Its been three years since I graduated from nursing school and began working in a med-surg Acute care unit in a large academic hospital. During an ACLS class, a nurse 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 basi 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 working in a hospital for this long, I understand why. Something else I emphasize with are the nurses who voice their advocacy for natural death-and their fear of ending up like some of our patients, in regular discussions of plans for DNR tattoos. 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."
One of my friends and co-nurses says that instead of DNR, shes 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 at most just a very dark joke.
But I know of a nurse who has instructed her children never to call 911 for her, and readily discusses her wishes (or suicide pact as she calls it) with her husband. You will never find a group less in favor of automatically aggressive, invasive medical care than nurses, because we see the pointless suffering it often causes patients and their families.
I cared for a woman in her late 90's whose family had considered making her a DNR but decided against it. After a relatively minor stroke that left her awake but not lucid, she went into kidney failure and started on hemodialysis. Because she kept pulling out her IV lines and the feeding tube we had dropped into her nose and down into her stomach, we put boxing glove-like pillow mitts on her hands.
When I approached with her medicine, she batted at me with her gloves, saying, "NO, STOP!" She frowned, shook her head and then her fist/glove at me. Her wishes were pretty clear, but technically she was "confused", because when I asked her name, the date and location she failed to give me the correct answer.
During the next shift, her heart stopped beating. But despite the "professional arguing" among her medical care-givers about her advanced age and poor state of her health, her family had nonetheless decided that we should do "everything we possibly can" for her, and so she died in a frenzy of nurse's pumping her with vasopressors and doing chest compressions. She spent the last few minutes of her life suffering with probably a few cracked ribs.
Another example, of a patient with advanced cancer, in this case an elderly woman with a well-informed husband who knew his wife was dying and that she didn't want to end her life with an extended hospital stay.
After her last tumor resection, this woman developed an infection, and during a meeting with her husband the attending doctor explained that he main problem we were immediately dealing with was the infection, which was bad and could well be something she would not recover from.
The patient's husband explained that he knew that his wife didn't want to be there and that her underlying diagnosis plainly meant that her life was going to end, that they both understood this and didn't want to painfully draw things out. The he asked if he had any decisions to make, in effect being as blunt as he could without simply insisting that they withdraw care then and there.
The doctor said no. She said that the patient needed to complete the antibiotics to see if the infection could be cured, after which they could approach the question of whether to continue with medical care. So the husband's efforts went unheard and the patient ended up in the ICU, comatose, for two more weeks, quite the opposite of her stated wish, before everyone agreed to let her go.
Nurses love the opportunity to save a life. It's why we chose our career, to help make a difference in someone's lives. And yes there are occasions when this happens in the hospital, and it is exciting and miraculous. But in the instances I've described, and many, many others, nobody involved is under the delusion that live is being saved.
The absurdity weighs me down, and so i want to describe it to you. Medical science can do incredible things. But you would not believe the type of life these life-sustaining treatments often allow.
People who are at the end of their life and are being kept alive artificially have a way of shutting down. Fighting this process is not a peaceful act.
Most patients end up on ventilators, with plastic tubes pushed into their mouths and down their tracheas in order to provide respiratory support. The tubes are taped to their faces, and patients who can move at all are usually both tied down by their arms and sedated when on a ventilator, because it is so physically uncomfortable that patients will use their last ounce of strength to pull the tube out of their mouth.
Intubated patients, and patients in comas are unable to clear their respiratory secretions and so we stick smaller rubber tubes connected to suction into the breathing tube, down their trachea and towards the entrance to the lungs themselves, in order to vacuum the secretions out of their lungs. Only adding to their discomfort.
These patients obvisouly can't eat, so they will have had a feeding tube pushed up their nose or through their mouth and their esphogus, down into their stomach. This often takes a few tries, requiring us to pull up the bloody tube, re-lube it and push it back in at a different angle.
If a patient is ill enough, these instruments will be replaced with a tracheostomy in the neck rather than a tube down the mouth and a feeding tube going directly into the stomach rather than down the nose. These are for patients who aren't expected to be able to eat or breathe independently in the long term.
These patients often develop diarrhea, simply because of the liquid food they receive, cans of smelly, nutritionally balanced, tan-colored slush; and sometimes because they have acquired a very hardy and aggressive bacteria, C. diff that is widespread in hospitals and causes profuse, foul stool. If they have diarrhea several times a day and their skin is exposed to it, the skin begans to break down, and so we place a rectal tube in their bottom, held in place beyond the rectum with small water filled balloon.
The diarrhea drains into a clear bag that hangs on the side of the bed.
Breathing, feeding and rectal tubes are only part of it. These patients also have catheters and IVs, often larger IVs that are placed centrally, threaded straight toward the heart to allow us to push drugs in concentrations that would damage smaller veins.
Healthier hospitalized patients complain sometimes about their IVs and frequently about their urinary catheter, a rubber tube up your urethra isn't pleasant.
You think all that sounds unpleasant and torturous, I haven't even had the opportunity to explain about the heparin injections. We treat most patients with small shots of heparin in the subcutaneous flesh, in order to prevent blood clots. This makes them bruise easily and many patients are often peppered with tiny bruises from the shots.
It's been said that dying is easy and it's living that's painful. Not so in the world of healthcare as a patient. Patients who have a hope of recovering from their injury, genuinely surviving it, may be fighting to live. For them the torturous days as a patient are required in order to surmount their illness. And there are always cases where nobody knows what the outcomes may be, where the right thing to do is maintain physical function and give the body time to heal.
But time and again we care for patients who are fighting to die, and having a very hard time of it, because in the hospital there are only two ways to die: with permission, too often not granted or granted too late, or in the last-ditch fury of a full code blue.
We are not helping these people by providing all this intensive care. Instead, we are taking these people and turning their bodies into nothing more then grotesque containers, and reducing their lives to a set of numbers: monitoring input ant output, lab values and vital signs, which we tweak to keep within normal ranges by adjusting our treatments, during the weeks and days immediately preceding their death. This the opposite of what should be prioritized when a person is known to be nearing the end of their life without the hope of getting well.
Nursing is a difficult job, emotionally and physically, and many times we are made to question our work. Many times we have to deal with feeling that our work is morally questionable and at times reprehensible.
Our goal is to help these people, and assuming that prolonging their lives for the longest time possible is the only way to do this is a foolish and harmful mistake. We have forgotten that our patients need to have the choice to choose to die with dignity instead of wasting the last few days, hours and minutes of their life fighting for the right to die on their terms.
