Wednesday, June 3, 2015
Reflections on Facing Death film (16June)
Thinking about death & dying is philosophical thinking: who am I? what will happen to me after I die? what gave my life meaning, etc. It can also give us a way to think holistically about biomedical ethics. What did you see in the video that relates to class? Are we fully addressing the needs of dying patients? Critique our health care system: what could we be doing better with respect to the dying?
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Death and dying is so hard for anyone to talk about and yet it is the one thing we will all do one day “die”. I was at a meeting today and the speaker said something that really makes since that is related to this topic. She said “All mothers have a birth plan why don’t we all have a death plan?” I know how hard it is to bring up the topic of death when working with patients but this course has truly made me aware of how much I avoid it and how much I personally need to work on this skill to help patients to be able to express their wishes. Watching the video on Facing Death I felt that the team could have given the patients family a better/stronger straight forward answer. However, allowing her to say the words that the “outcome does not look good” for her loved one might have been what she needed. Sometimes saying things and thoughts out loud make it real. All of the work we have reviewed during this course about death and dying has been great information and it really shows how a lot of medical staff struggles with this topic.
ReplyDeleteI agree with the talking about it making it a little better to cope with. I have had that discussion with my 71 year old mother and she is in the denial stage right now. I think the more we talk about it, hopefully the more comfortable she might be when the time comes. I know I have had my end of life decisions discussed with my children.
DeleteI completely agree Shirley. I feel this is a very hard topic to discuss but needs to be done. I agree with the saying, "every mother has a birth plan, so why doesn't every person have a death plan?" something to think about.
DeleteI think even as birthing plans drastically change when the moment truly presents itself, so would a death plan. We have seen it. It does unfortunately happen. Patient's wishes are overridden by their selfish families who are not ready when death is upon them. We know by experience that when a living relative wishes for something other than that of the patient, in some cases the relative's wishes are carried out. Sad, but true. I have seen it. It goes to show that you must have the early and often discussions with those closest to you, and for them to know wholeheartedly what you would want in the most detailed positions.
DeleteI think that those conversations with family need to happen early and often. I can understand how as things begin to decline that family would be fearful and want to hold on to every bit of time with their loved one that they possibly can.
DeleteI saw the difficulties that the families and Dr.s have with discussing end of life decisions. The ethical decisions the Dr.s live with to prolong life or not to prolong life, no matter what they believe is/was also hard. Then the Dr.s coping with the struggles with quality vs quantity of life given or taken from the patients was also evident. Even though we have covered these topics in class they still have a huge impact on me when I see them again.
ReplyDeleteI work in the ICU and I see a lot of struggle with death and dying issues, with the family and with the health care team. I have discussed end of life decisions with patients and their families. The conversation is mostly about the facts, options, and potential outcomes. I think education is the best thing we can do with respect to the dying and their family. This way whatever decision is made they have been informed and given all the options. So many time I've heard a family member say, "I don't want to be the one who made the decision to kill them". With all the education given about the disease and it's process they still can't change that thought in their head. I try to also use this time, tactfully, to help other family members consider living wills so their wishes will be carried out and the burden of making the end of life decision will not be in the hands of their children or family members. In the end, whatever decision is made, we keep everyone comfortable as it seems given enough time, the families slowly come to grips with death. I have to say that I have also seen that rare percent that defies all odds and leaves the ICU for a few days more. They are truly amazing events.
The discussion about death and dying are often subjects that health care professionals try to avoid. It almost like as a health care professional, you are expected to "fix" the patient and not to "let go". It is often a conversation that is uncomfortable to discuss. Working in the emergency room, I've had to encounter situations to discuss in some cases the "most unexpected" conditions of the patient such as trauma, cardiac arrest, infant death and ect. As horrible as this may sound, I think the best option for the critical patients loved ones is to witness the staff that are providing "life saving" interventions if the patient does not have advanced directives.Frequently when a family witness the code, they can be provided with a "better" understand the situation or "feel better" to terminate the resuscitation efforts. I think this is an example of a holistic approach of medicine. The ICU doctor in the video discussed knowing the probability of the outcome of the patient but realized that its difficult to discuss with the patients loved ones. I did like the doctors approach to ask the patients sister how she thought the patient was doing however, I feel that she should of discussed the expected outcome sooner. I don't think we are fully addressing the needs of a dying patient. Often the dying patient relies on the health care professionals to informed their loved ones to "help" make their decision. I think the health care system a provider that has a good rapport with the patient such as a primary care physician, should address the wishes of the patient about death and dying similar to discussing health promotion activities. This discussion should be addressed BEFORE the patient is in the terminal stages of their disease process. This could allow the patient and their loved ones to "prepare" or to be aware a plan should be in place. Death to all humans are at least that death is unavoidable.
ReplyDeleteI agree Jodi, I had that conversation with my family but I never addressed my wishes with my primary physician. He is definitely one to be included in my pre-plan for end of life care. Thank you for bringing that to my attention.
ReplyDeleteThe discussion of death and dying are always hard. We as health professionals are expected fix everything. Working in the emergency room this is never more present. When we see the dying it is usually unexpected. The family usually wants us to do everything that is possible to save the patient, even if it is futile. It is hard on us to let go sometimes also. The infant/child that we code for over 2 hours because we just can't let them go. One experience that I had was coding a coworker. That was the hardest day that I have had in along time. How can we give up on someone that we know and work with on a daily basis. I think that one decision that would help in an unexpected death is letting the family observe the code. We have been doing this in the er for awhile now. When the families do come in and observe I think this helps them see that we have done everything that is possible for the patient and it helps that make the decision for us to stop. I know decision's about "pulling the plug" on someone is a hard one. My dad was in ICU on a vent for 3 weeks. We were told he was going to get better and they were making arrangements to move him to a vent rehab facility when he took a turn for the worse. The staff asked my mom what she wanted to do and she turns to me and says" Do whatever she says to do". What do I want to do: I want to save my dad's life but the medical person in me says what would my dad want. to live on a vent for the rest of his life and to never wake up. Walking up to the nurse and telling her that we wanted to make my dad a DNR was the hardest decision in my life and even though we made the decision as a family after much discussion, It was me that carried the burden of actually saying do it. I feel like everybody no matter what should discuss with their families what they want done if they were every put into certain medical situations. This way the decision is out of the families hands and they do not have to feel guilty about doing something.
ReplyDeleteI'm so sorry for your loss and that you had to experience this first hand, it's hard to be the daughter and a nurse as well. This goes along with the point I made that it helps if doctors give their input so you don't have to carry the burden or potential guilt alone that it was your sole decision. I'm sure your dad was glad you chose to do that.
DeleteI agree that having the family see the efforts we go to try and save a life can help when a death unexpected. My sister and I are both nurses and we made the conscious decision to sit down with not only our parents, but our siblings as well and have an open discussion about death and what they would want. As my oldest brother just received a terminal diagnosis , I am comforted by the fact that we will all know what to do when the time comes. I understand the difficulty you faced in making the decision for your father and at the same time applaud your courage in doing so.
DeleteFrom the video, relating to this class goes along with our ethics on dying and euthanasia. Not everyone agrees on euthanasia or when it is acceptable, similar to how not everyone agrees on when to stop treatment for terminally ill patients. I think we try to address the dying needs of patients, the problem is that no one wants to admit that death is near until it is too late sometimes to address the needs. We keep trying treatments or therapies to make them feel better and improve their status for a while longer, but even despite theses efforts, it sometimes masks the real truth, that they are still dying. The real decision is sometimes left to the caregiver and not the patient, which hopefully they know the wishes of their loved ones. That is a huge responsibility on their shoulders to try and act on their behalf if they are not able to voice their opinion for themselves. I thin our healthcare system is amazing at technology and new research, but as far as the dying goes, it can be a crutch as well. There have been major medical breakthroughs that have cured patients and helped them live, but in some cases the effort is futile. We can keep patients alive a really long time with ventilation and chemicals, but this is not always ethical. To respect the dying, it takes a very courageous doctor and medical staff to acknowledge when that point is that modern treatment or life prolonging measures are no longer beneficial to the patient. This requires very difficult decision making for both the patient and doctor. No one wants to seem as if they are giving up or admit that death is happening, but at the same time, I feel like doctors know when there really is nothing else to be done and should not be afraid to have theses difficult conversations. Families appreciate honesty and want doctors to tell them the truth. An example from the video is when the one patients brother asked the doctor to tell her the truth about if her brother was dying. The doctor did not answer her, but asked her what she thought was happening with her brother, which she then agreed she was right. I disagreed with this, even though it was handled in a very compassionate way and had the same end result. I felt like the sister wanted the doctor to say it so it would help her with the guilt of making the decision on her own. I feel doctors should be more open and just say it, especially when asked point blank. This takes a lot of courage, but families appreciate it so much more.
ReplyDeleteI wondered, too, about that exchange between the doctor and the sister. Do you think that it is better for the family if they come to their own conclusions, which are then supported by health care providers? Since I don't have clinical experience, I wonder if my instincts and reactions are too blunt.
DeleteSometimes we need to take the reins and steer the family to a decision. They often have so much involvement and so many feelings they simply can't say the words, even when they know what is right for their loved one. Many times we are called to say that further treatment won't change the outcome and in most cases the family is relieved that the " elephant" has been addressed.
DeleteI agree that as health care professional's sometimes we need to guid the patients families into making a decision. I have had families ask me the question, What would you do? i I always given my honest opinion and give them reasons why.
DeleteI agree that the act of the sister asking probably indicated she thought he was dying . I think she was looking for an "ok" to stop treatment. Or at least back off a bit.
DeleteI also agree that the sister may have been looking for a reason to stop the treatment.
DeleteWhen I started as a new nurse, I often felt that the loss of a patient was considered a failure on me as a nurse and of the healthcare team in general. The longer you stay in healthcare you realize that this is not the case. Death is a part of life and it is a privilege to give a patient the chance at a good death. For me , honesty in a patient's prognosis and what the end may look like is important information to convey. Physicians are so focused on treatment , they often overlook the subtle signs that nurse see that indicate death is near. This is where our skills as effective communicators with both physicians as well as the family becomes important - what sets us apart from being task oriented nurses to being present and involved nurses. Lets face it - we spend a significant amount more time taking care of a patient than physician ever will, and can truly interact with patients and families on a much more personal level. The decision to pursue hospice or palliative care most often comes at the suggestion of a nurse on my unit. And physicians respect our input in that regard. While I do feel that physicians should approach the patient more openly when it comes to death and dying , I think it is within our scope of practice as nurses to step up and do this as well.
ReplyDeleteI couldn't agree more about the privilege to give patients a chance at a good death. I realize that things happen unexpectedly which may not give that opportunity. But when we as a patient's nurse can help facilitate the process which leads to an eventual peaceful passing it is the patient and family who benefit.
DeleteDeath and the process of dying are difficult topics for most people to about. I believe that when you are caring for those patients, especially those with a potentially life threatening disease or illness, you need to make certain to address the mind, body, and spirit of the patient. Family also needs to be included in care if the patient desires. As approaching death, patients may be reflecting on their lives and things such as their relationships, accomplishments, failures, and stones left unturned. Faith, I believe, can play an important role. For those who are looking for life beyond this world death may not feel so much like the end but a new wonderful chapter. I believe that palliative care is a very under utilized service for patients. Palliative care focuses on quality of life rather than quantity often times extending the lives of those who chose it. Symptom management is key to keeping those with chronic illnesses and diseases in their home environment and comfortable. I believe that patients need to hear about palliative care from their primary care physicians much earlier in disease processes. I think that some times physicians are not able to allow themselves to broach the topic of palliative care as they feel they are giving up on extending the lives of their patient. This may be doing a disservice to those under their care. Many times in this video, physicians talked about the dilemma of causing their patients unnecessary suffering. It wasn’t that they purposefully made suggestions that they knew would cause that suffering, but that there was a possibility of a positive outcome with the treatment that they had recommended which lead to the suffering. Another physician commented that you cannot avoid treatment that may have a chance of helping the patient because without pushing forward with treatments we may not make further advancements. I believe that as nurses we are in a position to start those conversations. The opportunity will not present itself with every patient you encounter and every area of nursing will not be appropriate, for example L&D or the nursery. Helping our patients have a good death, when death is imminent, may be able to provide comfort to them and maybe more importantly, their family. That may also provide for their family some sort of comfort or acceptance and help with the process of grieving.
ReplyDeleteBeing a nurse to a very sick dying patient is very difficult and challenging, but not as hard as it is to be that patients family member. To be in the situation of having to make all the decisions for your loved one that is dying is something I will never look forward to. With that being said I 1005 agree with the fact that everyone needs to address their living will status and power of attorney when the are young because you never know what tomorrow holds and you want to be able to be in control of the care you receive. In the event that you may need to be intubated or extubated you want to have discussed some situations like this with you family members so they know what your wishes are. I liked the fact that the doctors took the family members outside the room to discuss options that they had on the care of their loved one. These are very difficult decisions and the support and education from the doctors is greatly needed. Everyone wants a peaceful death in the end. As much as we want to prolong our loved one's lives, we need to always ask ourselves, "Would we want to live like this, and would we want all of this done to keep me alive?" Is it worth it.
ReplyDeleteDeath and dying is a difficult conversation to have with anyone even when it's actually not an issue at the time. My Dad is getting older and is in decent health, but we all know that can change quickly. My Mom has already passed and I continually tell my Dad that he needs to make decisions now about end of life before end of life actually comes. He is remarried and we all see it everyday when families can come to an agreement. I think everyone should be proactive in their own death plan and maybe a good time to do that is when someone gets or makes changes to their life insurance.
ReplyDeleteI do like how in the video the healthcare team ask the sister what she thought. She knew her brother was dying, but wanted to her it from someone else. By her voicing her concerns and opinions then having those backed up by the professionals probably made her more comfortable knowing that decisions she was about to make were the right ones.
Families don't want to give up hope and they are scared for their loved ones to be in pain. I really feel that palliative care and hospice care of underutilized. So many times we transfer people to hospice within hours or just a couple of days before death. I wish that families understood all that hospice has to offer, people could be much more comfortable and in a more relaxed environment to spend the end of their life.
I think making a plan with your family regarding your death is difficult because, although you may be confident in your belief of life after death, it is still difficult to think of yourself without your family or vice versa. I think as people grow older they may find a different reality of their aging life, but I think it is even more difficult with younger generations to discuss. I think the progression of palliative care since the 1960s has paved a great way for the dying process. I find in my unit, transitional care, the most encountered problem with death and dying is patient and family's unrealistic expectations with terminal diagnoses. The healthcare population could be doing a much better job at gradually explaining the potential outcomes of terminal diagnoses early on, when patients are first diagnosed. I think it is the physicians' job to present this information so that they patients and families are well informed, and not left with false hope. I think organizations, such as Hospice, have created comfortable environments for patients and families, and should continue to be presented to dying patients.
ReplyDeleteI agree that making a plan is very important in a family. I think it will also make the process easier when the times does come
DeleteI loved the part when the ICU Dr. states that it is the underlying conditions of the patient that most affect the outcome. I was sort of shocked when the sister asked if her brother was dying and no one answered her. Patients and families look up to healthcare workers, especially Drs. and I think they deserve honesty. I know in the end she was given an answer, at that moment, I just felt so sad for her. People are going to die and I so agree that at times where doing our best and trying to give the person a good death should be our goal. I am not as 'squeamish" as I used to be about death. Very early in my career I worked in oncology and had the honor of watching people die with dignity. It was ALWAYS sad, but not always bad. The older I get, it has become easier for me to discuss death with patients. As I watched my dad care for my mom, he had his eye on a goal of being the primary care giver. He put himself in a position to do that. He agreed to have his aortic valve replaced at the age of 84 and a hip replacement at 86, all so he would be physically fit to care for her. About a year after she died, as he neared 90, one of my sisters felt as though he needed a caregiver. He did not want help and my siblings and I argued a little over what was more important-to have him never miss a pill or appointment, or to continue to manage on his own as he requested. I felt as though his knowing we still saw him as able (not perfect) was best even if that meant his death may come 'sooner'. I had offered help on several occasions and he declined. The day he died, he had been visiting one of my sisters in Florida. He was not feeling well and the plan was I'd meet him at the airport the next day and help him decide which Dr. he should see, or even take him to the ER. He commented he just "didn't want to start all over again with the Drs." I know he knew the end was near. It was his 90th birthday, he spoke to all of his children (13 of us) that day and my sister kissed him goodnight about 1040pm, at 1110pm she felt she should check on him and he was dead. My point is, he had a good death. Many people would not have seen him as healthy, but he was alert, making his own decisions and I don't think he suffered at the end. He lived a wonderfully healthy life even with his chronic diseases and died a good death. I do not want to die for a long time and am saddened when I lose loved ones, but I do not want to let that keep me from giving my patients an opportunity to have input when they are faced with impending death.
ReplyDeleteThat was a very hard story to read so I cant imagine how it was to live. I agree with you. It must make you so proud of your dad and family for making hard decisions. That is the way I feel most nurses would like to live and die. Caring for others until it is time to go and then going to sleep. It seemed he faced his own mortality and was at peace with it. Thank you for sharing. We hear and see so many negative stories in our line of work.
DeleteConversations about death and dying are difficult for people to have. I think most people hope for a quick and painless death. To force these conversations they have to put themselves into a place of pain and sickness. It is also hard for the family members to hear and comprehend this when a family member is talking. These conversations can be made easier with a healthcare professional or social worker there to facilitate the discussion. I was not impressed by all of the healthcare professionals in the room with the family on the video. To make someone that is emotional from seeing a family member suffer make an assumption that they are not educated on is very unfair. I was with a good friend as her mother was coded four times within hours and she eventually told the physicians that was enough. No one had this conversation with her and she made this decision out of frustration and panic. It has now been four years and she still feels like she gave up on her mother. This was not a conversation that they had fully had, as she had just been diagnosed with lung cancer 21 days prior. I think people would benefit if these conversations started early in adulthood and were updated frequently throughout a person’s life. Continued education for physicians, nurses, and social workers regarding therapeutic conversations and death and dying. Healthcare is usually seen as curative or maintaining one’s best health possible. Death and dying needs to be brought into healthcare. We should be helping patient’s make educated and personal decisions for their future.
ReplyDeleteDeath and dying is such a hard topic to discuss. I think it is so much easier to have a plan in place if the circumstances arise. I was my Mom's poa and knew what her wishes were. Although telling her doctors to withdraw care and admit her to hospice was the hardest thing I ever had to do, it did make it easier knowing I was doing what we had discussed and this was how she wanted things to be.
ReplyDeleteI found it interesting in the video when the patient's sister asked the healthcare team if her brother was dying, they all looked puzzled and turned the question around back on her. The response is not what I would have expected, especially from doctors in the ICU.
Talking about death and dying can be very hard and upsetting. However this is a very important conservation to have with your family members before the situation comes about. It is much easier to talk about when you are healthly then when you are sick. My husband and mother all know what I want in case something horrible was to every happen.
ReplyDeleteI first would like to say how it was very giving for these families to allow us to watch something so personal. We as nurses who have experienced end of life care know the struggles that families face at this time. It is not always so viewer friendly but real all the same.
ReplyDeleteIf there was one thing I brought away from the show was that it is important to have your wishes known prior to an illness occurring. It is a good start but only a start. I think that plans of care are fluid. How many times in the show did people make decisions only for these decisions to change after failed or positive outcomes from therapy. I am a nurse. It is not my responsibility to make end of life decisions for patients. Only to support them with care and education during the process.
To make things better in our healthcare system the way we look at death needs to change. All of us are going to die. We sometimes can control the manner in how it happens or how we suffer before. I saw in one case that even though the patient stated in the course of their illness that they had changed their mind and did not want some life saving measures they were given to him anyway because his sister said that was what he decided in the beginning. I think at times when I have seen this happen at work it is mostly the family that is not ready to let go and the patient has a potential for longer suffering with no positive outcome. We as health professionals need to listen to the patients and their wishes as treatment progresses. If they are able to speak then let them decide.