Ethical discussion to follow...

[itku2er]

Do you think removing this conscious, coherent (based on incomplete reports I know) from her vent constitutes murder? Suicide? No I do not the vent only did this.. it kept her from DYING, but it didnt allow her to LIVE. It isn't murder we are following the wishes of our patient, this is no different than following a DNR or a Living will.

Does she have a right to ask people to, in effect, kill her? Yes you said yourself she was coherent and could make that decision. She has the right to make any decision about her health care as she wishes. Either to have extreme measures carried out or have them with held.

Do we as family members (hypothetically, of course) have a responsibility to pull the plug if our loved ones are awake and able to communicate? (Brain dead or in a vegetative state is different so please don't confuse the two.) Yes we do as their families we should follow what they want not what we want hard decision YES. Who better than to give us the comfort in the end of our lives than our family they know us best they know what we want.

Do we as health care providers have a responsibility to honor this woman's wishes? Would it constitute murder on our part? Does this violate primum non nocere? After all, we would actively act to take this woman's life. Yes we as health care professionals should follow her wishes like I said in the previous post we do not know what kind of mental hell she may be enduring knowing she is gonna spend the rest of her life on a vent and have no quality of life as she did before. Mike as health care professionals we have to follow the wishes of our patients. Reguardless of our own personal beliefs we have to allow them the freedom to make those decisions. If we do not follow them then we are guilty of a greater injustice to them.

I wonder if she had a living will would we be having this discussion its the same principle just different means by getting her wishes carried out.

How's that for a start? My apologies for a confusing introduction.

-be safe

[Doczilla]

I fail to see how this is murder. According to the article, the patient communicated her wishes that she wished to be taken off the ventilator. The ventilator was withdrawn as consistent with the patient's contemporaneously stated wishes.

'zilla

[Eydawn]

This is a very tricky situation. It hinges on a couple of issues; firstly, can nodding and blinking represent conscious, fully competent consent to anything? If she can shake her head "no" when they ask something and can also shake "yes," then I believe it can be legal consent.

Now... here's the rub. Let's say you have a patient who's able to speak, whose life is maintained only by kidney dialysis. They cannot survive without being hooked up to a machine to perform the function of their kidneys. They decide they no longer wish to be hooked up to the dialysis machine, ever... and they have the right to refuse that care. They are refusing kidney support, which results in definite death (albeit, taking a little longer to get to that stage). Is that their right to refuse? Are they in fact committing suicide, or simply refusing care as is their right? Answer that for yourself before you read the next part.

You have a woman, who can communicate by blinking and nodding. Her life is only maintained by artificial respiratory support provided by a machine. The machine, in effect, breathes for her, which is necessary for life, much as kidney dialysis is for the other hypothetical patient... she decides she no longer wishes to be hooked up to the machine. This will result in definite death.

Is it any different from refusing dialysis? There's a difference between unplugging someone from a vent who cannot communicate at all, and who has no living will, and unplugging someone who can communicate and indicate that they no longer want a life-sustaining treatment to be administered.

It feels different, because it is much more immediate and visceral to unplug someone from a breathing support. But in effect, it is no different from someone being unplugged from a kidney support, or pacemaker... as long as THEY are the ones dictating the action, whether through a living will or ability to indicate intent.

That's my take on it. Otherwise, we head down the road where we say that no living, conscious, decision making being has the right to choose to refuse an intervention that is maintaining their life- no matter what that intervention is. Choosing to no longer intervene is very different from active euthanasia...

Wendy

CO EMT-B

[island emt]

Mike If I personally was in this position please come pull the plug for me as I am unable to do so for myself.

This is nothing more than allowing a pt to decide what level of medical intervention they choose to receive.

The fact that I have become disabled by an accident does not remove my legal right to refuse intervention.

Keeping me in a functioning state by artificial or mechanical means is not my wish.

[VentMedic]

This does not sound like a C5 -C7 injury as described by Rid. His friend also sounds young.

I have seen several in our Rehab facility that were not only able to come off the ventilator but also be decannulated. However, even with that they run the risk of an infection or even a systemic reaction to pain or a missed BM that could become life threatening.

Take into consideration this lady was 65 y/o. The fact that they were not able to allow this patient to vocalize her requests, even with the ventilator, indicates a very high injury. Even a brief ventilator disconnect can create serious problems leading to an anoxic event. At this level she will not have much of a cough which will make her very prone to infections and plugging. She will also be very prone to decubitus ulcers. Care givers will have to do strict skin care, BM programs and catheterizatons. These are all very heavy responsibilites to place on the family especially if blinking will be her only way of communicating her anxiety. Being institutionalized in this shape will be the luck of the draw. While there are very good facilites, it doesn't take much for a bad event to happen. While that could solve the question about "brain function", one would not know what anxiety she would endure if her ventilator did not give her a breath from either a disconnect or plugged airway. She would try to struggle for breath but due to her paralysis, she could not actually achieve this. Life would slowly slip away. She might not die but just go through this anxiety each time her ventilator alarmed, not knowing when someone would come to her assistance. She would be constantly reminded not only of her paralysis but also of her inability to communicate.

Or, she could get PNA or sepsis. The V/Q mismatching and the feeling of shortness of breath without again being able to fully communicate her anxiety of not "getting enough air" would just be torture. Her loved ones even in their best efforts might see a decubitus form that eventually goes to the bone. She may have to undergo multiple surgeries in attempts to debride and cover it with grafts. Her family may feel the pain of failing her even though this might have happened even under the best of circumstances at her age and with the paralysis.

All hospitals have an Ethics committee to assist with the decisions for ending life support. This committee will be asked to step in to confirm the patient's decisions or to assist the family who may not want to be responsible for such a decision. If the decision is made, life support will be withdrawn and sometimes, if we feel the patient will die slowly we will have a Comfort Care suite for the family to stay with the patient. The patient will be kept comfortable until nature takes its course.

Others, like those with "near" end stage diseases, like AIDS, COPD, Cardiac disorders or CF, may have to be placed on a ventilator for something that "shouldn't" be life ending like PNA or CHF. However, these patients will stipulate that if there is any chance of them becoming ventilator dependent, they want life support withdrawn. Their wishes will usually be respected. There are many more situations in which a patient's or family's request will be honored to end life support and not put the patient through more painful procedures if the quality of life will forever be compromised.

As a Respiratory Therapist, I have participated in ending life support for all age groups many, many times over the past couple of decades. It isn't always easy but there is usually a feeling that the patient's wishes were honored. The family is there. They will have been prepared by the physician, the nurse and myself on what to expect when life support is terminated. A Minister, Chaplain, Priest or representative from whatever type of worship may be present. The nurse hangs one or two drips for sedation and/or including pain and gives a little bolus when everyone is ready. I unsecure the ETT holding devices while the nurse is getting the sedation ready. The CR monitor alarms are turned off. I then silence the ventilator, pull the ETT, shut the vent off and push the equipment out of the way. The patient may or may not be placed on O2. Rarely will anything more than a NC be used. The nurse and I will make sure we have made the patient and family as comfortable as possible and step aside for a few minutes. We will have tried to prepare the family for gasps and changes in the body's color. We will still be there to help the family as their loved one dies.

As Rid mentioned, there are cases that should be encouraged to fight for life. Yet, there are many cases in which it would not be a sound medical decision if the patient's wishes were not respected. However, our subacutes and nursing homes show that the U.S. medical professionals still can not always bring about these decisions either for their own personal opinions or trying to respect family members' choice more than the patient's.

[Arizonaffcep]

Ya...forget getting unpluged from the vent...I'll take 3ml of insulin any day instead.

[mshow00]

Ok...based on the replies so far I'm inclined to think none of you read the article. Or, if you did, you missed the point.

I disagree with the above stated, she is A&Ox3(argument sake) why can't she make her own decisions? Obtaining some level of mental status on her would not be all that hard, blink once for yes twice for no: Are you _______"; "Have you _______" (etc); until satisfied there is some level of coherentcy(sp?) then ask "Do you understand what will happen when I turn off this vent? (asked many different ways and explaining in your questioning what will happen). If you can reasonably assume this is her wish, thats when you get the ethics board impute. At the end of the day (in my book at least): "Did I do what was best for my pt, or follow their wishes to the letter"; "Can I look myself in the mirror and know I did right by them?"

[BEorP]

I truly don't even understand how this is open for debate. A competant patient refused treatment and she died because of it. It was her right to do so.

[VentMedic]

Here's a few links that may be of interest.

I found Texas' outline for end of life procedures which explains the terminology and decision making process in easy to understand terms.

Guidelines for Treatment and Life-Support Decision Making for (Minor) Patients

http://www3.utsouthwestern.edu/pmh-ethics/...pportminors.pdf

This article is about end of life for a baby in the NICU.

Understanding, Avoiding, and Resolving End-of-Life Conflicts in the NICU

http://www.mssm.edu/msjournal/73/73_3_pages_580_586.pdf

Florida's SCHAVIO case

http://www.myfloridalegal.com/schiavo.pdf

Now, here is another controversial subject. In the past "Brain Death" was the standard criteria for organ procurement. Today we can now use "Cardiac Death".

Organ Donation after Cardiac Death

http://content.nejm.org/cgi/content/full/357/3/209

Volume 357:209-213 July 19, 2007 Number 3

Since 1968, when an ad hoc committee at Harvard Medical School proposed a brain-based definition of death that became widely accepted, organs for transplantation have been removed primarily from hospitalized patients who have been pronounced dead on the basis of neurologic criteria, when they are on ventilators and their hearts continue to function. The continued circulation of blood helps to prevent the organs from deteriorating.

Obtaining organs from donors after cardiac death — when the heart is no longer beating — is the approach that was generally followed in the 1960s and earlier. Today, such donations typically involve patients who are on a ventilator as the result of devastating and irreversible brain injuries, such as those caused by trauma or intracranial bleeding. Potential donors might also have high spinal cord injuries or end-stage musculoskeletal disease. Although such patients may be so near death that further treatment is futile, they are not dead.

The United Network for Organ Sharing, a private nonprofit group based in Richmond, Virginia, operates the Organ Procurement and Transplantation Network under contract with the federal government and is committed to increasing the number of donors. OPTN/UNOS, as the networks are collectively known, has developed rules for donation after cardiac death. According to these rules, finalized in March 2007, the process begins with the selection of a suitable candidate and the consent of the legal next of kin to the withdrawal of care and retrieval of organs. Subsequently, life-sustaining measures are withdrawn under controlled circumstances in the intensive care unit (ICU) or the operating room; donation after an unexpected fatal cardiac arrest is rare.

The Definition of Death and the Ethics of Organ Procurement from the Deceased

http://www.bioethics.gov/background/rubenstein.html

Along similar lines, the 1999 IOM report specifies that "in most cases, the patient who becomes a non-heart-beating donor has suffered devastating neurological damage, most often from trauma or stroke. In rare cases, a conscious, paralyzed, ventilator-dependent person has requested non-heart-beating donation." (IOM 2000, p. 42)

[island emt]

Ventmedic: Thank you for bringing the medico legal evidence to this discussion.

It should be left up to the patient and their family members to have the authority to make these decisions without interference from the government , or fear of criminal proceedings being brought against them