Monday, March 7, 2016
Facing Death (16 Mar)
Thinking about death & dying is philosophical thinking: who am I?
what will happen to me after I die? what gave my life meaning, etc. It
can also give us a way to think holistically about biomedical ethics.
What did you see in the video that relates to class? Are we fully
addressing the needs of dying patients? Critique our health care
system: what could we be doing better with respect to the dying?
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Several aspects of the video, Facing Death, relate to this class in many ways. The most relevant aspect I see is the ethical dilemmas and decisions we see the families, healthcare workers, and caregivers in the video having to make. We see the struggle they endure as their thought processes change given the situations. The video begins with a family faced with the choice of whether or not to remove life support for their dying family member to which they choose yes. This seems to be a decision that repeatedly comes up for many different families and has been a topic of discussion in class many times. The video goes on to show other families and individuals who feel differently and choose to keep life support going.
ReplyDeleteI don’t think I can answer the question of if we are fully addressing the needs of dying patient’s or not. I feel that every individual and every situation is unique. Where we might be meeting all of the needs of one particular patient, those same interventions may not meet any of a different patient’s needs. There will always be room for improvement in healthcare as well as the need to just back off and allow nature to take over.
As far as what we could do better for the dying patient, I think as long as we respect and honor a patient’s wishes in regards to their end of life care then we are doing a satisfactory job. If those wishes are unknown, keeping a patient and family comfortable is top priority in my opinion. Like I said before, every situation, every patient, is unique. Our care should be tailored to fit their needs.
The video talks about extending healthcare interventions or possibly doing just “one more CAT scan” just in case something was missed. Keeping a patient alive via various interventions when the likelihood of survival is slim in hopes of a “miracle” does more damage than good in my opinion. I think one of the most important things we can do for a dying patient and their family is to be 100% honest with every aspect of care. Explain all of the options, all of the various treatments, risks, and outcomes. Never give false hope.
Frontline PBS. Facing Death. (2010). Retrieved from: https://www.youtube.com/watch?v=JoMfj49oyLs
Great points Erin. You are completely right that every case is different. There can be no blanket treatment given. Every situation needs to be looked at and dealt with differently. I feel like they sense when we are sincere and can tell that we care about them and the family or when we are just going through the motions and don't care.
DeleteCould g agree more, very well stated.
DeleteThe video shows many aspects of the dying that is all too familiar. Although, the scenes are familiar, it doesn't come easy. It reiterates to me the attitude toward dying is that it's something to be fought against at all costs. Our culture and technology states that we are living longer, but I beg to differ. I see what we are doing is dying longer. Aging, according to Atul Gawande in his book Being Mortal, is viewed as a medical problem. This brings forth many ethical issues in regarding to the aging population and healthcare in the later years. The video Facing Death depicts not only the aging, being kept alive regardless of their inevitability, but younger people who have suffered severe strokes or have other life altering progressive diseases that bring them to a point of 'living' on machines. Our healthcare system would better serve the dying by incorporating an attitude of treating humans. What I mean by this is to change the stance of 'stopping treatment'. These words should no longer be said, for it is not giving up, it is just taking a different course in the way treatment is given. After all, death is a part of life. Inevitably everyone will die. Some medical attempts become so over the top, it appears that we are trying to get out of dying. This merely prolongs suffering on many levels. I am not minimizing the pain and suffering the loved ones experience as they attempt to accept their loss. But, if the medical profession would not employ a sense of false hope, and be more realistic when offering treatment options, the one option of palliative care could be the treatment that is overall the best choice without the stigma.
ReplyDeleteFrontline PBS. Facing Death. (2010). Retrieved from: https://www.youtube.com/watch?v=JoMfj49oyLs
Gawande, A. (2014). Being Mortal. New York, NY: Metropolitan Books.
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DeleteExcellent statement about us dying longer, Gloria! You are so correct. I think when we are younger, or earlier in our healthcare careers its hard to understand that it's okay to let someone die, maybe even help them die, with dignity. I loved my ICU family and career, but toward the end, I was so tired of prolonging lives to watch these patients suffer or just exist. I felt like I was caring for empty bodies we were letting lie in beds while we kept them on earth. I often felt like I wasn't making a difference. It wasn't unusual to have he same patient for months in a row, until finally palliative measures were approached. I think we do a much better job now in instituting those earlier.
Delete"Dying longer". I like that, it's a very powerful statement which so much meaning. I also couldn't agree with you more, we need to not provide families or patient's with false hope.
DeleteGloria, that is a very good view of how medicine currently treats the dying. The term dying longer is definitely more accurate than living longer in a lot of cases. I feel as though even if we have the technology to prolong someones life it really needs to be looked at if we are doing that patient any good by it.
DeleteDying longer is a great way to put it! So many unnecessary tests and treatments. It can get very costly and even more we could be leaving them worse off by further decreasing their quality of life.
DeleteI agree when someone says the world palliative care everyone automatically thinks death and that isn't always the case.
DeleteI completely agree with the term "Dying Longer". We have long kept patient on treatments with no quality of life. I look at the dialysis patients that come through the ER and have no quality of life. They move from stretcher to bed as their only form of exercise. Families want everything that can be possibly done. This aspect needs to be the next issue to be addressed by our society. We all know the worst are the wards of the states. Every measure must be exhausted before they can die.
DeleteLove the use of "dying longer" it really definitely puts things in perspective. Yes, Chris, you are right with wards of the state, I hate being that way but they are the worst.
DeleteThis video is one that does a great job of showing many different facets of what healthcare workers deal with when it comes to death and dying. With the advances in technology we are doing great things as far as healing people that would have been a death sentence in the past. But the downside to all the technology is we are physically keeping people alive long past what their bodies naturally would have. One of the themes shown in the movie was the discussion between the physician and the patient about what the patient’s expectations and wishes are. We discussed in the book Being Mortal, written by Dr. Atul Gawande, that there is a huge importance in establishing care guidelines with a patient so that the guesswork can be taken away should they become unable to communicate their wishes. Death and seeing a loved one dying can be very emotional for families and letting go can be too hard for some.
ReplyDeleteI’d like to think that we do a great job at addressing the needs of dying patients when a plan has been set in place. Yes, we can keep someone alive by using machines to keep all of their organs functioning. Where I feel like we can exceed is when palliative care is put in place. I feel like our healthcare system could use a little more of the care, compassion, and respect seen in palliative care settings. The patient’s comfort at the end of their life is the number one priority. Surveys have found that patient’s top concerns include avoiding suffering, strengthening relationships with family and friends, being mentally aware, not being a burden on others, and achieving a sense that their life is complete (Gawande, p. 155). I think our healthcare system needs to incorporate the patient more in their own care, allowing for autonomy and self-determination. Patients and families will have a better understanding of their health and treatment regimens, and allowing them to review and create a plan for their end of life with their physician early on before they are unable to.
Frontline PBS. Facing Death. (2010). Retrieved from: https://www.youtube.com/watch?v=JoMfj49oyLs
Gawande, A. (2014). Being mortal: Medicine and what matters in the end. New, York, NY: Metropolitan Books Henry Holt and Company, LLC.
Excellent point about the younger people who suffered debilitating illnesses, Jocelyn. These are particularly hard for me these days, because they are my age or only slightly older. It's amazing how you start to face your mortality more the older you get
DeleteI love what Dr. Gawande says about establishing a treatment plan well ahead of the game. He has a series of questions he allows himself to shamelessly ask the patient regarding their wishes AND goals. I think this is a great way to handle a situation that feels so uncomfortable. Avoiding important issues is not the answer. A patient has the right to have his wishes and goals in life expressed, and know that someone is on his side for him.
DeleteI like that all the physicians round together and came up with a game plan. I worked the ICU for 4 years and saw that happen only one time. I am sure the reason was that she just had a baby and they were all present at the bedside trying to help her. We do well with allowing the elderly to pass on. I think most struggle when it is a terminal youth. From the family to the medical staff, you want to try everything to save the younger patients.
DeleteMany things in this video apply to things we’ve covered in class. Just the entire concept of biomedical ethics and how we value and see our patients. It mostly takes me to our discussions about passive euthanasia and comfort care, and those about the physician/ patient relationship. However, since taking this class, and completing the activities as assigned with our blogging weekly, I look at everything in the perspective of ethics and the theories we’ve learned. I’m always thinking about how things have met or violated autonomy, beneficence, non-maleficence, justice, the categorical imperative, virtue ethics, etc. It’s made me reflect upon my own actions and even look back to past situations and critique myself on how I handled them ethically.
ReplyDeleteAs I watched the video, I was taken back to so many personal experiences of mine in healthcare over the past several decades. I first started as a young nurse in the ICU in May of 1992, and I’ve seen all these scenarios in some form. They still touch me to my soul in most cases; I can recall all the minute details 24 years later, the smells, the sounds, etc. Often when I see someone in the community that I went through one of the scenarios with, it all comes rushing back to me. However, my goals have changed so much in the quarter of a century that has passed, much like the goals in healthcare’s approach to dying and dignity has changed over that time. When I was a new nurse, I wanted to save everyone, much like Dr. Gawande did in the early chapters of “Being Mortal”. I wanted to use my amazing new skills as a critical care nurse to save that patient, to save everyone. But as I evolved as a nurse, I realized we could not save everyone, and I needed to be there to support the patient and the family in their final moments, to give them the validation, assurance and dignity they needed in that time. If we really think about it, we are there (strangers originally, outsiders) in the most critical emotional times of patients’ lives: when they take their first breaths, and when they take their last breath. We go from being outsiders to being a core member of their group during that time. The way we handle moments, how we address the needs of our dying patients, is a huge responsibility, as this is it for the patient, there are no “do-overs”, and these are moments the family will carry with them for the rest of their lives.
While we like to think we are doing everything we can for our patients, and we have good intentions, the truth is, we do not always take the focus we should on these patients in the psychosocial aspect. The ICU is a technology-driven, skill-intensive area to work. When caring for these patients, as a nurse, you have so many things to focus on. You have to manage the ventilator for these patients, often you have the very critical tasks associated with caring for someone with an IABP, or CVVHD, both of which require every second of monitoring, anticipating; the complications with either of these can be deadly so often your focus becomes the equipment. The patient is your concern, that is why you have such concern for all, but if you miss anything, they could die or have a terrible complication, so you focus on all the equipment; you focus on their body as access sites, pulses, breath sounds, urine output, a cardiac rhythm on the screen, bowel sounds, and pupils reacting…. while we try to focus on the psychosocial and think we are seeing that patient as a whole, we are so bogged in the physiological that we don’t have time to step back as see that patient as the whole person they are.
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DeleteThis is where Atul Gawande’s book really touched me. When he evolved to the point where he realized the patients were in their final days, these are the last moments of their lives; he realized then that his training, his skills, our amazing medical technology cannot fix his patients when they reach that point. He focused on what they wanted to accomplish then, what they needed in their final moments to set their souls at rest and prepare them for their last breath. This is also basically what Dr. Karen Owen in the BMTU unit emphasized in the video. When we reach that point, we need to change our focus. In ICU you don’t have the time like Dr. Gawande did, though, to discharge the patient so they can go home to live their final days. As healthcare workers, we need to take a step back, and really focus on that patient, their family, and what they want to accomplish from this time. While the institution of palliative care and palliative measures has helped to better focus on this, I do think we can always make improvement. It is busy in the units, staffing is often low, we need to make that effort to step outside the technology, let’s fix it focus, and focus on those final moments of life.
Frontline PBS. (2016).Facing death: How far would you go to sustain the life of someone you love. Retrieved from: http://www.pbs.org/wgbh/pages/frontline/facing-death/https://www.youtube.com/watch?v=JoMfj49oyLs
Gawande, A. (2014). Being Mortal. New York, NY: Metropolitan Books.
Great post Shelly! I bet you've seen so much throughout your nursing career and have many stories to tell which I would love to hear. I've been in nursing for a little over 3 years now and have already experienced so much, I can't imagine the things you've been through.
DeleteThank you, Erin. I also know you've seen amazing, and sad things in L&D that I would love ot see and hear. I think it's important for all of us from the many different views of the hospital to share our stories and learn from each other.
DeleteI thought the video did a good job of portraying the struggles we can face as healthcare providers, families, and as a collaborative unit. The video was was a little emotional for me when the sister was talking to the healthcare team. It is a reminder of how important it is in giving the family all the facts and educating them properly. She knew in her gut what the outcome was but it hits on a deeper level hearing it.
ReplyDeleteI feel this touched on a few aspects we have learned in class. A lot of ethical issues can arise at times of hospitalization and sickness. It is a constant struggle between us and family in doing what is right on a moral level. The uphill battle is that we all have different cultures,thoughts, emotions, beliefs, and morals. Hard to sometimes get everyone on the same page at times. I feel as long as we are respecting others and giving there wishes we are honoring their autonomy.
As for are we doing everything to service the dying... I'm not sure we are. I think we have made great improvements but have a long way to go. Just some examples are keeping people a full code when they clearly wanting to die or have zero quality of life. Sometimes families have a hard time accepting the fact of ones dying and we exhaust medical tests and treatment. When one is a ward of the state not matter the age, a lot of times they are NOT a DNR and we end up exhausting unnecessary treatments. Is this realy helping them? Or are we just prolonging the inevitable and making them more miserable in the mean time.
I agree talking with the family to help the make decisions on DNR status are some of the most difficult conversations I've had I feel like we should could do training to help nurses in these situations.
DeleteI think that training would be beneficial in these certain scenarios. But also I feel that it is in our scope of practice to tell the patients family and explain all the things that we are doing and how that if their loved one is on 4 pressors and their blood pressure is still not good that this is not a good sign instead of just brushing it off to the next person because you don't want to have that conversation. It just is a hard topic, and maybe because I am comfortable in that area I don't see it as a hard thing but I can see where it could be hard for some others
DeleteEducation is critical with end of life issues. Emotions are so raw at the time with the patient and families. It takes practice and knowledge on how to tread in the sensitive area of dying.
DeleteThis was a great video and I really enjoyed it. This help me realize when dealing with this it may be better to give the family as much attention as the patient because that is what is important to them and they are the only people that you can have a lasting impact on. I don't know if we are addressing all of the dying patients needs because they aren't here to tell us but I do think when they are in the hospital setting we could do more of giving them a sense of that they are at home. For example allowing pets in which is something that isn't allowed in hospitals. Also maybe soften up the setting hospital rooms are very clinical. I don't know if we could do anymore to respect them other than continue to listen to the patient and family.
ReplyDeleteWe do allow pet visits at hospice. It is a great comfort for the patients and the families.
DeleteThat makes me so happy to hear. Such a small thing, but such a great comfort.
DeleteThis video was very good explaining what was happening to the patient. It touched some of the ethical issues we have discussed in this class. To allow one to die with dignity. The MD was careful to respect the privacy of the patient and also not hurt the patient during the exam. He must of not had any advance directives. I respect how all the doctors pulled the patient into the conference room and explained the prognosis as a united front. They were honest with the family and explained there was nothing more they could do.
ReplyDeleteI believe that the hospices that around this area do a good job helping the dying pass peacefully. They are usually given the parameters to keep the patient from a painful death. They respect the rights of the patient and the family. They put aside their belief systems if they differ form the patients.
We can get better in some instances. Some MD's exhaust every route when the prognosis is very poor. Families should not be able to override a patients DNR wishes. ICU is technically driven, with some patients no longer looked at as an individual. Overall, our culture is getting better letting are aged and sick die on their terms. We still need to educate the families and patients on the aspect of end of life care.
Frontline PBS. Facing Death. (2010). Retrieved from: https://www.youtube.com/watch?v=JoMfj49oyLs
Gawande, A. (2014). Being mortal: Medicine and what matters in the end. New, York, NY: Metropolitan Books Henry Holt and Company, LLC.
great point regarding the physicians working as a team to discuss the end of the patients life. I rarely see my physicians discuss death with our patients, they typically are not so forward and suggest further testing.
DeleteI really enjoyed the video. I think it hit excellent points at how we need to care for the family just as much as the patient. They are hurting too, but just in other ways. Sometimes families think that their loved one is going to get better even after pronouncing them brain dead. They sit at the bedside asking them the same questions we do in hopes that the assessment findings will change, when in reality there is nothing else that we can do. I understand people need time and time is what we give them but I think that there is a fine line with being more stern. We do have some great physicians that will like in the video pulled the patient into a room and explained outcomes to him, and I think that is great but I think that some doctors will continue to do everything that the can think of (test, procedures) anything before having this conversation with family and or the patient, but very well know thing that the patient is not going to survive this amount of insults to the body.
ReplyDeleteGood video though. I see this every day and I wish that more physicians and nurses were well educated and comfortable discussing end of life wishes.
great analysis Kourtney, I am sure you see this a lot and from a very different perspective as I do in the ER.
DeleteI did enjoy the video. It brought to light the struggles that families have after their loved one was "saved" in the ICU. But what do they do now? What quality of life does the "saved" ICU patient have if they can't breath on their own? Do we push artificial respiration and nutrition for who knows how long? Is the patient really "living"? It is hard for patients and families to come to grips with the reality of death and dying. It is going to happen to us all, whether we like it or not. We should be able to plan for a meaningful, comfortable death. With our families supporting us along the way. I get trying to beat the odds and finding a miracle, but when all possible cures have been exhausted, why not focus on the quality of the life that is left, not quantity. I believe physicians have come a long way in their idea of end of life care. Some are still focused on "saving" everyone at any expense, but when you have an elderly patient "existing" on a ventilator and tube feed for over a year, I almost think that is inhumane.
ReplyDeleteEducation and communication on end of life issues are the only way we can get the word out that there can be quality of life at the end.
The difficult decision to remove life support or maintain hope for healing that is addressed in the video is a difficult topic that healthcare has to help families make every day. Often times in the emergency room we "bring people back" which provides the family with hope for an outcome that will very likely not come to be. The advances in healthcare that allow us to maintain an airway, shock a heart, cool the body for hypothermia and assist in most bodily functions place healthcare professionals in difficult situations.
ReplyDeleteAs healthcare professionals often times our hands are tied with respect to respecting the needs of the death and dying. If a patient comes into my ER without written advance directives, we assume they want us to do all that we can. Often in a critical situation the family member has not yet arrived. on the other hand, when a patient wants us to do nothing for them, as a nurse, it is hard to sit back and watch life end. only once in my career have I had to see this happen. I am sure on the floors after difficult conversations have been had it happens more frequently.
the best way to honor the dying is to educate on advance directives and have difficult conversations with patients early on. This should take place with the primary care physician.