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Raising the Bar in Rehab

Decisions

Published February 4, 2010 10:51 AM by Lisa West
Those of us who work in health care know how many decisions we are faced with every day. MDs and pharmacists determine the best pharmaceuticals for patients. Nurses monitor a patient's status to know if they are stable enough for discharge or require more medical care. Therapists (along with the patient) determine and establish an appropriate plan of care to reach a patient's goals for mobility and comfort. We make countless decisions every day and each one impacts our patient's care.

After working in the ICU for the last month, one question continues to present itself. Who should decide when enough is enough? What if the patient is unresponsive and hadn't verbalized their wishes to family previously? What role should health care providers have? An unrelated, third party can offer a perspective which could be considered both good and bad.

The role of the ethics team in a hospital setting is a dynamic, ever-changing conversation. I call it a conversation because that's what it is - an open discussion considering every side to the patient's case. With so many things to consider, including prior function, comorbidities, motivation and other treatment options, these decisions don't come easily. In some cases patients have the luxury of time; other patients aren't as lucky.

There are a few patients who have come into the ICU on full vent support, with minimal active movements, who remain unresponsive and with very poor prognoses. As I walk by their rooms and see families waiting at their bedside, I can't help but wonder what thoughts plague their minds. I will never be able to understand the positions of these families and patients and my heart goes out to anyone in those situations.

This debate obviously surpasses the role of physical therapy. But we need to take a role in these decisions to the best of our ability. Providing patients and families with skilled stretching, range of motion, positioning, postural drainage with percussions, and even education regarding their diagnoses can add substantial quality of life during the most critical times. We need to be accountable in providing the best care, at all times, for our patients - even when life-sized decisions await.

posted by Lisa West

2 comments

Good discussion topic.  You Know Who shares an interesting perspective I've never heard discussed as it relates to advanced directives:  personal accountability.  Novel.  So simple and so taboo in our nation.

I have filled mine out, but honestly it has been so long ago, I'm not sure I could put my finger on them.  And that is okay to a degree.  Honestly, how can we say we would know what we would want?  You can guess what you would do in a certain situation, but actually GET in that situation and many a mind changes.  So, really, who is to know.  The bigger question is have you considered those who will be left behind and their reaction to your decision?  If I want the plug pulled, but my husband needs another week-or month-or year to come to terms with it, I want him to have that time.  If he is convinced there is no hope and continuing to keep me alive by machines will drown my family in debt, then pull the plug.  I want to leave this earth having given my family as much peace of mind as I can.

I hope I am never faced with a decision of choosing life or death for a loved one.  Obviously if that is ever the decision, then quality of life has become a debatable issue.  I can't imagine being the one to give the go ahead to pull the plug.  I don't know how I would live with those "what if"s.  While I hope I would listen to wise counsel from the educated medical community - as well as from friends, especially those who had lived through similar circumstances - I don't know how good a listener I'd be during that time.  So I also would hope to be surrounded by compassionate care givers who understood that the loved ones who were left behind had their entire lives to live with this life and death decision.  I would also hope that the weight of that knowledge would guide how care givers, friends and family responded to me.   From the posts I've read of yours, it sounds like you are that kind of care giver.  My compliments.

Janey Goude February 23, 2010 2:15 AM

Hey Lisa,

I took a philosophy class a while back and it was when that whole Terry Shiavo thing was going on.  Our teacher initiated a conversation about how obviously no one plans to end up in a vegetative state like that, so at what point does it become the patient's responsibility to be prepared?  Our teacher asked our class to show hands of how many of us knew what we would want to happen if we were to end up in a vegetative state or something similar.  Everyone in the class rose their hand.  Then our teacher asked how many of us had a written advance directive.  No one rose their hand.  I thought it was interesting that most people probably know what they would want done, but don't take the time or put forth the effort to make their wishes known.  It may be kind of morbid to think about I guess, but it's good to be prepared.  Don't you think?

You Know Who February 10, 2010 4:40 PM
Chicago IL

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