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Author Topic: A Real Ethics Question...  (Read 2134 times)
bethune
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« on: Thu 4 November, 2010 - 12:05 am »

Been in the local rag (ongoing as more people coming foward) and on the news (once) and the wireless...

Doctors filling out 'Not For Resus' orders without talking with patients and/or families first.

Is common practice.

I have my views, being a Nurse, but also on the other side of the fence as a daughter before my Dad grew wings last year.

It's more complex than what most people would realise.

Would be interested to hear others views...
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« Reply #1 on: Thu 4 November, 2010 - 12:23 am »

Tough profession, I should imagine. From the triage nurse at A and E, to the heart surgeons and transplant teams,right through to the humble GP, people have to make decisions that can fairly be described as 'life or death'. On these shoulders rests the responsibility of doing what is best and kindest for the patient.

Sometimes, what is best for the patient is not immediately apparent to the untrained eye. Emotions can cloud judgement. It must be very difficult for health professionals to let patients run their natural course, knowing that quite often the outcome will be defined as a success or failure by the patient's family purely on whether their loved one continues to breathe.

At the end of the day, I can take comfort from the fact that when my father passed, the medical team did what was kindest, without forcing him down a road that would not have wanted to travel.
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« Reply #2 on: Thu 4 November, 2010 - 12:31 am »

I think they should at least talk to the family first, so it's not a surprise at the very least.

And is it judged on strict criteria, like they'll be a vegetable if they survive, or is it based on stuff like availability of beds?

Do they seek a second opinion from a colleague to ensure that it's the right choice?

I saw something on the news(Palmy hospital wasn't it?) and I recall the person that had the DNR order pulled through fine, which to me says it was a bad call

I don't know the full details, so my opinion and assumptions are based on #1 and a small snippet on the news a few days or even weeks ago
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PaganRaven
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« Reply #3 on: Thu 4 November, 2010 - 07:33 am »

very difficult choice, because each situation is different, so it would be hard to set guidelines surely?

I do know someone who was resussed even though he'd requested otherwise. he had many health problems, some from after the ressuss, so it was hard on both him and his family.





are we so frightened of death that we have to save absolutely everyone?
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« Reply #4 on: Thu 4 November, 2010 - 08:38 am »

That's totally different, his choice was to not be resuscitated, not to live and have a doctor decide without any consultation with his family not to resus him.

And isn't the point of medicine in general to try and save absolutely everyone? What if it was somebody close to you, would you want them saved as well?
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« Reply #5 on: Thu 4 November, 2010 - 09:05 am »

Doctor's motto/pledge is Primum Non Nocere, or first, do no harm. They have sworn to try to preseve life where at all possible.
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PaganRaven
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« Reply #6 on: Thu 4 November, 2010 - 01:40 pm »

sometimes, harm can be from living instead of dying.
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Weevilgenius
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« Reply #7 on: Thu 4 November, 2010 - 02:10 pm »

sometimes, harm can be from living instead of dying.

 

Mum was a cardio-thoracic nurse for years before she retired, her opinion is one I've adopted. It's appropriate (and general practice) to inform (and gain consent) from the person and/or their family of decisions made.

I don't see any point in resuscitating someone who's quality of life is so compromised to begin with and which would be even worse after resuscitating... lingering illness is not something you should put someone through before their certain death.

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« Reply #8 on: Thu 4 November, 2010 - 05:42 pm »

Doctor's motto/pledge is Primum Non Nocere, or first, do no harm. They have sworn to try to preseve life where at all possible.

You've got that wrong Dan. Allowing nature to take its course is not the same as doing harm.
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PaganRaven
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« Reply #9 on: Thu 4 November, 2010 - 05:48 pm »

Original, translated into English:

“ I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement:
To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art.

I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.

I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion.

But I will preserve the purity of my life and my arts.

I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.

In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves.

All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.

If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot.”

Classic translation of the English:

“ I swear by Apollo the Physician and Asclepius and Hygieia and Panaceia and all the gods, and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant:
To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art–if they desire to learn it–without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken the oath according to medical law, but to no one else.

I will apply dietic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.

I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.

I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.

What I may see or hear in the course of treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep myself holding such things shameful to be spoken about.

If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honoured with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.”

In the 1870s, many American medical schools chose to abandon the Hippocratic Oath as part of graduation ceremonies, usually substituting a version modified to something considered more politically and medically correct, or an alternate pledge like the Oath of Maimonides.

The Hippocratic Oath has been updated by the Declaration of Geneva. In the United Kingdom, the General Medical Council provides clear modern guidance in the form of its Duties of a Doctor[6] and Good Medical Practice statements.


 Modern VersionA widely used modern version of the traditional oath was penned in 1964 by Dr. Louis Lasagna, former Principal of the Sackler School of Graduate Biomedical Sciences and Academic Dean of the School of Medicine at Tufts University:

“ I swear to fulfill, to the best of my ability and judgment, this covenant:
I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.

I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.

I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given to me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.
 
 eek
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Wolfdini
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« Reply #10 on: Fri 5 November, 2010 - 10:23 am »

can you condence that into 5 short single line sentences??   eek

I'm in a hurry today        
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bethune
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« Reply #11 on: Fri 5 November, 2010 - 01:10 pm »

Doctor's motto/pledge is Primum Non Nocere, or first, do no harm. They have sworn to try to preseve life where at all possible.

In my experience, there are Doctors who haven't got the balls to talk about dying and death with patients, let alone resuscitation. Their medical training lacks markedly in that area. Then, throw in their personal, religious and cultural beliefs and they 'preserve life' at all costs. Even when the patient has made it clear they do not want to be resuscitated. 

And, more often these days, they're covering their arses because Mr and Mrs Public are more likely to complain about treatment received - or not.


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PaganRaven
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« Reply #12 on: Fri 5 November, 2010 - 02:20 pm »

and to think that not all that long ago, a doctors visit was special and hallowed.

house calls  a long-forgotten past time, but necessary to stories like Black Beauty 
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bethune
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« Reply #13 on: Fri 5 November, 2010 - 02:47 pm »

Off Topic but...Black Beauty !!! 
I've still got the BB storybook  :book:I was given on my 5th birthday ...still gives me goosebumps when I look at it. Beautiful pictures and so 
Barstools ...treating such a beautiful horse like that

Was going to go out and save all the horses...well, the ones exactly like BB anyway...in the world  and look after them on a little bit of farm and...  Angel

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PaganRaven
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« Reply #14 on: Fri 5 November, 2010 - 04:08 pm »

not sure if I still have them, but I used to have some of the annuals from the old tv series too. watched it religiously 
I think I cried through most of the book
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bytey
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« Reply #15 on: Sat 6 November, 2010 - 12:55 am »

Dont you give the doc the "no resus" order in the first place?

If thats the case then your family should just respect you wishes.

If thats not the case, then yes, the family should definitely be spoken with first
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bethune
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« Reply #16 on: Sun 7 November, 2010 - 12:23 am »

Some patients come to the ward with a NFR in place. It stays throughout their hospital admission.
Once they are discharged, it becomes null and void.
If they are re-admitted, even within 24hrs, a new one has to be initiated.

Rarely do patients have Living Wills, Advance Directives or have already decided that in the event of an arrest, that they do not want to be resuscitated. Even then, most Doctors are reluctant to make the patients wishes formal by signing a NFR form.

A Doctor will decide a patient is NFR if the patient is already so ill and has multiple co-morbidities, that the chances of a successful outcome from an arrest is minimal and that to even attempt resuscitation would do the patient harm.

Full resuscitation is actually a violent, invasive and prolonged procedure. Even with the most experienced staff performing the resus, there is a high chance of further damage being done, more so if the patient is frail  and in a weakened state before the arrest.

Performing resus on the types of patients mentioned above is actually an ethical dilemma in itself, because we know that they will either not survive or their post resus status will be worse.

NFR's are not initiated for bedspace or fiscal reasons.
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bytey
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« Reply #17 on: Sun 7 November, 2010 - 12:48 am »

If the patient hasnt ordered a non resus themselves, then I think the family should be spoken with first.

With any risks etc being explained.
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bethune
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« Reply #18 on: Tue 16 November, 2010 - 12:40 pm »

Legally the spouse and/or children or nominated next of kin don't have to be involved in the discussion or decision making about resuscitation. If there is an Enduring Power of Attorney in place, for Personal Care and Welfare, that has been enacted, then that person is involved in the discussion.

Morally and ethically, the spouse and/or children or nominated NOK should be, and usually are, involved in the discussion and decision making. But that's only when the Dr has the balls to bring the subject up. As Nurses, we can bring up the subject of resus but not all Nurses have the experience and confidence to broach the subject.

Very recently, I had to initiate resus on a patient who was very elderly, very frail and acutely unwell. I had asked one of the medical morons to sort out his resus status because we all knew his chances of surviving an arrest, let alone coming out of it with any quality of life were slim to nothing. (Known as Medical Futility). The moron said the patient was for resus. He hadn't spoken to the patient of family. Less than 3 hours later, I was doing compressions on the patient. Despite the best efforts of the team, he didn't come out of it. Found out from his family that he would not have wanted resus anyway.

Is, and will be, an ongoing frustration, getting resus status clarified let alone the appropriate (for the patient) decision made.





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