Monday, September 21, 2009

Compassionate death?

I recently spent some time in another country that has socialized medicine and thought I would share a story that illustrates the differences b/w our system and socialized medicine:

72 yo deaf and demented male from a nursing home arrived looking pale, diaphoretic, and not responding to voice commands. The gentleman looked very critical, and my instincts were to get ready to intubate him. However, my attending on duty looked at the patient and realized his quality of life was very low considering that he was deaf, at the end of his life, and living in a nursing home. He told me to not intubate the patient(even though no family members were present). I then got an EKG illustrating a very wide complex tachycardia with high t-waves suggestive of hyperkalemia (high potassium). I drew a state venous blood gas which confirmed a high potassium level of 7.0 (normal is less than 5).

When the potassium gets very high, it can cause the heart to stop beating if is not corrected. I brought the EKG to the attending with the lab result of the high potassium and asked him if he wanted me to push calcium gluconate with IV glucose/insulin (the treatments for a high potassium). He said, "No. His condition is already very critical because he is in urinary retention and has an acute abdomen. We need to just let him die peacefully."

It was quite shocking b/c in America we would have intubated him and performed heroic measures, but it begs the question- "Why do we save everyone and not take into account individuals quality of life? Would I want to be treated if I was demented and lived in a nursing home? Is it more humane to just allow people to die peacefully?"

Rather then giving him calcium and glucose/insulin, I gave him Morphine for comfort. He died peacefully about an hour later.

-Doc Sensitive

40 comments:

Mel said...

The reason that doesn't happen so much in the US is that physicians, and by extension the public, have been accultured to think of death as a disease that must be cured and that a patient's death is always a failure of treatment, rather than a natural process.

GrumpyRN said...

Everyone's time must come and people should be allowed to go quietly, peacefuly and with no pain. Heroics and full intervention when needed but no favours are done prolonging the life of people with no quality of life and are obviously at the end of life.
I would be reluctant to attribute it wholly to socialised medicine but more that there is less chance of being sued for not "doing everything". As an aside, although this decision would be taken by the senior doctor, the team involved would all have a chance to comment and disagree if they felt it necessary.

Doctor D said...
This comment has been removed by the author.
Doctor D said...

Quality of life is pretty subjective, especially when you've only seen the patient once. How do you know this man isn't the happiest demented dude in the nursing home?

Had the attending ever seen this man on a good day? Did he know the man or his family enough to understand the man's values and wishes? Or did he just say, "Looks sick and old, therefore I feel his life has no quality."

It would be different if man had a living will saying "no intervention" or his family who knew him confirmed he wouldn't want the treatment. They can give morphine at a nursing home. Being sent to a hospital indicates someone is was interested in treatment.

I'm not saying do a whole lot of heroic or invasive stuff with tubes and probes. The guy is frail and probably wouldn't tolerate a lot of doctors messing with him. But calcium gluconate through the IV the ambulance already placed is hardly invasive or heroic. Heck, give him a touch of calcium and see if his body responds! If the old man still has some fight in him he might perk up. He or his family may want at least that chance.

I'm not a "do everything" doctor. I prefer to do as little as possible on someone nearing the end of life, but I recognize the patient's right to decide how they approach illness and death. The standard for declining an intervention should be obvious medical futility or the patient's wishes (and wishes can be expressed by proxy through family or a living will).

This attending had no knowledge of the patient's wishes. Treating Hyperkalemia is by no means futile. We have some very simple ways of treating it. Dementia is an irreversible condition, but with a K of 7.0 there was no way to know how advanced the dementia actually was. The man could have been mildly forgetful and hard of hearing to require nursing home care. Who knows, he might have had years of enjoyable and meaningful life ahead of him if he survived the Hyperkalemia?

This story is an obvious and disturbing example of an attending with a "god complex" using no standard other than his own feeling of repulsion to decide a patient shouldn't receive care. I wonder if this attending would have pushed morphine on disabled or depressed patients against their wishes just because he felt their lives had no quality?

It is reports of behavior like this that will keep us from having meaningful Healthcare reform in America. If we withhold basic care due to quality of life concerns, it should be the patient's judgment of quality not the physician's that determines this. The physician should only judge futility, and treating a K of 7.0 is obviously not a medically futile treatment.

Anonymous said...

I am working in an ED in the Netherlands, and with such a patient, nobody would even think of intubating him. But the hyperkalemia would have been something we would not leave untreated so easily, at least not without trying hard to contact the family to get their opinion on how to proceed.

Lonely Midwife said...

Have to agree with Doctor D. here.

As I was reading this, my first inclination was--who is he to decide "quality of life"? This is why it is so important to have a health care proxy/living will--it makes everyone's life's and death's easier. Plus, we have to factor in there is a cultural difference here.

GrumpyRN said...

I am based in a UK ED, and like anonymous we would not intubate this patient. I think that perhaps Doctor Sensitive has used a poor example as the patient had problems that could/should have been addressed. However, it does not change the original post's point that "doing everything" is not necessarily in the patients best interests. And as I stated, every single member of the team dealing with this patient would have the opportunity to question the decision. In almost 30 years of working in the NHS I have never seen an end of life decision made where all staff involved were not asked for their opinion and if they agreed with the decision. There are always legal ramifications when a person dies and our forms have a specific part where the nursing staff present are asked for their name and if they thought there was anything suspicious about a death.

TechnoBabe said...

It is a shame that health care in the US is dependent upon insurance and the fear of lawsuits which also affects someone's good name in the medical community. I understand the need for each person being responsible enough to have in place a living will or durable power of attorney for health care or whatever is their choice, as long as we have it available and information on how to reach a responsible party in an emergency. I enjoy reading this blog very much and learn something with most of the posts.

Lonely Midwife said...

Grumpy RN--

Just curious--are the dynamics so that the RN would freely speak up without fear of being denigrated?

I know that certain specialties attract certain personalities. As a rule ED nurses don't tend to be timid BUT here in the States a large number of nurses continue to practice in very hierarchical settings. It may sound good on paper but in practice may be difficult.

GrumpyRN said...

Simple answer is yes, RN's are empowered by our governing body - the Nursing and Midwifery Council (NMC) - to challenge poor practice by whoever is carrying it out. Doctors are only in charge of clinical matters, my boss is a nurse not a doctor. In UK NHS we have very stringent anti bullying policies in place.
As part of the team you would be expected to have an input, I would be shocked if a doctor made a unilateral decision about stopping treatment without discussing it or at least asking for an opinion from nursing staff.
But remember, almost all of these decisions would in fact be made in conjunction with the patients family. Where family are not available would be a cardiac arrest or collapse in the street and the decision would be made after unsuccessful resuscitaion in the ED and the doctor leading the team would ask if everyone was happy to call a halt, the police would be involved in this type of incident as it is classed as a sudden death regardless of age of patient. The other scenario happened to me recently where a patient was brought in with a sudden deterioration of his condition while at home and it was obvious to all that the kindest thing was to allow this patient to slip away and I had to call the family at home to tell them to come to hospital as their relative was dying.

Sorry, a bit long winded to answer your question but the days when the doctor was god have long gone although a few are fighting a rear guard action.

BangBangMedic said...

I have enjoyed reading your blog, but this post struck a discordant note with me. That is NOT your call to make. Who are you to decide if somebody has it bad enough to die? I understand that not everyone can and will be saved-that is what DNR's are for though. If he didn't have one, fair enough, but to not treat the issue at all seems like a violation of your oath. If my life starts to suck are you just gonna let me die? If my legs get blown off in Afghanistan next year, will you say "His quality of life isn't too good, lets just get him go." Screw that. You've lost a reader.

Liz said...

Not intending to engage in hyperbole, but this is the 'death squad' scenario that conservatives are warning against. So, it's not just hysteria...it's reality.

As making these decisions becomes more common, the line between reasonable treatment and extraordinary care will become more blurred. Slippery slope and all that. It's naive to think this sort of decision making won't occur more and more readily.

I like what Mel said about our culture thinking that death is a disease that must be cured and is a failure of treatment. I'm a hospice nurse and became one in reaction to this pervasive (in our culture) sentiment. It's ridiculous to dwell in denial of the inevitable. Death is as much a part of living as birth.

The problem is, who is qualified to decide who lives and who dies? Government flunkies? An End-of-Life Czar? The President? We know many (but not all) families go too far in demanding futile 'life saving' treatment...how do we keep the pendulum from swinging too far in the opposite direction?

Brave New World...the future is now.

Ont-RN said...

I took care of a 91 yr old with advanced COPD and bad pneumonia. He was brought to the hospital for acute SOB. Bipap was working but after an hour, he refused to keep wearing it. He had an advanced directive (DNR/DNI) and was totally lucid/competent. He told us he just wanted to die.

So I gave him some meds to ease his breathing. Just to keep him more comfortable until the end. He asked me: "Why can't you just put me out? I'm done with life and ready to die". I answered him honestly -that I wished I could but it just wasn't possible. So he struggled and struggled, waiting for the end to come. 91 yrs old and it still was not his choice to make.

We treat animals better than humans. As a rule, I don't condone euthanasia, but sometimes I wonder....

C. said...

"72 yo deaf and demented male from a nursing home arrived looking pale, diaphoretic, and not responding to voice commands"

Really, he didnt respond to voice commands? Is that because he is deaf?

j said...

BangBang Medic, it wasn't the blogger's call on this one. S/he's just presenting the facts, unless my reading comprehension is even worse than yours (a good possibility).

Anonymous said...

This is doc sensitive. No this was not my call- it was the attendings. I had already ordered Calcium and insulin/glucose b/c felt it was a reversible condition. I wanted to treat his high potassium. Being from the USA, I found it very difficulty to just "let someone die." Good point about not responding to voice commands- meant to say that he was blind- not deaf.

Anonymous said...

This sure seems to me to be a post to induce fear, uncertainty, and doubt in the general public who fears health care reform. Blindness and deafness are very different. It appears this is indicative of either a flaw in your storytelling or a flaw in your care of this individual.

BangBangMedic said...

Fair enough. I responded rashly. It seemed to me on my first read that you were actively supporting this type of decision makers, doc sensitive. If that's not the case, I'm remiss. If you ARE advocating this kind of choice, then I disagree whole heartedly.

Trust us....we're doctors said...

I would like to point out one major aspect of this case which everyone seems to be overlooking. This patient had a surgical belly with rebound and guarding. On top of urinary retention and elevated potassium, he had what I felt would be a condition that would require surgery. In this particular country, he would not have been operated on by our surgeons. My attending felt that it was more humane to allow him to die peacefully by not treating his potassium then to prolong his suffering. So the major point of the case was that he had an irreversible surgical condition and a reversible medical condition. He felt it was more compassionate to let the medical condition run it's course b/c it would be a quicker death and more humane death. To the reader who said this is a story to strike fear in socialized medicine, it is not and this did happen. I do believe MDs should have more say in allowing people to die peacefully without suffering. We treat animals and pets more humanely than our own family members.

Doc Sensitive

The Homeless Parrot said...

I feel positively ill reading this. Who gave that doctor the right to decide quality of life? Do they teach that in med school somewhere? The arrogance makes me nauseated. This guy was seen once by an attending and given a death sentence.

I am stunned and sickened.

The Homeless Parrot said...

And PS: I'm a veterinarian and I DO euthanize animals. I'm asked every single day of my professional life - is he/she suffering? Do they have quality of life? You know what I tell people? I CAN'T JUDGE THAT. I am not your animal, and I am not you. You know him/her better than I ever will, and you will know. I can only help them understand the medical aspects of disease.

Trust us....we're doctors said...

One more point- the family later came to the bedside and was not angry or mad that their loved one was dying. In fact, it was the exact opposite- the family accepted the death and stated that "he had a good life and we don't want him to suffer." In retrospect, if we treated his potassium then his surgical abdomen would have ultimately resulted in more suffering b/c the surgeons there would not have operated on him. He would have sat on the floor in terrible pain until his perforated (my best guess) ulcer seeded his stomach and blood with bacteria. The sad fact is that no matter what we did that night- he would not have cheated death without an operation. If the potassium was corrected, then he would have died an agonizing death over the next days or weeks.

Doc sensitive

j said...

Why couldn't he have surgery? The waiting time would be too long? No $$?

... No need to answer, really, this is probably taking up too much of your time as it is.

Sad story though. I have a feeling after everyone's done pissing & moaning in your comments here, that it'll boil down to 'you had to be there; it's different than what we do here.'

GrumpyRN said...

Doctor Sensitive,

This is not socialized medicine, this is third world medicine. It is a bit disingenuous of you to mention socialised medicine in this context. What started out as a post about being allowed to let someone die in peace when it was their time has changed into something completely different.

Yes, in this case it was a compassionate death but it would not be tolerated in any hospital in UK or most of Europe and posts like this has given rise to the 'death squad' nonsense that are being quoted by those opposed to health care reform in the US.

Doctor D said...

As I mentioned earlier the issue of medical futility is very different from quality of life. A doctor is usually competent to determine if a treatment is medically futile or not.

I recently had a 88 year old come in with change in mental status, abdominal distention and tenderness. Had he been 40 years younger the obvious answer would have been surgery. At his age surgery was the wrong answer--it would have killed him. I discussed with the family what he would want. They said he would want a chance but they understood that this was likely the end.

I gave fluids, wide spectrum antibiotics, and iv morphine prn for pain. The patient actually survived and went home with his family after a week.


First of all the quality of life decisions were his family's to make not mine. I made the call that surgery would be futile. But simply determining surgery isn't the right choice didn't mean I could offer nothing to him. (Elderly people can mimic acute abdomen when ill because bowels stop moving easily.) And just because I was trying some a potentially curative option didn't mean I wasn't going to treat his pain. Why do we discuss as if pain control is only for patients we have given up on?

We talk like you had only the options of major interventions and hospice-type care. Most of the time there is a middle option of gentle and less traumatic care.

The Homeless Parrot said...

You showed exactly why I find this disturbing:

"until his perforated (my best guess)ulcer seeded his stomach and blood with bacteria....then he would have died an agonizing death over the next days or weeks."

The plain fact is YOU DON'T KNOW what would have happened had you treated his potassium. You have no idea. You have a guess - as you said.

Do you know how many times doctors - human and animal - are wrong? I've had patients where I thought there was simply no way, but the owners wanted to try - and many of them have pulled through.

The simple fact was - in this case - the man had a treatable medical condition (hyperkalemia), and care for this treatable condition was DENIED because someone "guessed" that he probably wouldn't get better from the underlying cause of his problem.

There's something very wrong with that.

ThirdWorlds my a** said...

GrumpyRN you are an ignorant bastard. I am from, as your arrogant first and second world compatriots called third world. Yes we are poor but we probably have more moral integrity than most of you. Just look in the mirror and ask yourself if your country is first world in morality, compassion, humanity. People like you makes me sick.

ThirdWorld my a** said...

We take care of our elders till the end. We gladly serve them regardless of the cost, time and money. While you sit on your high horses and throw your elders in the nursing home, because you are all too busy and hey after all you all have your own life to live, so goes your excuse.

I wonder if you are all paying out of your pocket for the care of a dying 90+ year old "loved one" in a hospital. Would you all be as generous. I bet you are all this generaous only because the money for care is coming from somewhere else, otherwise, you'll probably be tripping over each other trying to pull the plug on your dying elders. That's first world????

Gert said...

Geez, Dr. D: Your cutoff age for surgery is 48 years old? Maybe if the 88 y.o. had been 20 years younger?....

So far I'm a healthy 50 year old. I would really be unhappy if they start refusing interventions prior to age 75....

Trust us....we're doctors said...

It's rather arrogant to assume this occured in a "third world country" when it, in fact, happened in a very advanced country. They do have socialized medicine but don't feel socialized medicine has anything to do with this particular story. It's a difference in the way the American system thinks about death. We believe that we can all cheat death or reverse dementia or cure anything and everything. I can't tell you how many people I have intubated or followed on ICU rotations who clearly would never survive, or if they did, would be a vegetable. In the country I worked in, the doctors have final say in if they want to perform heroic measures or determine that it would be futile. I was amazed at how many families, when told that their loved one was dying, accepted death and agreed that further intervention would not be needed. It rarely has occured here in the US for me. Most families usually want us to intubated, poke them to get central lines, art lines, and then later they pray for a miracle that doesn't happen. Is that how you want your grandfather treated at the end of his life? I love my 90 yo grandfather and would never consent to have him poked, intubated, and proded at the end of his life- it's inhumane. We spend all this money, energy, and time to try and forego death but sometimes we have to accept that death is inevitable and no doctor, machine, drug, or surgery will save them. In the end, we are only humans and death is something that should be accepted as a normal process of life. Oh, I still believe that this gentleman's potassium should have been corrected and am not an advocate of not treating reversible conditions.
doc sensitive

GrumpyRN said...

Third world my a*,

I am neither ignorant, arrogant nor a bastard, and my moral integrity is such that I do not abuse and swear at people I have never met and know nothing about. I made no comments about the third world merely pointing out that the story had changed and now resembled medicine I would expect to see in a developing nation.
Doc Sensitive wrote 2 things; first, "In this particular country, he would not have been operated on by our surgeons" and second, "He would have sat on the floor in terrible pain". These things led me to believe that there are not enough beds and that there are not enough local surgeons, problems usually associated with poorer nations.
As for paying for other people's care, I would like to point out that I, and every other employed person in UK, pays national insurance to ensure that the poorest and least able are cared for as and when needed - so high horse placed firmly back in it's stable.
The whole point of this story as I read it was about allowing people to die with dignity and in peace without pain when it has become obvious that it was their time. This is something which is absolutely accepted as normal in the UK and we as nurses and doctors do not understand and do not want to go down the road of trying to save everyone regardless. Unfortunately, Doc Sensitive had used an example which as I have already stated was poor, this patient had treatable problems and would in UK have been treated - 72 is not old.

Doc Sensitive,

I made no mention of a third world country, I merely thought that it sounded like third world medicine. I agree with your response of 9:20am, heroic intervention and trying to defeat death are doing our patients no favours, as I have stated, in UK doctors would make this decision but it would not be a unilateral decision. Family and the rest of the team would be involved and the decision would in fact be an easy one as it would be obvious that it was right by the patients condition. My only complaint was about associating this story with socialised medicine which is incidental.

Anonymous said...

Why on earth do you make the connection between the medical system being socialized and decisions like that? That's a pretty big jump.

I am in a socialized medicine country and we also would have treated that (and many worse-prognoses) aggressively. In some ways, even more so because it isn't leaving a family with a big bill - it feels like it's free because it comes out of a public coffer.

Don't confuse the issue at hand with the issue of socializing medicine in the US meaning "We'll kill Grandpa."

ThirdWorld my a** said...

You change the words you used but you basically said the same thing. You just don't get it.

GrumpyRN said...

Yes, you are right, I don't get it. I have repeated my point of view, I have not abused or denigrated or been superior to the third world. I only wrote that I thought that the medicine being practiced was third world as opposed to socialised but take from that what you wish. You do not know me, and you know nothing of my beliefs or values however you feel able to abuse me and swear at me - troll behaviour. I will repeat myself - I believe that there is a time for everyone to die, it is as natural as being born and it is part of life. I was taught to respect life and also taught that when the time came people should die with dignity and be pain free, I also believe that people should not die alone and as such I have held a few hands (and shed a few tears) when patients have died. So no, I do not understand what you are on about, but in this case I claim the moral high ground.

DreamingTree said...

Quite the debate going on here, Doc Sensitive. I read your post tonight after just writing one of my own -- on the flip side of the subject. It's beyond me how anyone could be against end of life counseling. No one will escape death. Make your wishes known, people.

Anonymous said...

Are you guys serious? anyone could figure out his quality of life....he is very old, blind, demented, and living in a nursing home? let him go in peace whats the point?

Anonymous said...

I spent the last hour of my shift lady night trying to encourage a large family into making their 98 year old grandmother DNR and comfort care versus going to the OR and everything that comes with that. 98 years old!!! Come on people at some point we have to call it quits on people. Doctors have a pretty good idea at determining quality of life and/or futility of treatment. Way much $$ is spent on end of life care. We need to develope death as a concept and not a failure and focus on making those at the end of their lives comfortable

heartnurse said...

OH, we do the heroics in socialized medicine too. Sometimes the family demands it but I don't know how they can stand seeing their relative blown up like a baloon and weeping albumin all over the bed, a tube down their throat and us suctioning green mucous out, jaundiced from multisystem failure and tubes in every orifice.
Really, I see 70 yr old who don't think hteir 96 yr old Mother/father should ever die. Comes as a terrific surprise!

PRPA said...

you're all silly. I hope when you are too demented to know what's going on that you are forced to live through procedure after procedure and treatment after treatment, because of stupid sentimentalities like this. A high potassium induced arrhythmia is a peaceful death. I hope my doctor has enough compassion when I'm stuck in a nursing home because my dementia and chronic medical conditions have made it so that I am no longer able to perform my activities of daily living! (the definition of a nursing home resident) I wish the tube, the trach, the peg and the suprapubic caths upon you all. May our failing, bankrupt medical system then come crashing down on your childrens heads. a pox on you all!

Adirondackcountrygal said...

I worked at a nursing home for 18 years as a CNA and saw way too many people being kept alive in a vegetative state of either brain damage or dementia etc.. if they get sick they get shipped off to the ER for meds, fluids etc.. and then shipped back usually with a bed sore. Then again there was the one case of a lady who was in a wheelchair but had all her mental capacity. She needed a new battery in her pacemaker and her family said no. She died. That to me was wrong.