physicians to withdraw life support that has already begun, in the absence of a relevent advanced directive, and with consent of the family.


Re: payor source, yes there is a big difference in reimbursement amounts. I am salaried and generally am not even aware of my patients' insurance status. Yet in either case, I have yet to see that play out in terms of applying DNR. Not to sound cynical or insensitive, but in theory you could imagine an extreme where it might be financially advantageous to apply DNR to nonpaying patients to lower your uncompensated work load.

But in the real world that I see, no, DNR and money don't connect. Maybe it's different elsewhere, but not in the 3 states I have practiced in.

 

[Brat]

Ok, I am going to pour gas on this fire, again....

Good old Newt ( ) has an article about how to improve the health care system, "Value-based health care means that providers, health plans and other health care professionals are rewarded--and procedures and products are encouraged and utilized--based upon the true value they bring to the consumer. This means critiquing every aspect of the delivery of care, divining its true value by knowing its cost and quality. This formula works in every other market, and it must be the foundation of health care."

How do you get the consumer of health care to make the hard choices on end of life care if there isn't a substantial co-pay in play?

Maybe hospice care should be offered for minimal cost to the patient, hospital services higher cost.

 

[Nords]

Ok, I am going to pour gas on this fire, again....

Good old Newt ( ) has an article about how to improve the health care system, "Value-based health care means that providers, health plans and other health care professionals are rewarded--and procedures and products are encouraged and utilized--based upon the true value they bring to the consumer.

I think good ol' Newt should test his value-based principles on his parents & kids (and his girlfriends) and let us know how that's working for him...