The tricky business of death has hit the news again lately, with Bob Brown’s proposed euthanasia bill, two pro-euthanasia ads banned on television and various discussions of the problematic ethics behind making death a political dilemma.
These have made me stop and reflect on my thoughts on the matter. I am a recently registered nurse in my new graduate year. I also have an extensive history in working in aged care. Issues such as euthanasia and especially “do not resuscitate” orders, are not avoidable for me, as they are part of my work day in, day out.
I once looked after a mother of two who had a minor fall at home. She lost consciousness, couldn’t breathe on her own, had minimal brain activity and was kept alive in ICU. Her family was stuck with non-functioning mother who couldn’t communicate, made little response and will suffer chronic health conditions for life. Her children were traumatised and her husband unable to cope with the “loss” of his wife, while still dealing with her being kept alive medically.
Another patient, a woman in her late 90s, was admitted to emergency with chest pains. She tried to refuse all treatment, but doctors persisted and persisted (which, legally, they had to do). She kept claiming she was allowed to refuse but they went on with the treatment. She ending up deteriorating in hospital, despite her pleas to go home to her house of 40 years and be with her cat. Eventually, she was sent to a nursing home.
As always with bio ethics (ethical dilemmas in health care) issues, the law is tightly wound through the whole problem. As registered nurses in Australia, we have a legal requirement to act ethically and ethical principles woven into our common law and legislation in Australia. To become registered nurses, we must agree to abide by the ethical principles of the registration board. However, in situations such as “do not resuscitate” (DNR) orders and euthanasia, I do not believe that the law is ethical.
DNR orders are a constant headache for many nurses working in the health system. If we get a “bat call” (a call from ambulances officers informing us of a serious accident or injury) we have to treat that person. If we don’t know who they are and they are not able to communicate with us, the law gives us implied consent and we must treat them.
Not treating people, even with their wishes, is a very tricky minefield. The four ethical principles guiding medical professionals are autonomy, non-maleficence, beneficence and justice. Nurses work to find a balance between achieving these principles, but at times this can be extremely difficult. Autonomy refers to a person’s right to self-determination while non maleficence asks us to do no harm, and beneficence then tells us to do good. How can we respect that someone wishes to die with dignity but do no harm to them? More importantly, how can we not provide treatment without being called up for negligence?
Our health systems are currently stretched and deeply underfunded. While I do not believe that health has a price, we need to consider the benefit of using over-stretched resources in instances where the success of our treatment may be minimal.
In nursing we talk about two different success rates. Success as in the patient being brought back to life or being kept alive by medical technology and also success as in the quality of life afterwards. Not often enough is a person who is brought back to life or woken up from intensive care rewarded with a perfect quality of life.
Today, if I was in an accident and left with constant pain and injuries preventing me from communicating with my friends and family and contributing to society, I have no doubt the doctors and nurses would work to save my life with little regard for my wish to be allowed to die with dignity. This is due to the reality that DNR orders are currently only the domain of our palliative or seriously ill citizens. Hospitals have a culture of intervention with the aim to save people’s lives and preserve their health. We may be young, happy and healthy today but life changes quickly. We can only give consent for a “do not resuscitate” order when we are of full legal capacity to give it but DNR orders are not given to the happy and healthy. Wouldn’t it be nice if we could have our wishes placed on a register that our medical doctors could not ignore?
A final thought to leave you with is when you are about to pick up the phone to call an ambulance for a palliative, ill or dying family member: strongly consider whether you are making the right decision as you may just be prolonging their death, not giving them life. Maybe pause for a few moments with them and remember the life you have had with them and the “life” that may lie ahead if medical intervention occurs.
This was an extremely interesting read and the end paragraph, while initially I thought was very good it suddenly occurred to me that people who have got a family member at home who is in palliative, ill or dying situation probably would stop and think before calling. Why? Well this person is at home so everyone was already aware of borrowed time and how do we really want to do this. People who call are either, those who still want to live and those who don’t want to see someone they love die. Just a thought.
If the parliamentary system was not run by gutless politicians living in fear of the lunatic “god bothering” right, we will would be able to have a Do Not Resuscitate register into which we could enter our individual desires while we are still mentally capable, and provide some leverage for relatives and medical staff when physical or mental incapacity is such that continuing life becomes problematic.
However we live in the thrall of fundamentalist religious zealots who cannot see beyond their own narrow preconceptions and wish to force their views on everybody else. In Victoria, I have contacted the whole of Victorian Parliament several times on this matter and barely receive an acknowledgement, with the exception of a few courageous individuals with sufficient conscience to acknowledge the issue in the affirmative. The substantial majority continue to hide under their desks and/or a torrent of “weasel words”.
I’m quite happy for religious adherents to suffer until the last breath, but I for one want the ability to die with dignity when the time comes. Whilst I am no great admirer of Bob Brown or the Greens, I totally support them in this matter.
Writing as a nurse of 33 years experience, 18 years in critical care, and now a Lecturer Tutor in Law and Ethics for nurses,, and still a casual nurse in critical care on weekends, I support the concerns of the unnamed nurse above. As a new graduate s/he has pinponted already the legal and ethical dilemmas that face nurses even more than doctors on a day to day basis in their care of patients. Nurses work 8,10 or 12 hour shifts in close proximity to patients requiring end of life care. They see the pain that cannot be relieved. They see the patient’s distress and the distress of the patient’s family. Doctors may visit the patient for a short period and talk with the family for a short period, but they rarely have the close one on one contact that nurses have. The law needs to be clarified in relation to the whole issue of end of life care. We have NSW Health’s Guidelines on End of Life Care and the Guidelines on Advanced Care Directives, but they are only Guidelines. If patients are able to consent to treatment, why do we not allow them to refuse treatment , to draw up a legally binding Advanced Care Directive that is respected by the medical profession. Much of the problem with end of life care in my experience lies with the medical profession being unwilling to stop treatment. They will treat every treatable cause right up the very end. It seems to come from their medical education, that stopping treatment is failure. But is it failure if that is what the patient wants? If the conservatives in the NSW Parliament are going to continue to block law reform on euthanasia, then there may be more of a chance in the Federal Parliament, provided they have the constitutional power to legislate effectively for all of Australia.
As a fellow nurse, I agree NFRs are definitely a huge issue. Lately there’s been a lot of talk about Advanced Care Planning (in Melbourne) which seems to be a good way to go about it – planning for what you want before everything happens and you have to decide in the moment. I think one of the things that makes end of life or care after major trauma hard is that without prior planning, the patient’s family are often the ones asked to decide on Limitation of Treatment Orders (including NFRs). At such an emotional and stressful time, families are often not willing to ‘let go’ of their loved one, even if it might be in the loved one’s best interests or be what they would have wanted. I’ve worked often in aged care wards, and to me, and many other nurses I’ve worked with, it really just seems cruel when some patients don’t have NFR orders, or have conflicting measures on their LTOs which really just make them redundant. For example, I’ve had patients in their late 90s with PEG feeds, traches, dementia (the list goes on), and they’re still for resusc. In my opinion, people really need to think about quality of life rather than quantity, and think now, while they’re well, about what they want to happen to them in the event of an accident, then talk to their families about it.
I really like this discussion, on a very good article, as a 76 yo, I have a health directive signed, but if I have an accident or stroke, and am taken to hospital, I wont be able to inform them that I want nature to take its course.
Maybe I should have a capsule on a chain around my neck, I wouldn’t feel right to have it tattooed on my forehead,but going out with dignity is my goal.
Any ideas?