How Mr. Jones Died

Mr. Jones was 83-years-old when he died. He came to us by ambulance from with shortness of breath beginning a little after lunch. He was from a nursing home; he had the alphabet soup of morbidities: CHF, CVA, NIDDM, CAD, COPD  — topped off by dementia related Parkinson’s.

He had pancreatic cancer, and plainly, he was dying. His advanced directives, outlining the plan for end-of-life care stated no heroic measures, but if he became seriously ill, he was to be transported to the emergency department for evaluation.

The nursing home where he lived did just that. He went through the usual emergency department process — seen, treatment started and referred to the internist for admission — all the while obtunded and gasping for air, despite the high flow oxygen. He  was a tall man, broad-shouldered; he lay restless in the narrow emergency department stretcher, his gnarled feet hanging over the end.

A flood of patients had deluged the hospital. There were no beds upstairs. I talked with Bed Flow and we made Mr. Jones a priority for a bed. But somehow his criteria never met bed availability, and when I came back two days later, he was still in the Observation room — and still no room on the floors. I had Housekeeping look for a regular hospital bed for him. There were already three being used in the department, and the overflow of  admitted patients meant there were none to spare. The Obs room nurses provided comfort measures, did mouth care, applied barrier cream over bony prominences, repositioned every two hours. They did what they could, but in truth, they were not palliative care nurses, a unique speciality unto itself. He never opened his eyes and he died by inches. Mr. Jones finally went three days after admission. His feet were still hanging over the end as we packed him away in the body bag and sent him to the morgue.

For the nurses, who knew what care Mr. Jones deserved, the experience was distressing. For the family, it was devastating, a layer of suffering over grief. For the patient himself, we can only hope he knew little and felt less.

There is absolutely no space in the system for patients like Mr. Jones — elderly, debilitated and often requiring complex amounts of care — to die with dignity. Nursing homes, despite their demographics, are very poorly equipped and frankly don’t have the resources to deal with dying patients. They dislike having dying patients; they will send them to the emergency department even when the advanced directives explicitly state the patient is not to be transported. Emergency departments are similarly not geared for end-of-life care, even though death is something we deal with frequently. We have neither equipment nor expertise; we don’t even have ready access to expertise.

And yet the case of Mr. Jones is not exceptional. How can we ensure people can die comfortably and with dignity? It’s a problem, I think, without at quick fix, but is by no means intractable or even complicated. It means explicitly recognizing that for the majority of cases, the best place to die is not in hospital, but at home or under nursing care in the community, and providing the resources to make it possible. And if such patients must come to ED, giving us the tools to do our jobs properly, so we can provide safe, competent and ethical care. That would be a good start, and a necessary one.

Because all I can think, that might be me one day. Or you.

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Some Days You Just Gotta Post Links Vol. 7

A little more than the usual linkage, to carry you through the holiday season.

• Handy guide to those darn cranial nerves (Oh, oh, oh,  to touch and feel. . .)

• A medical wiki, supposedly written only by real physicians. There ought to be a nursing wiki, don’t you think? How would we start one?

• The structure of your brain makes how you see the world unique:

“Optical illusions mystify and inspire our imagination, but in truth they show us that how we see the world is not necessarily physically accurate, but rather depends a lot on our brains. Illusions such as the ones we used influence how big something looks; that is, they can trick us into believing that two identical objects have different sizes.

• A story with a moral at the end.

• Thoughts on chaperons.

• “Specially trained nurses, known as nurse practitioners, may help speed the diagnosis and management of patients with back pain who would normally wait months to see a surgeon, according to a new study.”

• Discussing euthanasia is still pretty taboo, according to this CMAJ article, but:

Although 67% of Canadians and 85% of Australians support legal euthanasia, according to polls conducted by Angus Reid in Canada and by theNorthern Territory News in Australia, Nitschke says support from the medical community is lower than the general population. “Some people think you can either support palliative care or euthanasia. They don’t think you can have both.”

• When does the duty of care end in the Emergency Department?

• V-fib arrest:

“Let’s shock him!” Without even batting  an eye, the pads were placed on the patient, “EVERYONE CLEAR?” The familiar sound of charging I hear the daily, when the equipment is tested.  And then a very new and different sound as 200 joules of electricity surge through the machine and into the patient and the patient nearly leaping off the bed, yelling, and grabbing his chest, as his heart is told to beat differently. His eyes bulged in his head. He looked like he might vomit, might punch someone in the face, and then, nearly as soon as it began, he lied peacefully. He converted. Heart rate 130’s, A fib.

• Everything you wanted to know about healthcare hashtags.

• Some good news from the Amazon.

• If you wear scrubs, this is just very funny.

• None of them true, except all of them.

• Hospital stupid, in which player pianos are more important than rape kits.

• Burning Tiger’s living will:

Under no circumstances are any healthcare providers, paid or volunteer, to perform CPR on me, including artificial respirations or chest compressions. There are exceedingly few people that survive such therapy and frankly, I’d rather use that slim chance to win the lottery

Should the preceding request go unheeded and I am on a ventilator, under no circumstances should artificial ventilation continue for more than one week. If I cannot be taken off the ventilator in that time, please remove the endotracheal tube or whatever artificial airway is in my body and turn off the ventilator. I will take my chances.

Under no circumstances am I to be fed. This includes tube feedings via any port in my body including intravenous, nasogastric, orogastric, percutaneous endogastric or duodenal routes, or even if someone should offer to cut up my food and/or feed it to me. Should the recommendation for such a form of nourishment be mentioned as part of my care, I summarily refuse it.

• Me too!

• And now, a message from the hospital CEO:

I have been sitting down with the Vice-Presidents and they will shortly begin having meetings with upper-level management who will then be meeting with middle-management, who then will meet with your unit managers to work on the operating budgets for the next fiscal year.  Sacrifices will have to be made at one point.  We’re hoping this doesn’t include layoffs, but instead we will flex and cancel people so that they have a de facto pay cut since they no longer work their scheduled hours.  We’re all doing it.  In fact I am taking off time this month as well, flexing.  Of course, my salary isn’t remotely effected.  We here at the Head Orfice do appreciate your sacrifices, but are asking for more.  We need you to do more with less.  Our new operating budgets will reflect that.  There are going to be hard decisions to make in the next year and I hope that our staff will be willing and able to make the changes needed and if not I’m sure there are plenty that will.

[But read the whole thing.]

• Nursing Times’ retrospective for 2010.

Some Days You Just Gotta Post Links Vol. 6

The ultimate, time-honoured, blogging fake-out, where your faithful blogger shouts, “Look over there!” while going off and doing something else altogether. Enjoy.

• A nurse ethicist on end of life care: “The fact that families feel that they haven’t felt that they’ve been part of the decision-making processes regarding end-of-life care and wishes, means that something is definitely wrong with how the health care team is functioning, at a very basic level.”

• End-of-life care for dementia patients: “But dementia does kill, and caregivers can request better end of life care for people with severe dementia by asking some tough but crucial questions.” [Via]

• Our First World obsession with the never-ending War on Drugs (among other things) harms palliative care patients in developing nations: “This lack of availability is not because morphine is costly or difficult to get hold of. What is to blame is the so-called war on drugs, says Lohman. So concerned are developing nations such as Columbia, Egypt, and India about the potential for addiction, or the illicit use of morphine, that they make it almost impossible for doctors to give morphine to patients.”

• Massive health cut job cuts on the table in Britain?

• A takedown of Cash for Work/Food for Work programs in Haiti. Long read, but worth it if you’re interested in development issues. [Via]

• Guess who’s 500 years old this year? [Via]

• The antecedents of modern crazy hatred for Muslims. Think Guy Fawkes.

• Trouble is the culture wars, like most wars, are about the money. But still, a good question: “Could we all find a way to take up the Hippocratic Oath to ‘first, do no harm’ regardless of our beliefs on ‘culture wars’ issues? Clearly, it would not be easy – but isn’t it worth trying?”

• Maybe it was just me, but were some of them really obvious? ECG intrepretation slideshow. [Via]

• Also, an ECG wiki: ECGpedia! Because I love cardiology and intend to bore you all. [Via]

• Some spectacular photos.

• My mother once served this at a party, circa 1969. I think it’s boiled potatoes atop the kohlbasa. God knows.

Some Days You Just Gotta Post Links Vol. 3

In honour of a certain otitis media.

• Some more really bad food. “Four adult men would have to share this entree in order to each stay within a day’s worth of saturated fat.”

• Quackery. (Also reminds me of that nursing “diagnosis”, “Disturbed Energy Field.”)

• “Signs that your opinions function more to signal loyalty and ability than to estimate truth.”

• More opinion on Nurse vs. Police Officer.

• Older nurses will remember “MONA greets all chest pain.” Turns out maybe the “O” isn’t so good for you.

• Palliative care and chemo: “The care the palliative teams offer lets patients be more active, which means they stay healthier. They’re less depressed so they’re more likely to be out and about and keeping physically fit. Of course, they live longer.”

• Prisons warehouse psychiatric patients, mostly because they can, and because, you know, they’re in prison and the federal government has determined the punishment must go on and on.

• Also in prison news, this hasn’t been fixed: ” Court and prison documents obtained by the Star show how the young woman’s complaints of inhumane treatment were repeatedly ignored and how she wound up a “caged animal,” four years after first entering the correctional system for throwing crab apples at a postal worker.” See also here.

• Tex is back. I hope.

On Death and Dying

A couple of articles of note, both longish, but definitely worth reading. For nurses, in any setting, providing care around death and dying is probably the most profound and meaningful thing we can do — and I have seen nurses do it exceedingly well, with sensitivity and empathy. Excerpts:

The Last Hours of Living: Practical Advice for Clinicians

Clinical competence, willingness to educate and calm, and empathic reassurance are critical to helping patients and families in the last hours of living. For most dying patients, predictable physiologic changes occur. Management principles are the same at home or in a healthcare institution. However, death in an institution requires accommodations that include ensuring privacy, cultural observances, and communication that may not be customary.

In anticipation of the event, it helps to inform the family and other professionals about what to do and what to expect, including matters such as when rigor mortis sets in, and how to call the funeral home, say goodbye, and move the body. Care does not end until the clinician has helped the family with their grief reactions and helped those with complicated grief to get care. Care at the end of life is an important responsibility for every health professional, and there is a body of knowledge to guide care.

Life Review in Critical Care: Possibilities at the End of Life

When any form of life review is undertaken, a life is examined, and questions such as the following are asked: Who am I? How did I do? How did I live my life? Thus, an important difference between reminiscence and review must be addressed. Life review is “not a random sharing of pleasurable past events, but rather a structured process containing a component of self-evaluation.”  Life review can be used with both patients and patients’ families; the outcomes include increased life satisfaction and accomplishment, promotion of peaceful feelings, and a state of integrity. Furthermore, Garland and Garland contend that life review has a distinct purpose in end-of-life care by upholding the unique value of each person’s life. These themes are consistent with Erikson’s theories of development: the final task is ego integrity versus ego despair. Ego integrity involves acceptance of the course of one’s life, acceptance of one’s place in history, absence of death-anxiety, and satisfaction with life. In contrast, ego despair echoes in the words of the poet Robert Frost: “. . . nothing to look backward to with pride, and nothing to look forward to with hope, so now and never any different.”