Sunday, June 12, 2016

End-of-Life Concerns

The second thing of interest to these seasoned (and a few not so seasoned) RNs was end of life issues. This is also a concern of mine. I gained an interest in it over the last several years, while teaching a professional development course to RNs. It's a survey course: we cover a number of topics, and I really try to elicit their concerns and then incorporate their concerns into the material.

One thing that emerged was the distress they feel during resuscitation efforts in the hospital. People outside of the business mostly get their experience with resuscitation--essentially CPR--from TV. They call a "code blue" or simply a "code", and a few super-efficient doctors and nurses rush in, pushing gingerly on the chest. That's not real CPR. If they were doing real CPR the actors would be compressing the chest about 2 inches--and you'd likely hear some ribs cracking. CPR is rough stuff!

Survival isn't great, either. Various studies have found that survival with out-of-hospital CPR is less than 20% or less than 1 in 5, and often less than 1 in 10 cases. Even when cardiac arrest occurs in the hospital, survival isn't much better, although it may rise to about 40% under the best circumstances. This would maybe be a patient who arrests on the operating table and perhaps because of the anesthesia. Those cases are pretty easy to save, comparatively speaking. They're also ideal. I mean, you're right there with all the drugs and the defibrillator and the best people to revive you!

That's not most cases.

Survival with full mental function to leave the hospital, that's even less common. People are often led to believe that when grandma wakes up after CPR she'll be ok. But odds are she'll never wake up, and if she does, she'll be in considerable pain and perhaps have suffered some loss of mental function from the lack of oxygen to the brain, depending on how long it took for CPR to start, how long it took to get a heartbeat back, and grandma's other health issues at the time.

As an ER nurse and an EMT, I worked a lot of "codes". Hardly anyone ever lived. That's partly because a lot of them were performed on the very elderly, many of whom already had significant disease. The few who did survive? They were mostly younger, and the cardiac arrest was witnessed by us. Arrests in "the field"--outside the hospital at accident scenes or in homes--things weren't so good. We would bring those folks sometimes, but then they'd go to intensive care and die again there.

Pretty grim stuff.

What a lot of the nurses and doctors suffer from is just a sense of fruitlessness and sadness over this. Yes, it's hard to lose a patient, but it's often even harder to participate in these efforts when you feel like you're just abusing a corpse. Since a lot of folks getting coded are older and sicker and frail, it is appropriate to just let go. Why doesn't that happen more often?

Mainly, it's a lack of communication between health care workers and patients and families. Now it is true that a lot of times, there is good communication, and many times we allow natural death to occur. That can be a good, well-planned death when the diagnosis is fatal and hospice services are at work. (I do some hospice work, so I've seen this a lot.) But a lot of families aren't fully appraised of just how fatal a family member's condition is, and there's been no discussion of the circumstances in which the hospital staff can allow death to occur.

I've been to codes--and so have my students--where families are in conflict about this decision, even when the patient himself made his wishes clear. There's also a lot of misunderstanding about what a "living will" and similar documents mean. For example, it is typical that a living will or other health care power of attorney doesn't go into effect unless the doctor has declared that a person is terminal, or if in a persistent vegetative state, that is, brain dead. Or it might be in effect if the person simply won't wake up and have any life quality.

So a living will isn't a will to forestall CPR. It's just a statement of assent to the withholding of lifesaving measures in the event that the person is in one of the specific states I described above.

A "DNR"--"do not resuscitate"--is an order written by a physician, and in some hospitals, it can be written by a nurse practitioner or physician assistant, who is working on a team with a physician. Some hospitals call them levels, and so a level 1 is "do everything". Level 2 is don't do CPR but you can use drugs like adrenaline to try to bring someone back, and so on. They usually go to something like a "level 5" or comfort-care only.

Most people don't realize that such orders are routinely suspended if someone goes to the operating room, even for a "comfort" procedure. This is partly because sometimes the anesthesia itself caused the cardiac arrest--so why not just reverse a doctor-caused problem anyway? But it is also because surgeons are graded, in part, on their intraoperative death rate, so they don't want anyone dying on the table.

What bugs me about this is that nurses and doctors often don't tell patients or their families that this will be the case. They just don't like having the conversation. For my students, I try to teach them how to advocate for their patients' wishes, how to negotiate with often-reluctant doctors and families, to have more productive conversations. Sometimes it can be enough that a patient simply says "if my heart stops, don't bring me back." The nurse or doctor can then chart that information as a legitimate expression of a person's last wishes, and write the DNR order.

I said in another post that I'd discuss how what I teach my students says about health care in America. Recently, Atul Gawande, himself a doctor, wrote Being Mortal, on how we do death in this culture. We don't do it very well. We're often convinced that medicine and surgery will cure everything. We often allow popular culture to convince us that technology can do more than it does. We don't stop to think what it might be like for our loved ones, having their chests broken, having tubes shoved into lungs and veins and bellies. You might think that "unconscious" persons don't hear or feel. They often do. How miserable it must be to suffer those physical insults when all you wish to do is die peacefully.

So if I could give one piece of advice to everyone, it would be the advice I teach my students: make the conversation happen before it's too late.

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