Thursday, August 11, 2016

ICU GUIDELINES

Government guidelines recommend cutting out tests and treatments.  New government approved guidelines recommend cutting out tests and treatments.   It is based on “Evidence Based Medicine.” Facts are twisted to show today’s procedures and treatments are not necessary.  Medical personnel and your doctor are being trained in Obama-Care.

Doctor training involves discussing end-of-life issues, the savings of reimbursement dollars from labeled “ineffective treatments, and paying more attention to alternative withholdings strategies to meet family needs, are aimed to show you the medical profession still cares about you, the patient.

Doctors are not required today to provide all life-sustaining measures possible. They must only accomplish treatment goals within the bounds of accepted medical practice. A doctor does not have to write a futile order, like IV nutrition. Even when a treatment might prolong life by giving antibiotics or IDs, the patient has a right to refuse and the doctor has an obligation not to provide this service.

Medicines will be stopped, drying agents will be given, but you will be given good lip and mouth care to leave your thirst. You will be told dehydration improves endorphin release and you will have an improved mood.

You are given enteral nutrition to improve your strength and avoid starving to death. Many people feel that you are weak because you are not eating. They also feel if you do not eat you will die.

The new guidelines want to administer fluids subcutaneously.   They will tell you it eliminates the need for skills to locate a vein, and avoids the risk of infection, clot, bleeding, when IDs are given.   Has anyone seen this treatment to be used in the past?
 Incidentally, no medical technician needs to administer this procedure. A large needle is put in the belly or thigh and 3 quarts of fluid are given every day.  Each quart contains something different. One has more salt, one has less salt, and a third has equal amounts of salt and water.

If you have cancer that can’t be reversed, you are told the causes of the anorexia also cannot be reversed.   Gastrostomy feedings are no longer popular since suddenly they are found to increase the risk for aspiration rather than reduce it. You are told feeding tubes result in increased mortality, and these tubes are associated with infection, swelling, obstruction, and desperation pneumonia. 

In summary, the new guidelines show that there is no evidence enteral nutrition will improve the quality of life for survival of your sick family member.

By providing training in discussing the end-of-life issues, the reimbursement dollars of ineffective treatment, will be saved, and spending more attention on alternative withholdings strategies to meet family needs shows they care for you the patient.

Is withdrawing or withholding hydration and nutrition euthanasia? 

 It is a decision and action that allows cancer to progress on its natural course. The action is not to seek death and end-of-life? Contrasting, euthanasia actively seeks to end a patient’s life.

The doctor must use the means necessary to accomplish the intent.  Heavy doses of opioids are given for pain, sedatives for sleep, and other treatments controlling symptoms with dosing guidelines to promote death.  Death is not the treatment, since the aim is to relieve the symptoms; it does not intentionally caused death.

Today’s guidelines state that there is no evidence artificial nutrition alone improves functional ability or energy, relieves fatigue, or improves survival, it is a cancer responsible for your anorexia and weight loss.

 We know that large doses of opioids to relieve pain also result in respiratory arrest. These large doses are permitted as appropriate, if the intent and doses given are titrated to the patient’s needs.  (Who defines needs?).

 COMMUNICATING THE BAD NEWS 

 The guidelines encourage doctors to follow a six-step protocol, called SPIKES.   If a treatment has no chance of achieving an intended benefit, it need not be offered (the example given is: like CPR on a body with a head severed).   Doctors are told patients want to discuss treatment decisions even if the benefits are zero. Talking about this builds trust and doctors must sharpen their persuasive skills when they discussed withholding treatment.

 The first discussion is about general goals of care. The doctor is to discuss specific treatment preferences in light of whether they will help achieve the overall goal (who defines the goal).  

An end-of-life nurse specialist, a part of the healthcare team, will continue the discussion and prevent some conflicts within the team. They will spend additional time talking to the patient and family. The team will give emotional support to both family and patients.

 Despite all this discussion, the doctors still must write the medical order and assume full responsibility for its accuracy.
Doctors find it hard to discuss withholding artificial feeding and hydration. They have not been trained to do so. Food and water were symbols of caring. Withholding hydration was always seen as neglect by the family the patient, and all caregivers.

 The doctor must get familiar with the new policies and statutes their hospital is establishing.  Many doctors presume their hospital had a specific policy on hydration, reflecting state and federal laws.   Doctors must now be reminded that no state requires artificial nutrition and hydration when a cancer patient cannot eat.  Most states leave those decisions to the doctor and his patient.  So it’s legally safe to withhold hydration.

 A doctor must ask the patient and family what they understand.   He must make sense to them about the patient’s eating, drinking, and disease patterns.   If a family member says: “ Mom would get better if she ate”, the doctor must review why mom is weak. When the family went to hydrate their loved one, the doctor must explain how normal dying occurs.

 The selling continues by doctors saying:
 “Can we review our overall goals for your care?
 Let me tell you what I understand you want as we plan your care.”

 The doctor must talk about the general medical condition and if the patient has advanced cancer, let the family understand the overall situation. They will be told the expected course of the cancer, and told everything that is meaningful to them is not reversible.   Finally specific life sustaining treatment preferences are discussed.

 A well-meaning doctor might say: “do you want us to do everything? “ A misleading question like this must be avoided. Everything is too broad, and misinterpreted, especially when the family believes everything has not in fact been done.

 The family must see that improved energy and strength will not occur with artificial fluids, and above all will not accomplish the hospital’s medical goals.  The family must understand that the goals for artificial nutrition are appropriate.

 Specific treatment preferences must be discussed in a language the family will understand. Perhaps a translator is necessary who is trained in the skills.   Information must be given small doses daily. The decisions made must be reinforced.   The team must check for reactions, ask the family for questions, and clarify misunderstandings. In other words, diplomacy is the rule of the day.

 It is quite confusing to ask families to decide about specific treatment preferences.  Doctors must not state that all possible therapies will be offered, but the can choose some medical items from a menu, as in a restaurant.

 Contemporary medical care requires, a fundamental ethical principle called “informed consent.”   Patients deserve a clear, complete understanding of all therapies proposed for them. Some want to know all the details, and others prefer to do nothing.

The doctor must be prepared to simplify the aspects of hydration that conforms to the principle of informed consent including: the problems of the treatments, what’s involved in the treatment, what happens if the patient decides not to have the treatment, the benefits of the treatment, and the burdens created by the treatment.   The patient is then given a patient’ family education handout during these sessions.

 What if the family of the patient says: “ don’t want mom to starve to death, dehydration is a miserable way to die, and we can’t just let her die”.   The family must be reminded these are goals for the family and not goals for the patient.    The family may believe there loved one’s lack of appetite and oral intake of fluids is causing the patient’s level of disability.

 The programmed doctor must answer: “Cancer is taking all your mom’s strength and her heart is so weak. This is what causes her to lose her appetite and feel so tired. I understand why you think that, but mom is dying of cancer, not starvation”. The family must know that a dry mouth will not improve with intravenous fluids, but will be more likely helped with oral lubricants and lemon swabs.

The doctor will be programmed to say:” I wish things were different”, acknowledge the situation, and then become silent.  He then will turn the emotional support to other friendly members of the healthcare team.   Since emotions are challenging, other better-trained members of the healthcare team will assist.

 A well-articulated and understood plan will be established. It may be simply, will be discussed again at the next visit, or the team will convene a family meeting to discuss the proposed treatment plan.   Discussion will include social work, a chaplain intervention, notifying a key family member from out of town to come in preparation for opium death, and organizing the nursing staff for the end of life protocols.

 If the doctor is forced to give a time limited trial of artificial nutrition and hydration, he must set a measure of success: We will see if mom feels stronger or can resume eating for the next two weeks. “ Just tolerating the feeding is not a good endpoint.

 The plan must be documented and spread around, to the healthcare team, so the entire team can work in an organized fashion.   The doctor, after writing the appropriate orders, must document the discussion in the medical records, and talk about the plan to the health care end-of-life team.

 Families change their goals and treatment priorities periodically.   After being presented with a situation and information, the family must know that the plan can change at any time. How to change it is not discussed.

COMMENTARY

Your mom may feel very lonely as she fights for her life in an intensive care unit.  She may be curled up in a blanket, the hospital blinds remain closed, and she sees herself at the edge of the world.   Today, many people have few friends, are very lonely, cut off from their family, few friends, and the real world outside of the hospital. 

A hospital filled with doctors, nurses, and healthcare professionals, does not help relieve the loneliness of dying. Friends do not visit because they can’t handle their friends suffering.  They are not alone, but they feel alone—it’s not like dying in your own bed at home.

Loneliness contributes to weakened immune system and a lack of desire to fight for life. We humans have evolved to depend on each other.   Since we do not connect with others, we are more likely to die without support.   Our desire to fight loneliness is as strong as our need to eat, drink, and relieve pain.  We all seek companionship and fear being ostracized—a hospital ICU does not provide this.

We all seek support in whatever way possible. A hospital is cold when one is alone.  Few Americans today die at home with their family around them.  Now with the hospital no longer providing medical help, it makes more sense to die at home among your compassionate family.

We are all going to die, but our culture dreads death.  We all seek the latest new treatment that might add months to our lives.  After all, if it is something new, why not try it.  Maybe it will help, just maybe! Now the guidelines remind us:  there is no hope.

Most of us now must consider shifting our primary attention to compassion and palliation of pain, rather than dreaming about medical intervention.  After all, Medicare says: “we all must die sooner or later! “ 

What do you think?


This is a good way to ration health care.  New are government approved guidelines recommend cutting out tests and treatments.  It is based on “Evidence Based Medicine.” Facts are twisted to show today’s procedures and treatments are not necessary.  If you are on the wrong side of the “evidence”, too bad1 by saying:  “Yearly screenings are not necessary, your insurance will not have to pay for them,” now that Obama- care is implemented



SOURCES
 EPEC™-O: Education in Palliative and End-of-life Care for Oncology (Module 11: Withdrawing Nutrition, Hydration Copyright The EPEC™ Project, Chicago, Ill, 2005).   
 (The EPEC™ Project, receives major funding from the National Cancer Institute, and the Lance Armstrong Foundation).

President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Washington, DC: US Government Printing Office; 1983. 

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