Wow...that's just a tragic statement of how badly we need to overhaul our collective thinking about end of life care and the quality of living for these people. I can't imagine this patient wanting to be hooked up to all that tubing...
ARRRRGGGHHH. I know exactly how you feel--mine are usually about 94 years-old with the neglectful children at the bedside, demanding us to save granny at all costs. When did the ICU become "palliative" end-of-life care? You can't cheat death, but you can certainly approach it with dignity and a reverence for its inevitability--a concept that seems lost in our present society.
If it ever comes time that I can't change my own diapers, I'm going to take up smoking and heavy drinking. If that doesn't work in two or three days, I'm going to become the world's oldest heroin addict. Then, I'm going to donate my body to science. I've always wanted to be the skeleton that hangs on a hook in the biology lab.
9, nine, NINE! different IV pumps! WTF!
The heck of it is that by the time you need diapers you won't be likely to be able to get out and buy the cigs and beer.
eh, I'll get my kids to buy them for me. Anything to speed up their inheritance...
No wonder we can never find an IV pump. You have them all there!
I now know why you haven't blogged much lately.
Let me guess,dopamine, levofloxacin, midazolam or propofol, TPN, potassium, antifungal, another antibiotic, muscle relaxant, narcotic.
Oh yeah, one pumps for the carrier fluid, so only 7 medications if you don't count the TPN, hope I'm doin that well when I'm 87.
Frank - What, you forgot Amiodarone? EVERYBODY gets IV Amio...
Levaphed,Vasopressin, Amiodarone, Insulin, Diprovan, NS, 2 Chasers for meds, ?TF's.
Classic picture... but your dogs frighten me a little. Sort of have that vapid, slightly sinister look in their eyes. And the outfits...
Did anyone bother to notice where the call bell is located? If for some reason the patient woke up, do you think s/he could ring in for help?Once again, one picture reminds us of the importance of having a living will/medical proxy. Read page 11 for a student-written resolution: http://www.nsna.org/pubs/pdf/Resolution2008.pdfAside my rant, this picture makes me ponder: is this patient dying with dignity or at the expense of what "medicine" can do?
little heck: Waking up? Really?
er's mom,I count Ten different pumps. Not that it really matters.
I'm noticing a high equipment-to-patient ratio here. That is never, ever a good prognostic sign.And really...wake up?
Let's just remember that if there weren't people put there that wanted their loved one saved at all costs, no matter what the quality of life may be, this would not happen. It seems like it's always the poor old lady who never would have wanted this, whose family thinks of 10 stories where someone they knew had someone they knew get very sick and recover. I hear these stories day after day. After a while you just smile and keep adding more drugs.
Nine IV pumps and one tube feeding pump. No TPN - she's on a tube feeding. And I spotted a bottle of propofol so waking up ain't gonna happen unless the nurse wants it to.All I can say is if this is the way things are going to continue investing in some 4 channel IV pumps would be helpful. Well, I also want to say I'd have to KILL any doc that wrote an order for a CT or MRI. Can you imagine dealing with all that mess AND the ventilator for a trip to radiology??? Especially if that involved an elevator ride. Even unhooking everything except pressors, sedative, and vent it would still be a nightmare to disconnect and reconnect!
If you think it's bad when adult children demand everything be done for their 97 yr old mom, come work with me for a few days. I am an RN in a pediatric ICU. Try getting parents of a young child to accept that nothing can be done for their child and let go. I understand that this is a much more difficult situation, but the sad truth is that children do sometimes get sick and die. The picture posted here would be the set-up of one of my more STABLE patients. I have had patients in which a bedside EEG was flatlined, but by law, that wasn't enough to declare brain death. We have to transport to CT to look at the brain and also to nuclear med to do a "flow study" which shows if there is any blood flow to the brain. No disconnecting and of the pumps here because doing so would be a withdrawal of care. I have actually had to testify in court to withdraw support on children because CPS says that is the parents decision even when it was abuse BY THE PARENTS that caused the condition!! Hmmmm, it's your decision whether or not we allow you to now be guilty of murder vs. just abuse.....makes sense to me!! NOT! Sorry for the rant here, just had a situation as described this past week, so am a bit touchy right now.BTW, those meds in Peds would be...Dopamine, Milrinone, Vasopressin, Norepi, Epi, Nipride, Fentanyl, Versed, Vecuronium, TPN, IL, IV fluids to chase drips, Lasix, and insulin. And, yes, tube feedings as well. If we cannot meet calorie needs with tube feedings alone, we frequently use tube feedings and TPN at the same time!
Yeah but look at the bags. TPN (or even PPN) has a distinctive appearence and I don't see it hanging.
Yep, you're right....no TPN hanging.
We could cut down on these situations a bit by requiring the family to pay for a portion of the care, esp. if they are receiving grandma's social security check. No we can't - it would be cruel to require people to pay for the goods and services they and their family use.
Why are you doing that? Shame on you.
we doctors like to blame the crazy families of dying patients for forcing grandma to be alive at all costs even at the expense of quality of life. but we really only have ourselves to blame, since essentially we are allowing irrational people without a medical degree to make medical decisions on OUR patients. It is not rational medical behavior to offer exploratory surgery to a healthy person just because they want it. We do not offer whole body CT scanning to healthy patients because there is no evidence to support any benefit. Likewise, treatments to extend life in a dying patient are not warranted because there is no benefit. I'm not sure why its so hard for docs to get this - irrational fear of lawsuits? It is time we put our foot down as physicians, and reclaim old territory as authoritative figures in medicine. Patients and their families need to be guided by a firm hand, to be told that medicine has its limits, and we need to refrain from offering a smorgasbord of options in this era of "patient choice" - as if hooking up poor grandma to ten different drips, a ventilator, feeding tube, dialysis, pressors, sedation etc, was a really desirable option.
anon 0615:Go here:http://fatdoctor.blogspot.com/Go to the post from yesturday titled "Unprofessional Moment In Time"Did you change your mind?
Anon 6:15 here,No, that story does not change my mind. I think it is possible to be compassionate with family and still act in the patient's best interest. A more appropriate response may have been to explore the daughter's fears regarding morphine and simply listening. Agreed, hard to do at 3 am, especially when you are sleep deprived. But I find this approach more helpful than in assuming what the other persons' beliefs and attitudes are. This still doesn't mean we have to take the path of least resistance and cave into the daughter's demands. BTW, I think it's been shown that lawsuits are less likely when patients and families believe doctors actually take the time to talk to them.
I count 9 IV pumps and a TPN pump. There needs to be a point where the family really should just let go and let the person die with some dignity instead of as an ethic professor once told me "aerating a corpse". I would prefer my family just bring in the priest to give me last rites and let me slip off in peace with a large dose of morphine rather than be tied to so many machines at such an old age, I'm being called home and should be on my way not tethered down to a bed. Let my family remember me when I was healthy, not looking like that with so many tubes in my arms.
You know, it is not always the families or the patients that are going for the care. I blogged awhile ago about a 90 year old friend who had a bad fall and was found to have a PE, never had one before, and the hospital went whole hog with the "protocol" treatment with the blood thinners and she got pretty sick before anyone realized she was bleeding out. She was not offered any alternatives. What she heard is, this is what we have to do. She could have probably been offered "watchful waiting," and care for the symptoms--some pain meds and some oxygen--and not gone through a massively debilitating week as she did. So, not to negate what you say about families, but this one is going to be a tough problem to solve and we've got to look at all the intricacies of how decisions are made.
What if the family is following the patient's wishes? My father said clearly and unequivocably that he did not want to die and that we were to make the hospital do whatever it could to save him. It brought him another two weeks of extreme suffering, but it is what he asked for.
This looks VERY familiar to me. Only, on the other side of the bed, next to the vent, would be the CRRT machine, too.
Didn't these people ever the movie 'Harold and Maude'.. you are just supposed to accept the end of your life as part of life. We are meant to die as much as we are meant to be born. Leave it to a nitwit society like ours to not understand that.
Hot diggity dang I work all day to make my racks look that clean. Maybe having a bigger room versus a 10x10 prevents the bird nests that seem to accumulate in our patients room around their IV poles.
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