Facing Death - when to pull the plug

[Chew]

---

Members don't see this ad.

Hi everyone. After lurking SDN for a few months, I finally decided to finally post something.

http://www.pbs.org/wgbh/pages/front...epage&utm_medium=proglist&utm_source=proglist

This Frontline documentary, Facing Death, is about the decisions doctors and family members must face and the hardships they go through when "pulling the plug" on the machines that sustain life. This documentary captures firsthand the emotional hardships that the families go through, and takes the opinions of doctors, nurses, and healthcare providers.

My personal opinion is that there's no point in trying to extend life on someone who cannot be helped. Even though the process is emotionally difficult, its better to let them go rather than have them live unnaturally on a ventilator. It's just painful for everyone involved. It's also an extremely delicate matter for the doctor to discuss with the family. The documentary is 54 minutes, but it's well worth your time.

 

[apumic]

This is an interesting discussion. It takes us into the whole question of "futile care."

IMO, when care becomes futile (i.e., the pt's outcome can be nothing but pending death), it likely makes more sense to let the person die naturally. Instead of trying to do utterly anything to preserve life, you do what is necessary to let the person enjoy the rest of his/her life -- be that giving pn meds, emotional support, etc. While ventilators can be great lifesavers for some, they can also be abused in such cases as those you mention.

 

[Bojangles85]

Every person needs to talk about DNRs and the like. What kind of quality of life does someone have when they are a veggie cyborg? I rather die naturally in my home or somewhere NOT at the hospital.

 

[DancinSarah]

"First do no harm". There are instances where keeping the patient alive violates of this statement, though it may seem counterintuitive...

 

[eablackwell]

"First do no harm". There are instances where keeping the patient alive violates of this statement, though it may seem counterintuitive...

Agreed.

 

[apumic]

"First do no harm". There are instances where keeping the patient alive violates of this statement, though it may seem counterintuitive...

Shall we start naming off ways...


Pt's dignity

Family's financial future (futile care)

Use of resources (i.e., best for society as well as pt's family)

...

 

[DancinSarah]

Use of resources (i.e., best for society)

I've always been interested in this particular topic... how would you propose looking at this issue? I can't imagine any other way besides somehow placing a dollar value on someone's life. Certainly no easy task, but something that must be done IMO.

 

[apumic]

I've always been interested in this particular topic... how would you propose looking at this issue? I can't imagine any other way besides somehow placing a dollar value on someone's life. Certainly no easy task, but something that must be done IMO.

I don't think we should put a dollar amt on someone's life persay. Instead, look at it in 2 ways: 1) only provide gov't, charitable, and/or insurance support to the pt where a medical provider determines further care is futile (a good legal definition needs to be given here, but most experienced physicians have working definitions they could give, I am sure -- esp. those in fields like EM and critical care; one working definition might be that the person is not expected to live beyond 6 mos from the current date w/o in excess of $1 million in care over that period and/or there is no medically-sound reason to expect the person to regain consciousness or recover from a vegetative state in the next 6 mos and the person has been in said state continuously for at least 6 weeks); 2) once care is determined to be futile, the family may choose to keep the person on life support up to the point at which they can no longer fund the person's medical bills out-of-pocket (pt families would be advised as to the reason the medical provider has determined care to be futile and would have the option to appeal the decision within the same hospital system with the decision made by the physician committee being legally final). Something like that might work.... but chances are it'd never pass as law. Obviously, some work would need to be done on the process but....meh

 

[Chew]

I don't think we should put a dollar amt on someone's life persay. Instead, look at it in 2 ways: 1) only provide gov't, charitable, and/or insurance support to the pt where a medical provider determines further care is futile (a good legal definition needs to be given here, but most experienced physicians have working definitions they could give, I am sure -- esp. those in fields like EM and critical care; one working definition might be that the person is not expected to live beyond 6 mos from the current date w/o in excess of $1 million in care over that period and/or there is no medically-sound reason to expect the person to regain consciousness or recover from a vegetative state in the next 6 mos and the person has been in said state continuously for at least 6 weeks)

But what if there's a slim chance that the patient can recover? How do you weigh these odds against the costs of support? Is the small chance that they will recover be worth the money spent on the patient? I'm sure the family will want to do anything and everything that can be done. Having to stop vents because of lack of funds will just add to the guilt the family feels of not being able to sustain their loved ones.

Cost-wise, patient care costs are insane. >50 Billion dollars was spent in 2008 for the last two months of patients' lives.

 

[apumic]

But what if there's a slim chance that the patient can recover? How do you weigh these odds against the costs of support? Is the small chance that they will recover be worth the money spent on the patient? I'm sure the family will want to do anything and everything that can be done. Having to stop vents because of lack of funds will just add to the guilt the family feels of not being able to sustain their loved ones.

Cost-wise, patient care costs are insane. >50 Billion dollars was spent in 2008 for the last two months of patients' lives.

Honestly, though, we cannot sustain such spending. The small, <1:1x10^6, chance that someone "might" recover is why the family could keep paying if they so desired. The reality is that at that pt, the chance of the pt surviving is so small as to make the resources needed to continue care better used elsewhere. The reality is we cannot save everyone. Face it -- there are limited resources. Some may consider health care a "right" (in reality, it's not a sustainable one; more like a privilege we wish to offer everyone using whatever means are available); however, it's simply reality that we cannot treat every person who gets sick. If you have ever worked in a hospital setting -- esp. a busy ER -- you know this is true. If you've ever worked an underfunded specialty (psych comes to mind), you know pts are sometimes d/c'd at the earliest possible time to make rm for more pts. Is it ideal? No, but it is reality. At the hospital where I work, an executive decision was recently made to eliminate an entire unit of the hospital because they could no longer afford to sustain it. The reality is that this unit is the only one of its kind in 60 miles and considered the best unit of its specialty in the entire region (in a 500+-mile radius). The problem is that the unit doesn't make money (it loses money due to indigent pts). It has outcomes unlike any other in the state. Even with this unit, the state is desperate for more of this type of health care. Nevertheless, the hospital system simply does not have the money to keep this unit open. As a result, it will close within the next year. When that happens, the community will be less able to care for pts who are in critical need. Pts will die as a result. There is no "pts might die." Pts will die as a result. The fact of the matter is that the resources are simply not there for every pt to be cared for. Getting into ethical/philosophical discussions over this is useless. At some point, pragmatic solns are the only way to go.

 

[toooldforthis]

Really it's a giant issue...in my mind it comes down to a multitude of factors - and each patient/family encounter may be different.

Some of the factors which rule everyones day to day decisions:
-Spirituality
-Experience with death or serious illnes in the past - or lack thereof
-Living Wills
-DNR's
-Family / Peer Pressures
-Survivors Guilt / Anxiety
-There's more....that what i can think of in my sleep deprived/no coffee state this AM.

My wife and i have an understanding, if either of us reaches a vegatative/brain dead state the we are to wait for 7-10 days to allow family and friends time to visit and say goodbye, and to allow for whatever the body is going to do to. i.e. repair, renal failure, etc. after that the "plug" is be pulled. whatever happens happens. (the last i heard we are not allowed to be organ donors due to our time overseas with the military-but i believe that can be a factor to families that find themselves in a "keep the pt alive to be a viable donor" situation.)

 

[45408]

I've always been interested in this particular topic... how would you propose looking at this issue? I can't imagine any other way besides somehow placing a dollar value on someone's life. Certainly no easy task, but something that must be done IMO.

The average value of life in this country = the amount of money we can/do spend on health care divided by the number of people we spend it on. I don't see any reason to make it more philosophical than that.