Amanda Anderson, BSN, RN, CCRN, is a critical care nurse in New York City and enrolled in the Hunter-Bellevue School of Nursing/Baruch College of Public Affairs dual master’s degree program in nursing administration and public administration. She is currently doing a graduate placement at AJN two days a week, working on a variety of projects. Her personal blog is called This Nurse Wonders.
Evelyn Simak/ via Wikimedia Commons
Nurse and writer Theresa Brown wrote a piece for this past Sunday’s New York Times on the dilemmas physicians face when their patients want to stop aggressive treatment (the latest installment of Brown’s quarterly column, What I’m Reading, is in the September issue of AJN
Brown’s Times column talks about physicians who have trouble letting patients go and instead push for more unnecessary and often unwanted treatment. She describes a case in which—after palliative care has been decided upon by the patient’s family members, the palliative care team, and even the heartbroken oncologist—the patient’s primary care physician intervenes and pushes for still more futile treatment. (Much of the article delves into the broader issue of palliative care and the benefits it has for patients in many stages of chronic illness.)
Have you ever disagreed with a physician’s choice to continue treatments in a situation where you thought these treatments were against a patient’s real desires or best interests? Have you felt cornered in your care? What conversations did you start—or want to start but maybe felt you couldn’t?
Many times, we nurses at the bedside are afraid to speak openly with our patients about end of life, especially when physicians have different views on what should be the patient’s treatment goals. The situation feels thorny, fraught. Moral distress—when you know the right thing to do for your patient but don’t feel you have the ability to do it—can lead to burnout, high turnover rates, and many emotional stressors among nurses. Often, we simply can’t say what we want to say, despite a duty to our patients to accurately educate them on their care and conditions.
As Brown discussed, palliative care is an option for treatment, as much as aggressive chemotherapy or surgery. While we don’t recommend openly advocating for palliative care without the support of the primary care provider, inquisitive patients (and their families, in many cases) have a right to understand comprehensive options, as stated in the universal Patient’s Bill of Rights, and nurses play a vital role in providing such education.
Check with your nurse manager and familiarize yourself with hospital policy and available institutional resources before any such discussions. In the meantime, begin educating yourself on the topic, the options, legal guidelines, and palliative care’s many benefits.
Here are some resources:
The Conversation Project is an organization that’s dedicated to helping people talk about their wishes for end-of-life care. They even provide a free conversation starter kit, and share patient’s stories and videos driving home how much of a difference it can make to start talking about end of life.
The Caregiver Space is an organization that helps caregivers. Whether you’re a caregiver for an ailing parent, or your patient’s wife is his sole caregiver, this group provides support, resources, and guidance for understanding and handling the stressors that come with this role. The site is light on nursing-specific support, but provides good general resources for family members and nurses alike.
Get Palliative Care is a great place to start when looking for local resources and palliative care departments—for your own interest, or to share with patients. This site is a comprehensive primer with current statistics, available resources, and a screening tool for patients on whether palliative care is right for them.
I’m a visiting nurse and part of my visit is to discuss advanced directives and healthcare proxies. I always emphasize that it is up to the individual what they choose, and I always answer questions about aggressive care honestly, but make sure to let them know that they have the final say.
I think if one approaches things this way with both patient (if conscious) and family, that they are left in a place where they can decide for themselves what to do. I’ve always been a fan of give them the facts and let them choose. Less stress overall for the nurse.