End-of-Life Choice, Palliative Care and Counseling

Posts Taggedend of life care

On a Mission to Transform End-of-Life Care

by Michelle Brandt
November 27, 2012

No one likes talking about dying, but Stephanie Pincus, MD, MBA, believes we all need to do more of it. Pincus is one of the key people who participated in the work that resulted in  a new Institute of Medicine committee tasked with exploring and preparing a report on the current state of end-of-life care in the country. The committee’s ultimate goal is to ensure that people are able to die as they wish.

“People do not want to die alone, in a hospital bed, hooked up to 15 different machines, with buzzing in their ears. They want to be with their families in familiar surroundings, able to say their good-byes peacefully,” Pincus, who recently gave a talk at the medical school sponsored by the Stanford Palliative Care training program, told me.

“Until about 100 years ago death was part of life. In early times in the U.S. when someone died they were laid out on the kitchen table,” she continued. “But as we moved medical care to the hospital, death became isolated and isolating. We need to reclaim death from the hospital and reintegrate with the family.” More

End of the Line in the ICU

by Kristen McConnell
The Brooklyn Rail
November 16, 2012

Last year I graduated from nursing school and began working in a specialized intensive care unit in a large academic hospital. During an orientation class a nurse who has worked on the unit for six years gave a presentation on the various kinds of strokes. Noting the difference between supratentorial and infratentorial strokes—the former being more survivable and the latter having a more severe effect on the body’s basic functions such as breathing—she said that if she were going to have a stroke, she knew which type she would prefer: “I would want to have an infratentorial stroke. Because I don’t even want to make it to the hospital.”

She wasn’t kidding, and after a couple months of work, I understood why. I also understood the nurses who voice their advocacy of natural death—and their fear of ending up like some of our patients—in regular discussions of plans for DNRtattoos. For example: “I am going to tattoo DO NOT RESUSCITATE across my chest. No, across my face, because they won’t take my gown off. I am going to tattoo DO NOT INTUBATE above my lip.”

Another nurse says that instead of DNR, she’s going to be DNA, Do Not Admit. We know that such plainly stated wishes would never be honored. Medical personnel are bound by legal documents and orders, and the DNR tattoo is mostly a very dark joke. But the oldest nurse on my unit has instructed her children never to call 911 for her, and readily discusses her suicide pact with her husband. You will not find a group less in favor of automatically aggressive, invasive medical care than intensive care nurses, because we see the pointless suffering it often causes in patients and families. Intensive care is at best a temporary detour during which a patient’s instability is monitored, analyzed, and corrected, but it is at worst a high tech torture chamber, a taste of hell during a person’s last days on earth.  More

Early End-of-Life Talks Tied to Less Aggressive Care

by Genevra Pittman
Reuters Health
November 12, 2012

Terminally ill cancer patients are less likely to get aggressive end-of-life treatment, such as chemotherapy in the last two weeks of life, when they talk with their doctors early on about how they want to die, according to a new study.

Treatment aimed at keeping those patients alive at the end is often expensive and may not improve patients’ quality of life or comfort. Such therapies usually involve more time in the hospital rather than at home or in hospice care.

“Aggressive care at the end of life for individual patients isn’t necessarily bad, it’s just that most patients who recognize they’re dying don’t want to receive that kind of care,” said Dr. Jennifer Mack, the study’s lead author from the Dana-Farber Cancer Institute in Boston. More

The Cost of Dying: Simple Act of Feeding Poses Painful Choices

by Lisa M. Krieger
The Oakland Tribune
November 2, 2012

A small plastic tube is all that stands between survival and starvation.

The benefits of a feeding tube — helping elders who have forgotten how to eat — seem so obvious that it is used on one-third of demented nursing home residents, contributing to a growing device market worth $1.64 billion annually.

Except it does little to help. And it can hurt.

Decades after the tube achieved widespread use for people with irreversible dementia, some families are beginning to say no to them, as emerging research shows that artificial feeding prolongs, complicates and isolates dying.

The tale of the feeding tube, known as percutaneous endoscopic gastrostomy (PEG), is the latest installment of “Cost of Dying,” a series exploring how our technological ability to stave off death creates dilemmas unimaginable decades ago, when we died younger and more quickly.

Food is how we comfort those we love; when all other forms of communication have vanished, feeding remains a final act of devotion. So the easy availability of feeding tubes forces a wrenching choice upon families: Do we say yes, condemning a loved one to dependency on a small plastic tube in their stomach? Or do we say no, consenting to their death?

Tubes are useful as a nutritional tool for patients struggling with a critical illness, such as Lou Gehrig’s disease, or recovering from stroke, cancer or anorexia.

But if no turnaround is in sight — particularly in elders with progressive neurological illness — they can be a dreadful mistake, medical researchers now say. More

A Revolving Door to Avoid

by Judith Graham
The New York Times
October 25, 2012

Two weeks ago, Dr. Arif Nazir got a call from a colleague about a 79-year-old woman at an Indianapolis hospital. The cardiologist on the phone explained there was nothing more that could be done for this patient, who had advanced heart failure, chronic lung disease and diabetes.

After a brief conversation, Dr. Nazir agreed to admit her to a nursing home and try to keep her out of the hospital, respecting her recently signed “do not resuscitate” order, or D.N.R.

It was a promise that was broken within several hours, much to Dr. Nazir’s dismay. The reasons highlight troublesome problems with long-term care that frequently frustrate caregivers and that are receiving fresh attention from medical providers and Medicare. More