On The Other Hand...
"I think most people don't understand what intubation is, or what a mechanical ventilator is, or what CPR is for that matter," agrees Emily Rubin, a lawyer who's now in her fourth year at Dartmouth Medical School and is the student member of the Ethics Committee. "A lot of people have these conversations in a very rushed way," Rubin adds. "There's a lot of room to improve on the way we talk to patients about these things."
CPR, which stands for cardiopulmonary resuscitation, is an emergency procedure administered after someone has collapsed and has no detectable pulse. It involves blowing into the mouth and pushing on the chest—and sometimes inserting a breathing tube into the windpipe, giving intravenous drugs, and applying an electrical shock to the chest—in the hope of restarting the heartbeat and breathing.
Often, admits Rubin, caregivers neglect to explain what it means for elderly patients who are very ill to have CPR and have their heart shocked back into rhythm. "When you really sit down and talk to families in detail about what it means to be DNR-DNI, or what might happen after somebody's resuscitated, families often will rethink their initial decisions." She goes on to explain that "DNR" means "do not resuscitate"—in other words, if a patient's heartbeat stops, CPR will not be administered. And "DNI" means "do not intubate"—that is, do not put the patient on a mechanical ventilator.
Families also have misconceptions about ventilators, says Priscilla Robichaud, R.N., a continuing care manager who serves on the Ethics Committee. They'll sometimes want a loved one to come home on a ventilator. DHMC will send
DMS's Bernat is past chair of the American Academy of Neurology ethics committee and the new chair of an ethics committee being set up by a division of the U.S. Health Resources and Service Administration.
"We equate feeding someone with loving them," says nurse Peggy Plunkett. "And yet at the end of life . . . providing them food and fluids through some kind of tube . . . may not provide them any more length of life and may actually provide some harms."
family members for training in the use of a ventilator, but Robichaud says people just don't understand how difficult it is to care for someone in that condition in a home setting.
Mary, a woman in her late seventies, had suffered a major stroke. She is being kept alive by machines in the ICU and is also hooked up to a feeding tube. She is unconscious, and her caregivers have explained to her family that she will never recover. Her husband of 50 years isn't sure whether to remove her from or keep her on life support, so an ethics consult is called.
"One role the committee can play is being an objective outsider" in helping patients, families, and physicians make decisions, says Margaret Plunkett, M.S.N., a clinical nurse specialist in psychiatry and a member of the Ethics Committee. The committee encourages physicians to have "clear and direct conversations about . . . specific goals of care that make sense . . . [and] what kinds of treatments really match that goal of care."
Although Mary's husband understood that no amount of aggressive treatment would bring her back, families often struggle with the thought of withholding artificially administered food and fluid at the end of life. "We equate feeding someone with loving them," says Plunkett. "And yet at the end of life . . . providing them food and fluids through some kind of tube . . . may not provide them any more length of life and may actually provide some harms. And yet the idea that we're not going to feed this person is a very difficult concept even for professionals to understand, let alone families."
The ethics consultants were able to help