Heroic Measures question

[Oceanbeach]

Dear Forum Friends,

I was asked a question by my second cousin and it is something that does affect all of us so let me begin:

I have never met Gene, he is the brother-in-law of my second cousin.  He is in his 60's, has been disabled since his teens from an accident at his job in a dairy.  I have known of him for decades, he has C.O.P.D., has been in a wheel chair and on oxygen for at least 20 years.  His children, grandchildren and wife are gone and he lives alone in a small house with his caregiver.  His caregiver is one of his sisters.  His brother lives close by and helps out as much as possible but does have a construction job and suffers from migranes and possibly some depression.

Gene has been found unconscious several times over the past few years and more recently over the past few weeks.  A DNR has not been discussed or signed.  This happened a week ago, second time this year.  This time, it was a heart problem, his brother was in the hospital with him as he was being moved from ICU.  He was moved into a room and went "code blue,"  they say his skin actually turned blue and his heart never stopped beating.  Doctor was in the hospital and arrived immediately.  Doctor said the prognosis was not good and asked the brother if there was a DNR on file.  Gene was revived again.

I was just asked the question of, "When do heroic measures become abuse to the patient?"  My answer was, the moment right to life/quality of life and the right to die with dignity are taken away from the terminally ill and placed in the hands of others, whether it be medical personnel or family.

We all live with a life threatening illness, when do you think heroic measures become abuse to the patient?  Have the best day
Michael

www.Commission-on-AIDS.org

[jkinatl2]

I think thats an important personal decision people have to make. Many of us are uncomfortable talking about it, but like you point out, if you DONT make advance directives, then your body will be kept alive to the best of medical science's ability. This is not always in the best interest of the patient, trapped in that body.

I have an advance directive which clearly states the circumstances under which a DNR should be applied.

[JohnOso]

Michael,

Interesting question you posit.  At our hospital, he is the classic case of DNR/DNI ("do not resusiitate/do not intubate"), but if there is nothing on file per his wishes, he is a full code.  UNLESS the closest relative decides to change his code status. 

I must say, the doctors where I work are incredibly efficient at talking with family members at getting a code status changed for someone who is not expected to survive with a reasonable quality of life.   This starts in the Emergency Room.   I'd like to think it's because we're a teaching hospital for the Family Practice program @ UC-Davis and the residents are more attuned to ask these things, but the cynical side of me secretly thinks it's because Contra Costa County doesn't want to spend the money on a hopeless case.

I will (sliightly) break patient confidentiality, and tell you of a case of a young man in his 20's that we had in ICU, that was diagnosed with AIDS.  His wishes were that he didn't want anything done.  Now I've taken care of many, many AIDS patients in my career that have pulled through after weeks on ventilators and have gone on to live productive lives post hospitalization.  The family dynamics of this "kid" were heartbreaking.  Father wanted everything done.  A touchy situation to say the least.  The docs figured that we could do something with this "kid," and the father agreed that everything should be done.

So....he was intubated when the inevitable time came.  And he stayed intubated for months.  Was quite traumatic to see him go thru several chest tubes, ARDS, etc.  Terrible, terrible situation for me personally.  Finally the ethics committee got involved, and the father finally decided to extubate and let him go.

So...we failed this young man in my view, in retrospect.

I guess I didn't really answer your question, did I?  Something we all need to think about though.

[DanielMark]

when do you think heroic measures become abuse to the patient?

Well for me that would be the moment the patient's wishes were disrespected, assuming the person's wishes are known beforehand. I have made my own wishes known legally. I have a DNR notification on all my medical records, have a Living Will, and my Trustee (my former partner and best friend) knows without question what I want should I ever not be able to decide for myself or convey my wishes.

Daniel

[AlanBama]

a very good topic !

I recently had to re-think my advance directives.   The one I had on file with my doctor and the hospital was from my 'dark days', and I specified no heroic measures under any circumstances.

Now, it would be a shame for me to have survived 19 years with HIV and have a heart attack, and die because of an old DNR directive.   So I updated mine last year.

Alan