Comments on GeriPal - Geriatrics and Palliative Care Blog: Palliative or terminal sedation

qwAs a hospice nurse, I must emphasise that we are...

2010-12-07T00:29:07.333-08:00

qwAs a hospice nurse, I must emphasise that we are well aware of the difference between palliation and euthanasia. The primary goals of hospice are to take in a patient with a terminal prognosis of six months or less, either with or without aggressive treatment. The choice of the patient is to either suffer with invasive, painful, and futile treatments in a last ditch effort to buy more time, or to be treated palliatively via the end-of-life care philosophy of hospice to a similar life expectancy that focuses not on curative treatment, but on palliation, dignity, psychosocial and spiritual counselling, and whenever possible, various forms of wish fulfillment. The majority of patients are treated in their homes by visiting physicians, nurses, and nurses aides serving as caregivers. These are supplemented by volunteer services that range from housekeeping, shopping and errands, pet walking, reading to or writing for the patient, prayer circles, meal preparation, and even "wishes" such as a last trip to a bowling alley, a favorite restaurant, or even a fishing trip (with a nurse on board) if the patient is able.

As far as "termiinal sedation" this is a propagandist statement from the right, which as a registered republican I am very ashamed to hear of. I can not state strongly enough that we DO NOT sedate our patients to death. This would be the legal equivalent of euthanasia, and constitutes murder. Understand that it takes a tremendous amount of education and skill to be a nurse, and continued education and skill to specialize in the field of palliative/end-of-life care. We earn our license only once, and it can be revoked either temporarily or permanantly for any infarction, including the murder of patients. Congress has done our image no favors by referring to us as "death camps," and adding to this the handful of "angels of death" nurses who have been apprehended over the past several decades, the specialty of hospice has become all too misunderstood. We are healthcare providers who specialize in the provision of comfort, dignity, a healthy environment, mental and spiritual preparation for patient and family, which we attempt to end in a peaceful passage for the patient, and an experience that will not give their loved ones nightmares when it is over. We also provide 1 or more years of grief management services through counselling provided by our social workers, chaplains, and grief counsellors, along with grief camps for children of deceased patients, and support groups for adult mourners. Compare this to having major heart surgery and never, ever seeing your heart surgeon after the fact.

Thanks Guy for the post! I'd like to say a bi...

2010-01-04T17:17:08.104-08:00

Thanks Guy for the post! I'd like to say a bit about "framing bias." The pictures, particularly of the patient alone (see picture in post), are leading. In this picture, implying that palliative sedation is isolating or is for isolated individuals.

Similarly, one's description of a code blue can bias patients and family members, as in Ori's comment. We've touched on this in previous posts, but perhaps we should make it a post of it's own. Simply put - how do you frame discussions of code status to patients? What language do you use? How do you change what you say based on the clinical situation. And where does persuasion - which is ethically permissible - cross over into coercion?

The question regarding terminal sedation is compli...

2010-01-04T11:42:42.092-08:00

The question regarding terminal sedation is complicated, I agree, and highly individual. Missing from the article is the fact that in these situations the doctor often has 2 patients, the one in hospice and the family member(s). Treatment is often aimed at the family, simply because they are the ones often doing the talking, asking and negotiating. The "Ivan Ilyich" moment may be denied because of competing concerns, or often, compassion. The opposite can also be true, where family/doc may force a suffering person into an undesired "conscious death." Asking "would do you think she would have wanted" often helps, but not always.

The question regarding whether Gloria Scott was "pushed" into 'no code' is really not the question to ask, from my perspective. Given the known data about the futility of coding a patient with terminal cancer(Bedell, Rozenbaum, many others), and the added harm it often causes (broken ribs, pain, tubes in every orifice and places that aren't meant to be orifices at all, just to name a few), shouldn't the question be why is "full code" often our default position in these patients? This is one of the most crazy making aspects of American medicine from my perspective, and a place where we 'lie by omission', 'lie by TV show', or 'lie by euphemism' to our patients the most. I think a more realistic (than what we usually do) way to present the code options to a patient with terminal cancer is: "would you like us, in what would naturally be your final moments, to press on your chest and break your ribs, shove a tube down your throat and poke you with needles in lots of places in a chaotic attempt that has a very small chance of giving you more time to be technically alive but unlikely to ever return to meaningful communication with others?"

A code blue event in a patient with terminal cancer is much, much more likely to lead to the above description than to an Ivan Ilyich moment. Indeed one might argue that to code blue moment actually interrupts Ivan Ilyich moments, or other important aspects of the dying process.