Can doctors pull the plug on someone with a sharp mind?

[Courtesy Flush]

My father is not recovering from last week's surgery. Half a lung was removed, and he has not been able to breathe on his own, as he was expected to do. He now faces a lifetime of tube feedings, dialysis, and having a machine breathe for him through a trach. This would be unacceptable to him, and his doctors are considering cessation of treatment, to let him go (if my step mother's account of their conversation is accurate).

He is 73 years old, and has smoked for 60 years, so he cannot breathe with one lung. He needs the full lung on one side, plus the half a lung that remains on the other. The half lung is not working at this time.

He would not want to live like this, and would choose to die rather than live with this quality of life. He cannot speak now, because he has a ventilator tube in his throat, and he is kept sedated because of the stress that this causes.

I want to have the trach done, discontinue his sedative, and have him express his own wishes. I honestly think he'll choose to die, but I wonder if doctors can allow this if his mind is still functioning normally. I've never encountered a situation like this, and don't know what's accepted medical practice.

Can anyone enlighten me about this?

[rfranklin]

1. If his mind is clear, he has to say take me off the machines...

otherwise it would be a breach of ethics for the doctors.

[hedgehog]

2. My mother wanted off the ventilator and she wanted the liquid

feedings topped. She was moved from the ICU and placed in a quiet room with an oxygen mask. She passed quietly two days later.

[Courtesy Flush]

3. I don't have a problem with that

I really think the patient's wishes should be known. I don't know what he wants at this point.

[McCamy Taylor]

4. Yes, if he is of sound mind he can refuse any treatment.

[Mr.Bill]

5. My mother had half a lung removed.

Although she wasn't a smoker, the half lung expanded and improved her breathing capacity over time. She lived 14 more good hears and then died of a massive stroke.

Whatever you do, get an advance directive filled out (if you haven't already) while he is of sound mind. This will give someone the authority to make medical decisions for him should he not be able to.The hospital will assist and advise you on this free of charge. My thoughts are with you during this difficult time. BTDT.

[shanti]

16. similar story

my ex-smoker dad also had half a lung removed when he was 70, due to emphysema, COPD, asthma. he came out of it ok, but he felt he was ready to die, and was never without his cannister of oxygen after that. his quality of life went downhill, and had to take daily lung "treatments". thank god, mother was RN, she handled most of it. he did last until he was 80 though. his death was not due to the lung problems. he fell and hit his head getting out of bed one night, never regained consciousness, and died at home shortly afterward.

[Avalux]

6. Unless your father has a legal document (living will) stating he wishes to be let go -

they cannot ethically pull the plug if his mind is still functioning. Talk to the doctors yourself and let them know what you would like to do; that you'd like him to have a chance to speak for himself. Don't go through your mother since sometimes the information gets mixed up, she is under a lot of stress right now.

[McCamy Taylor]

13. Wrong. If he is of sound mind legally, he can refuse any treatment. Period.

It is the principle of autonomy, and every adult "of sound mind" has it.

Advance directives are for when your mind is no longer sound.

[Avalux]

18. But what if he is unable to communicate?

I see your point though....since he is still of sound mind he could change what's in the document.

[DreamGypsy]

7. Advance directives

This type of situation is why everyone over 18 should have an advance directive (aka a living will).

http://www.nlm.nih.gov/medlineplus/advancedirectives.html
http://familydoctor.org/familydoctor/en/healthcare-management/end-of-life-issues/advance-directives-and-do-not-resuscitate-orders.printerview.all.html

What kind of medical care would you want if you were too ill or hurt to express your wishes? Advance directives are legal documents that allow you to convey your decisions about end-of-life care ahead of time. They provide a way for you to communicate your wishes to family, friends and health care professionals, and to avoid confusion later on.

A living will tells how you feel about care intended to sustain life. You can accept or refuse medical care. There are many issues to address, including

The use of dialysis and breathing machines
If you want to be resuscitated if breathing or heartbeat stops
Tube feeding
Organ or tissue donation

A durable power of attorney for health care is a document that names your health care proxy. Your proxy is someone you trust to make health decisions if you are unable to do so.

NIH: National Cancer Institute

[Courtesy Flush]

12. He may have done that already

I'm a 3-hour drive away, and I came home for a break after being there for a week, so I'll go back tomorrow, and get more information. But he should have signed a directive when he was admitted (or at least he would have been offered the opportunity to sign it). I signed a living will several years ago when I had a major surgery. I think it's routine.

[marions ghost]

17. Do not agree

"living wills" are not one-size-fits-all.

If there is a family member with medical power of atty who can speak for the patient (the patient in his right mind has given them the legal power) then this can be better than letting medical personnel decide for someone who is in their right mind but unable to express their wishes.

In the OP's case if the patient can speak for themselves, and the doctors should make every effort to let him do that. Otherwise the family may never be at peace.

When in a critical medical situation, a living will can be used to with-hold or delay treatment. If you don't believe me, ask a nurse.

[Doremus]

19. I'd like to know more about a living will being used to withhold or delay treatment.

Or are you referring to the option of the guardian named in the living will to refuse treatment on behalf of the patient? Expressing the wishes of an incapacitated living will signor is the purpose of the document, no?

A DNR is used to withhold treatment but is similarly signed by the patient and posted so that caregivers are aware of the patient's wishes if they are unable to communicate them.

[marions ghost]

22. I suggest you talk to someone who has seen the realities

in hospitals today--where yes, life CAN be prolonged but costs need to be kept down. The medical personnel are caught in a bind and I don't envy them having to work with "choosing to die" situations fairly often. However from what I have seen, there is more impetus to rush the process if the patient cannot speak for themselves. I do not think the patient (esp if elderly) should worry so much about being "kept alive against their will"--they should worry a bit more than they do about being offered life-saving treatments (if they have a will to live in the first place). Hospitals don't like to make people suffer any longer than the patient wants to put up with it, but in the effort NOT to be found guilty of undue prolonging of life, I have seen "comfort care" offered too soon and options not discussed.

All I'm saying is--IF there is a family member the patient trusts who has medical power of attorney authorizing them to express the patient's wishes should they become unable to do so (and who is nearby or on the scene), then this is the optimal situation.

Every effort should be made to get the patient's wishes from him/her directly of course, and this is what hospitals try to do. But the only reason I would advocate a living will is if there is no family member able, or close enough in proximity to the situation--to speak for the patient via medical power of attorney (which of course must have the patient's signature). All I'm saying is, it may not be appropriate in some situations. If it makes any critical patient feel better to sign a living will, then fine. But I'm here to say that every case is somewhat different, and living wills may not always be appropriate.

But research it and talk to people who deal with this everyday if you are concerned. Thanks for the question.

[DreamGypsy]

26. I included the durable power of attorney note in the excerpt.

But didn't specifically call it out in the title or text...an oversight.

A durable power of attorney for health care is a document that names your health care proxy. Your proxy is someone you trust to make health decisions if you are unable to do so.

Here is another description:

What is a durable power of attorney for health care?

A durable power of attorney (DPA) for health care is another kind of advance directive. A DPA states whom you have chosen to make health care decisions for you. It becomes active any time you are unconscious or unable to make medical decisions. A DPA is generally more useful than a living will. But a DPA may not be a good choice if you don't have another person you trust to make these decisions for you.

Living wills and DPAs are legal in most states. Even if these advance directives aren't officially recognized by the law in your state, they can still guide your loved ones and doctor if you are unable to make decisions about your medical care. Ask your doctor, lawyer or state representative about the law in your state.

The proxy can be anyone you appoint and, as you point out, should be someone you trust. The proxy may be a medical practitioner which can be a good choice if you have a good, long term relationship with your doctor or nurse or if no family member is comfortable fulfilling the end of life conditions of your advance directive.

[marions ghost]

29. Thanks for posting the specific guidelines

Good summary, and good point about how the laws vary in different states.

It says more or less what I found out--a living will is more useful if you have NO family member or other person willing to speak for you who has power of atty.

I am not against the living will concept --I'm just saying that, especially in the case of elders, keeping people alive against their will is NOT what I see being done (having spent much time in hospitals)--sometimes it is hard for the patient to convince medical personnel that they DO want to put up with some medical tortures even if it only prolongs life and does not cure. The family is generally kept out of any end-of-life decision--unless there is power of attorney. So it may boil down to how much the patient trusts the family to act in their best interests. In my case, I would trust my family completely, but I understand that not everyone can say that and the Living Will works better for them. But it should NOT be seen as THE "responsible" thing to do--it is not a one-size-fits-all solution. People need to look at it more closely, esp with regard to elders.

[Auntie Bush]

8. I'm so sorry for you, your father and the family. That's an unfortunate situation but I think your

your father should have control of his life. My husband had cancer but was of sound mind. When he felt is wasn't worth it anymore he just decided to stop eating and then he stopped drinking. With a little bit of morphine he died peacefully within a week. Your father can make those same decisions if he wants. He doesn't even need the family's permission...especially if he's of sound mind. Good luck to you and all your family. May you soon find peace.

[noel711]

9. Doctors cannot 'decide' to pull plug..

that's why 'advanced directives' (living wills) are so necessary-
the decision lies with the patient or his/her family.

In my state (PA) doctors/hospitals are impelled to do anything to
preserve life, no matter the cost, if there is no advanced directive
or family decision.

I encourage anyone to have a talk with a parent/relative
before they go in for surgery; most doctor's offices have
the paperwork. Lawyers do.. but most AD must be signed by
witnesses before they are considered legal.

If there is doubt as to the pacient's 'viability' they can do
a brain scan, but there are many conditions to be considered.
A functioning mind is important but if the physical body is failing,
there is little that can be done.
The family needs a meeting with the medical and nursing team
to determine what needs to be done, and what is the goal.
If there is little hope or rehabilitation, the patient must be
treated with dignity, consider comfort care, and
allow him to go on his own pace.

[elehhhhna]

25. wanna bet? in Texas they can, and DO. Not for Medicare patients,

of course, but uninsured people get unplugged due to our Repub gov'ts "Futile Care" law. Children, even. DEATHPANEL.

[bluestate10]

10. If he can write, have him write his wishes in his own hand.

If you dad wants to die, I am with him on his choice given the physical limitations and pain that he will face for the rest of his life.

[hamsterjill]

11. I can offer no more advice that what is already expressed in this thread, but

Simply wanted to express my sympathies to you and your family for having to bear this situation. My best to you all.

[riderinthestorm]

14. I am so sorry that this rough road is now yours to travel....

Hugs and condolences to your family. Stay strong!

Yes, your father can decide to stop treatment.

[slackmaster]

15. A person who is lucid and communicative can decline any form of treatment

I'm sorry about your father, CF.

[GoneOffShore]

20. Very good program on Fresh Air with Terry Gross about this yesterday.

Here is the link - http://www.npr.org/2012/10/09/162570013/when-prolonging-death-seems-worse-than-death

A thought provoking and interesting show.

Here's the link to the organization that was talked about - http://www.compassionandchoices.org/

[Courtesy Flush]

21. You know, I heard that story when it aired this week.

It aired as I was driving home after a week at the hospital. I listened, but didn't think we'd be facing this decision so soon. Literally two days ago we were optimistic about his recovery.

Thanks.

[catchnrelease]

23. Don't be suprised

if when the sedation is stopped, your father is mentally not as he was before the surgery. In older patients it's not uncommon for them to seem to be in a dementia like state after a major anesthesia. We saw this in my Dad after he fell and broke his leg and had surgery to set the bone. He was 89 and prior to the operation he was mentally ok--irascible, getting forgetful, but otherwise 'normal'. After he came out of the anesthesia it was like he was gone. He was talking to his father, commenting about the train going by his window (and he was on the second floor) etc. He did recognize the family, but he could not understand what had happened or where he was. The surgery was not complex or particularly long, but I have always said that he did not survive that operation. He lived for about 6 weeks and was never the same mentally. It was really kind of weird.

My husband has a good friend that is an anesthesiologist and when we discussed this, he said that trying to find the right drugs to use in surgeries for older people is one of the biggest problem he has, and that this post-op dementia is not uncommon.

I guess my point is to be prepared yourself, in case he is not capable of making a decision for himself. I hope things WILL turn out well for you all.

[nenagh]

24. My Dad died at 92 yrs of age in a Florida hospital when I was living in Canada.

The Drs kept him on a positive pressure breathing apparatus until I could get there to say goodbye.

I was his only surviving daughter and had the legal power to remove the machine. My Dad was furious about the machine and while in ICU, he threatened to call the police to have the machine removed.

When I finally arrived around 6 pm, there was evening staff there ..his friends expected that I would say unplug the machine he hates... But I couldnot do it. My dad had a functioning intellect, he wanted the machine off...and everyone but himself knew if the machine was taken off he would die immediately.

I did not feel he would have believed me about the severity of his condition....no one had really explained he would not live without the machine..

I asked for a social worker or trained professional and she came down, explained the situation, gently to him and asked if he wanted the machine to stay on or be removed. He chose to keep the positive pressure machine..

By the morning he was very low...and the great girls from the palliative care spoke to me and we moved him to their unit where we all could be at peace...they removed the machine, moved him from ICU to palliative care where he passed away quite rapidly as the nurses predicted.

I could not pull the plug ,so to speak, on a thinking man..who did not understand that he would pass away without the machine.

It is not always an easy decision...but I think it is NB that the patient is made aware And the social worker or palliative care nurse, sitting down on the side of hid bed, explained his choices..so he could get the treatment he decided upon...

I have always been happy to have made the decision to have another professional speak to my Dad and he had the choice of treatment until his body was too weak to survive.

[Michigan Alum]

27. If he is capable of signing the papers when someone explains the situation he should be good.

As long as he has mental capacity. Your stepmother can also sign for him (sort of saying he's not capable of signing but is mentally capable). If he has been diagnosed as having 6 months or less to live he should be able to get hospice services at home, a hospital, nursing home or at a hospice house which I highly recommend having been a social worker at a hospice. They can guide you every step of the way and help your family and your Dad with all kinds of support.

As long as he has the current mental capacity, he needs to sign all papers letting your stepmother be his healthcare surrogate and to have a DNR (Do Not Resuscitate) if you can trust your stepmother BEFORE he is unable to make decisions.

I don't know if you want to discontinue a sedative (unless it's temporary in order to communicate his wishes). You don't want a person at the end of their life feeling any trauma or pain - it's very frightening and traumatic for them.

Best of luck by the way, and sorry for your Dads pain (and your families). You should stop the dialysis because that is very tough on a patient. Without it, he will probably only live for a few days to a few weeks and will not have to drag on in pain with a low quality of life. All of the measures currently being taken (dialysis, tube feeding) are unnatural measures vs. natural methods. That is the hospice philosophy: let a person live out the end of their life in a natural, peaceful, and dignified manner. People do not live any longer being tube fed and it is actually painful and inhumane to force them to eat. At the end of life, a person does not have the hunger and desire to eat (due to their inactivity) and that needs to be also be respected.

[Princess Turandot]

28. I'd start with his doctor..

Hopefully, the physician will see the merits of your request; s/he will know what the process is to accomplish it. If for some reason s/he dismisses you out of hand, speak to the main hospital administrator. If you don't get any direction from the doctor in terms of who you should speak to, call the hospital president's office and find out from them who you can discuss the situation with. (I'm not suggesting that should be the president, but usually his/her assistant can direct you to the right person.)

Hospitals generally have ethics committees which, depending on the specifics, may need to approve decisions which will very likely lead to a patient's death, because the person is also the hospital's patient. Speaking to the ethics officer/ ethics committee chairperson is another possibility. I do not know if they would need to be involved with your dad's case but they should be able to shine some light on the process, if all else falls.

But start with the doctor, since there's no reason to push the request up to an administrative issue if it isn't necessary.

I'm sorry for your situation.