Tuesday, December 13, 2011

How Long is too Long to Live?

We often say we don't want our loved ones to suffer at the end of their lives, that we hope they just die in their sleep one day rather than have a prolonged illness. Often, in my line of work, I'm faced with hard decisions to make on behalf of a patient who cannot speak for him/herself, but more often than that, I am relying on some family member who just can't let go to direct the care of the patient.

Recently, I went to see a patient in an in-patient rehab facility. If you don't know what that is, it's one step above nursing home rehab. It's the type of rehab facility that treats head injuries and strokes; multi-trauma victims often benefit from the care that's offered there. Unfortunately, some in the community have figured out that some people make it there instead of going to a nursing home after a hip surgery or total knee replacement. This is all fine and dandy until it becomes obvious that no amount of rehab is going to put a 95 year patient on her way to living independently again. 

Mrs. Longevity looked really BAD. Most of the patients that afternoon were up in their wheelchairs, or up in the room, fully dressed, visiting with family members. This one not so much. I had seen her a couple weeks before, and had admitted her to the unit. At that time, she looked OLD, but not BAD. Make sense? This day, she looked dusky and gray; her voice was weak, but she was answering my questions with one word answers appropirately. She admitted to feeling short of breath, and her daughter just happened to mention that she had vomited after lunch, but only after I asked. After doing a physical exam and finding some major issues, I began to address them with the daughter. She mentioned that the swelling was new, that no one was following the fluid restrictions that had been ordered, and that her mother seems to be getting worse instead of better. She had not mentioned any of these concerns to the three specialists who had already been by that day (physiatrist, nephrologist, and pulmonologist). They had all written orders for various treatments like diuretics, chest xrays, EKGs...but no one had addressed the real question - how aggressive are we going to be here  in this rehab unit where we don't have telemetry available, or any type of standard cardiac monitoring. 

You see this patient was a full code status, meaning if her heart stopped, she was to be resuscitated. Her daughter was expecting full treatment and recovery, but the staff appeared to just assume that she was going to die in the rehab unit if she didn't make it out to a nursing home soon. The nurses kept saying to me, "she has been like this since admission." Which I knew was not true, since I was the one who admitted her and did her exam on admission. They documented she could walk 50 feet with a walker (but that was with the assistance of THREE people).

So you see, in a patient who is critically ill, which she definitely was, just being a "DNR" does not mean "Do Not Treat." She was neither, and was not being and could not be appropriately monitored in a rehab facility. The best a rehab facility can do for a critically ill patient would be comfort care, and in those cases, she would never have met criteria for in-patient rehab.

So then the conversation took place with the daughter:
Me: do you think your mother is worse today?
Her: oh, yes, she's been getting worse the last few days.
Me: are you prepared for her to get worse, because from what I see, she is much worse already?
Her: yes, I know...but what do you mean, prepared?
Me: well, if her heart stops, do you want us to do everything we can to keep her alive?
Her: oh, I can't make that decision, you'll have to ask her because she has always said she wanted to be on machines if it came to that.
ME to the patient: Ma'am, you appear to be very tired and sick today...
Patient:( in a very weak voice): yes, I sure am
Me: well, I think we need to be prepared in case something really bad happens, although I don't think it's happening right now, no one has put your wishes on the chart. If your heart stops while you are in rehab, do you want us to do CPR and life support, or just keep you comfortable?
Patient: keep me comfortable.
Daughter starts crying, and says she agrees it's the best choice.
I go out and tell the nurse, who says she has to get a paper signed by the patient, and at that point, she goes back in with the paper to sign, and says "Do you want us to do CPR if your heart stops?"
Patient: YES...(sometimes it's the delivery of the question, sometimes the patient really had no clue what you were asking them).
So at this point, I spoke with the ICU physician who came and talked with the patient and daughter...the patient remained quiet, but the daughter, when presented with the options of comfort care vs full court press, wanted everything done "because I can't send momma to a nursing home, we have to get her better." She was not hearing a word we were saying. (Later, according to the staff, she told one of them "I can't send momma to the nursing home because I can't live without her check.")
So, the patient went to ICU, received a foley, IV, telemetry, xrays, EKGs, and continued her dialysis (yes, she was on dialysis already when she was accepted to this rehab facility).  She will likely end up on a ventilator and her loving daughter will get to decide when to turn it off. (Update, she did end up on dialysis three times a week, totally bedridden and dependent on others for meals, toileting, turning, etc; but thankfully they decided not to do CPR at the end, approximately 3 weeks later, still in the acute care hospital).

What a way to go...would love to hear your thoughts!

Wednesday, December 7, 2011

Ashamed and Frustrated Nurse

Today I went in to see a patient in the hospital, and while I was taking his history, the LPN came in to give him some medication through his IV line. Lung cancer had taken its toll on his little body, and even though he has finished treatment and was told he is in remission, he is still quite frail. As he lay there, telling me about how the last two days had been filled with nausea, vomiting blood, and diarrhea every time he drinks water, the smiling nurse went about her business. She seemed so competent from where he lay. No hesitation in her actions, as if she's done it a million times. Oh, the confidence he had in her. He had no idea that she (1) didn't wash her hands upon entering the room, (2) laid two syringes on the bed without capped ends (one with saline and I assume the other with medication for pain) and (3) that she didn't use alcohol to wipe the IV port where she attached the needleless syringes - the same ones that were lying open on the bed. She smiled as she left, he thanked her and called her "honey."

This is not the first time I have reported this nurse for incompetence. I really don't think she understands that those simple omissions could lead to bacteremia, and in a patient this weak, possibly death. Please remind your students and colleagues to treat every patient as they would want their own family member to be treated.