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Sunday Ethics: Who Decides “Futile” Care?

Posted by realityrounds on January 24, 2010

I was alerted to this story from a comment left by a reader.  There is a very emotional case causing controversy in Canada.  It revolves around a three-month old infant who suffered catastrophic  and irreversible brain damage during delivery.  The infant’s physicians want to remove the infant from the ventilator stating  that removing the child from the ventilator is medically reasonable, ethically responsible and appropriate.  The parent’s do not want their son Isaiah removed from life support, and sought a court order to stop the physicians from doing so.  According to the CBC-Canada news article, the case currently stands as follows :  “An Alberta Court of Queen’s Bench justice has ordered an Edmonton hospital not to remove a ventilator that is keeping a three-month-old infant alive until a court hearing can be held on his medical condition.”

This story illustrates the real life difficulties of “deciding” on futile care for any human being.  When the case involves an infant, it is even more emotionally and ethically challenging, since the infant can not speak for themselves.  So who should decide futile care?  Should it be the patient’s physicians who are keeping the patient alive with their treatments?  Should it be the patient’s family (in the above case the parents), who will bear the ultimate burden of either grief from the loss of the child, or burden from caring for a severely disabled child.  Or, should it be the courts supported by expert opinion and detached involvement?

In ethical cases like these, there is never a black or white, right or wrong answer.  What ever answer you feel is right, will be wrought with other ethical questions to follow.

RR


Posted in Sunday Ethics, Uncategorized | Tagged: , , , , , | 2 Comments »

Friday Fun Fact: I Hate Private Practice

Posted by realityrounds on January 22, 2010

Why didn’t someone warn me?  I have never watched  this show, but for some reason I watched it last night.    Why do I hate it?  Here are some reasons:

  • Storyline of a mother “forcing” her daughter to get an abortion.
  • Making fun of a woman wanting natural childbirth.
  • Doctor stating she could only help a pregnant woman if she wanted surgery.
  • Nurses saying asinine things like “dead infants are God’s Angels” to a grieving mom.
  • Lit candles in the delivery room next to an oxygen tank.
  • A resident helping the natural child birth mom labor.  Nurses nowhere in sight.
  • Resident repeatedly asking natural child birth mom if she needs pain meds.
  • Teenagers roaming the halls un-escorted in L&D while viewing stranger’s labor in pain.
  • Doctor mom who drags her pregnant teenage daughter into a NCB delivery so she can see how it would ruin her life.  (HIPAA hello!).
  • Resident delivering NCB mom with no nurse in sight.
  • OB’s living in a house on a private beach in California.

I could go on, but I won’t.  Why didn’t anyone warn me about this show?

RR

Posted in Uncategorized | Tagged: , , , | 18 Comments »

Sunday Ethics: Maternal vs. Fetal Rights

Posted by realityrounds on January 17, 2010

There has been much press regarding the case of a Florida mom who was forced to undergo court-ordered bedrest at 25 weeks into her pregnancy.  For those who are not familiar with the case, Samantha Burton showed signs of preterm labor at 25 weeks, and her hospital physician ordered her to be on bedrest.  Ms. Burton refused due to issues of childcare and work responsibilities.  The hospital received a court order to confine Ms. Burton to the hospital on bedrest and any other medical treatments deemed appropriate by the hospital.  She subsequently underwent a C-Section for a 25 week fetal demise.  For a thorough round-up of this story, go here.

The conventional debate on this story is one of maternal rights vs. fetal rights.  Does the state have control  over the body of a  pregnant sentient adult female, over the rights of a “viable” fetus?  I do not believe those in power can dictate the decision making capacity of any pregnant female.  Ms.Burton refused treatment due to childcare and work issues.  Conventional wisdom makes her reasons for refusing bedrest, logical,  understandable and acceptable.  From where I stand as NICU nurse, I did not view this debate in a conventional way.

For those whose lives have been touched by the NICU, conventional wisdom goes out the window.  This story made me think of the many anecdotal stories I have heard from pregnant  Neonatologists and NICU nurses  saying  that they would run away to a remote location in order to avoid their “periviable” infants from being resuscitated against their will. They said these things tongue in cheek, out of fear and desperation.  In the United States, viability is defined at about 23-25 weeks of gestation.  Infants born between 23-24 weeks should have a consultation with the parents and doctors to decide what is the best action for the infant.  Infants born at 25 weeks or above, there really are no options.  A full blown,  full court press of resuscitation will occur, regardless of outcome statistics or parental wishes.

So the questions arise for those families who do not want a full court press for their 25 or 26 weeker.  They may not want the extreme (real or imagined)  pain and suffering of a NICU admission.  They may not want or can not handle the financial and emotional toll bringing home a medically fragile infant can extole on their family.

Should these parents have a choice?  Is it permissable by law to allow parents to make those kind of decisions for their families?  Can parents say no to a forced hospital delivery or resuscitation of a viable infant?

Tough questions

RR

Posted in Sunday Ethics, child abuse, ethics | Tagged: , , , , , , | 10 Comments »

New Years Baby…..BFD

Posted by realityrounds on January 3, 2010

Someone tell me what the Big eFfin’ Deal is with the New Years Baby?  Since I’ve been a nurse, hospitals trip all over themselves to brag that they delivered the first baby of the New Year.  So what?  It drives me crazy.  Why is this baby so special, or more special, than that baby born on Arbor Day or Flag Day?  If a mom is pushing at 11:55 pm on New Years Eve, we may be “coaching” a little louder to PUSH, to get that baby out at 12:00 am.  (and, do you go by the clock time or the time on the fetal monitor?  I think it’s the monitor.)

I have never been involved with covert inductions or sections by a provider to win the coveted prize of the first baby born on the New Year.  But I bet other nurses have, fess up! Yet, working in the big, bad, inner city hospital, some patients will take matters into their own hands to deliver that coveted New Years Baby.

The craziest New Years Eve was of course…..1999!  It was a very big deal to be that hospital to deliver that first baby of 2000.  There were rumors galore that some hospitals were offering free college educations, and cars, and tens of thousands of dollars to New Years  Baby 2000.   I was on call New Years Eve 1999.  The hospital had pretty much everyone on call due to the Y2K computer crash, and Armageddon, and Godzilla destroying Manhattan, or some shit like that.  More horrifying than Godzilla was the fact that I  had to carry a pager, and could not drink alcohol on  New Years Eve 1999.  Nursing is awesome!   You should see the pictures of me dressed to the nines, carrying a pager as big as a toaster on my very big eighties belt.  Dayum I looked hot.  I was lucky enough not to be called in, and the hospital I worked at was lucky enough to deliver the celebrated New Years Baby.  What an honor.  New Years Baby Momma 2000 decided to take matters into her own hands to be the first woman to deliver in 2000.  New Years  Baby Momma 2000 took matters into her own hands, partied like it was 1999, and snorted as much cocaine as humanly possible to contract her vessels and contract her uterus.  Who needs pitocin anyway?

That morning there was much pomp and circumstance as we presented New Years Baby Momma 2000, with her big ole gift basket stuffed with toys, free formula (thank you Enfamil), diapers, and grocery gift certificates.  Now, smile pretty for your publicity shot!  But New Years  Baby Momma 2000 would not smile.  She…would…not...smile. New Years  Baby Momma 2000 took one look at that over sized and over stuffed gift  basket, and went off like the fireworks the night before.  Oh No.  She was not having it.  She went through a lot to be the first to deliver on 2000.  She took a taxi, yes a taxi to this inner city hospital to deliver.  She could have taken her taxi to any other big city hospital, and she chose ours.  A gift basket?  Oh Hell No!  New Years Baby Momma 2000 wanted a free college education for Baby 2000.  She demanded a new car.  She needed tens of thousands of dollars in cash.  She did not need some dumb cheap ass gift basket.  Smile pretty now!

So we all stood there slack- jawed and stunned at New Years Baby Momma 2000′s speech.  We would not smile pretty.  We…would…not…smile pretty. New Years Baby Momma 2000 did not get all that she wanted.  She did not even get the gift basket.  New Years Baby 2000 got a urine bag and positive tox screen and a mandated DCFS report.  Happy New Year! The staff got a life lesson, time and a half that was not worth it, and a Holiday cafeteria lunch (not free) of prime rib (?!) and mashed potatoes from a box.

Screw Baby New Year!  That’s right, I said it.  Flame on!  Let’s celebrate Flag Day Baby, or Arbor Day Baby, or Armistice Day Baby, or  Boxing Day Baby (Canadians count ya know).  The New Years Day Hype Baby is done to me.  Done I say!

RR

Posted in Uncategorized | 12 Comments »

Crash C-Section on Dead Mom with Miraculous Result

Posted by realityrounds on December 29, 2009

Happy endings are certainly needed now-a-days, and this story has one.  As reported by ABC news, Tracey Hermanstorfer of Colorado went into a complete cardiac arrest (no pulse, no blood pressure, cyanotic) during labor with her third child.  It is being reported that Tracey was being prepped for a “catheter”  (epidural, my guess), when she became unresponsive  and in complete arrest.  Her doctor performed an emergency C-Section right in the room (no anesthesia, pour betadine over the abdomen, and cut) and placed the lifeless infant in the father’s hands.  Within seconds of delivery, mom’s vital signs came back, and the baby started to show signs of life right in his dad’s hands.   Tracey’s doctors state they have no idea why she went into a complete arrest, and are even more stunned that she recovered.  This is truly an amazing story…….and of course…..I have many questions.

I have unfortunately been in Crash C-sections on “dead” moms before.  Most often, we have a reason for the code right away.    One mom was a severe alcoholic.  She was crashed, and during the section her liver essentially disintegrated due to cirrhosis.  She eventually died in the ICU, and her baby died of Fetal Alcohol Syndrome in the NICU.  Another mom presented in the ER in full arrest.  She was slashed right in the ER.  unfortunately both her and her baby died.  Turns out she had a severe cardiomyopathy.  Another mom had a very normal labor, just like Tracey’s, and crashed out of the blue.  She was progressing normally.  It was her third child and all was going well.  All of a sudden she crashed.   She was rushed to the OR and both her and her baby were fine.  The tentative diagnosis:  amniotic fluid embolism.  A rare condition, and an even rarer condition to survive.

We may never know why Tracey coded during labor.  Some differential diagnosis that I can think of are a highly placed epidural (this can cause respiratory depression and paralysis), and amniotic fluid embolis (very rare, and even rarer to survive), a pulmonary embolism, and undiagnosed congenital heart defect.

Another issue that makes me pause is the fact that they placed the depressed neonate in the father’s hands.  Why they did not immediately begin neonatal resuscitation on this infant under a radiant warmer is beyond me.

So, what are your theories on what happened to this mom?

RR

Posted in health | Tagged: , , , , , | 33 Comments »

Nuthin’ Says “Happy Holidays!” Like a Code Green

Posted by realityrounds on December 23, 2009

All the health care worker elves are so busy at the station,

Cuz from December to Jan-u-ary, you can’t take no vacation.

So we work and we work, and keep the bitchin’ to ourselves,

Cuz’ holidays don’t exist for the health care worker elves.

**********

In the rooms we intervene and we assess and we admit

and at the station the angry elf , he don’t care, don’t give a shit.

He is so very mad, he is so very entitled.

He want what he want, and he don’t care bout what is vital.

**********

Us health care workers elves, we stay calm, we say “don’t be mean.”

But the angry elf just escalates, we must call a mean “Code Green!”

**********

“Code Green!  Code Green”!  A color we do not want to hear.

A color festive for the holidays

But in the big house brings only fear.

**********

And Santa’s security helpers ,they all come a runnin’

They tell the mean ole’ elf to take  his story walkin’.

**********

So the health care worker elves

Watch the activity in silent night

We shake our heads in saddness

We know there is no light.

**********

Will mean ole’ elf who threatened us

Get the help he does not want?

Will next Christmas bring him

The souls he still does haunt?

**********

Us health care elves will think the best

Of peace for all, not one.

God bless us health care elves,

God bless us everyone.

*Code Green:  A violent person.
RR

Posted in nursing | Tagged: , , , , | 8 Comments »

Empowered Patient or Entitled Patient?

Posted by realityrounds on December 17, 2009

In my past life I was a journalism major, and I know about the power of an article’s title to suck a reader in, and maybe, sway their judgment about a subject before they ever read the article.  Case in point:  CNN just ran an interesting article in their “Empowered Patient” section.  The article addresses the case of Joy Szabo who had one previous C-Section and would like to have a VBAC for her fourth child.  Her obstetrician informed her that she would not be able to have a VBAC due to hospital policy and liability concerns.  So, Joy packed up and moved to Phoenix Arizona three weeks before her due date to have a VBAC, which she did very successfully.  Yeah Joy! You are a fellow VBAC sister.

The title of the CNN article is this:  Mom fights, gets the delivery she wants. Does anyone else see anything wrong with this title?  To me, it sways the reader, especially the lay reader, to believe the mom is being selfish and entitled to get something (a delivery) that she “wants.”  What if the title was this:  Mom fights, and avoids getting sliced open against her will. Do you think readers, especially lay readers, would view the article in a different way?  I wonder.

Obviously it is not just a title that will sway a readers opinion.  Personal experience means all and everything to a  single person.  If someone had a tragic VBAC experience, that is all that matters and all that anyone needs to know.   This is proven over and over again in the comment thread to the CNN story.   Anecdotal stories can be very heart wrenching and moving, but public health policy certainly should not be swayed by anecdotes alone.

If you dare, read the over 450 (and climbing) comments included in this thread.  I refuse to get sucked in to comment, especially when the comments are filled with people who do not know what the hell they are talking about.  (I have also been reading an article about Michelle Duggar who just delivered a 25 weeker, on People magazine’s website.  The comment section on that thread is also filled with dunder heads who do not know what the they are talking about, like mom blaming.  But anyway, that is for another post. ).  It can be frustrating reading what some in the general public believe about women, and women’s and infant health care.

From this article in a very main stream media outlet, it seems from many of the comments that Ms. Szabo acted more like an entitled patient and not an empowered one.

Thoughts?

RR

Posted in health | Tagged: , , , , | 29 Comments »

Sunday Funnies: A Birth Blogger Rap

Posted by realityrounds on December 6, 2009

A little history.  This weekend Jill from The Unnecesarean, posted a very well thought out piece on race issues and childbirth.  To some of her readers’ chagrin, another well-known birth blogger who has very different views on childbirth, chimed in.  Dr.Amy from the Skeptical OB blog added many, many comments to Jill’s post which left a lot of Jill’s readers furious.  Because I work in a hospital, I can actually agree and sympathize with a lot of Dr. Amy’s points.  But there is also so much cynicism and lack of compassion in her points that it makes me suspicious that she is deliberately trying to push buttons for attention. (I could be wrong though).    The comments on the thread was a debate about childbirth choice, racism, class warfare, natural childbirth, modern obstetrics and many more issues.  If you want to go down that rabbit hole of comments, check out Jill’s site (linked above).

I of course, being the class act that I am, stayed above the fray (actually, I am a NICU nurse and do not have enough OB knowledge to even leave a good comment).  The blog war did inspire me, the class act that I am, to write a rap song inspired by this Dr. Amy thread.  It is not so much a song about Dr. Amy’s actual birth practices, but the general distortion and demeaning of “alternative” methods of birth, and Dr. Amy’s presence in the blogosphere.

Please sing in the tune of Kanye West’s “Gold digger”. (Because who else would you think of when debating American childbirth than Kanye West?…..God, I need help.)

**********

She take my web hits when she in need

Yeah she’s a trifling “friend” indeed

Oh she’s a blog digger, way over town

That dig’s on me

**********

Doctor the bomb

Met her at the website Salon

With perinatal statistics under her underarm

She always right

Yeah she never be wrong

And if you ready to push,

She’ll say you’re closed, thick and long.

**********

Now I aint saying she a blog digger

But she aint messin’ with  low traffik-ers

Now I aint saying she a blog digger

But she aint messin’ with  low traffik-ers

**********

21 years, 21 years

Plaintiff attorney got docs for 21 years

You say you wanna push and not be pushed to the O-R

But  lawyers on docs backs want to make themselves richer, and docs poor-er

**********

Now I aint saying she a blog digger

But she aint messin’ with  low traffik-ers

Now I aint saying she a blog digger

But she aint messin’ with  low traffik-ers

**********

Now you had one C-Section and feel under attack

Cause you want a normal birth, yeah you want a nice VBAC

But she will scare you to death, and you will not get to far

And you will leave her institution with a second  uterine scar.

**********

Now I aint sayin’ she a blog digger to get someone mad

She got a website to promote, have you seen all her blog ads?

She wants babies to be safe and women to be healthy

But to generate traffic you must be controversial and stealthy

**********

So let’s stick by her side, yeah that’s what I said , yeah that’s right

You can get your word out, yeah you can put up a fight

Cuz’ when she done slammin NCB and homebirth no further,

She’ll leave all our asses to hi-jack an unassisted childbirther.

**********

Now I aint saying she a blog digger

But she aint messin’ with  low traffik-ers

Now I aint saying she a blog digger

But she aint messin’ with  low traffik-ers


*I should probably just stick to my day job.*

RR

Posted in health | Tagged: , , , , , , | 22 Comments »

Is a Hospitalized OB Patient Sick Until Proven Healthy, or Healthy Until Proven Sick?

Posted by realityrounds on December 5, 2009

Posted in child birth | Tagged: , , , , , | 20 Comments »

So Very Thankful

Posted by realityrounds on November 25, 2009

It was a slow Thanksgiving day shift.  The nursery was quiet, and I was counting the hours until I could be home celebrating with my family.  Half way through the shift a call comes in from the Mother/Baby unit.  A nurse is concerned about one of her babies, who is not eating well and is breathing fast.  The pediatrician would like him admitted to the NICU for monitoring.

I received report from the Mother/Baby nurse.  She informs me that mom is a 40 year old gravida 10, para 9–now 10 (she has been pregnant 10 times, and has 10 living children).    She has custody of none of her children due to issues with drug addiction.  She is living in a local community shelter.  She had no prenatal care with this pregnancy.  Her drug screen is negative, and she states she has been clean and sober for over two years now.  She denies knowing who the father is.  She was brought in by ambulance, and had an uneventful, but precipitous delivery about 18 hours ago.  The infant’s drug screen is negative.  Social Work has been notified, and the Department of Children and Family Services is investigating.

The mom accompanies the baby to the NICU.  The mom looks as if she is 60 years old.  She is haggard, and weary, and scared. Her hair is unkempt, and her nails are caked with dirt.   I introduce myself and she gives me a worried smile.  She has not one tooth left in her mouth.  She sits quietly as I proceed to admit her baby to the NICU.

The baby is full term and his size is appropriate for gestational age.  He is markedly tachycapnic with respirations of 80-100 breaths per minute.  He is active to irritable.   He has a soft heart murmur.   I do the routine care of monitors, starting an IV, drawing an arterial blood gas, etc.  The infant’s oxygen saturations are 60% on room air. I place an oxygen cannula on the infant and paged the neonatologist.  I proceed to measure the baby’s oxygen  sats from his upper extremities and obtain a four extremity blood pressure.  His upper extremity saturations are 85%, and there is a positive difference between the upper and lower extremity blood pressures.  His overall oxygen saturations do not improve while on 100% inspired oxygen.

The neonatologist gives the mom the bad news that her baby most likely has a cyanotic heart defect.  He needs to be transported to a Childrens Hospital immediately for surgery.

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

This mom, who has more than a lifetime of hurt and pain, this mom who has lost 9 children because of her own drug use and inability to care for her babies, this mom who has been abused and beaten and who has sold her own body to survive, this mom who was homeless, this mom who has turned her life around and is clean and sober and struggling to survive, this mom…….

This mom turns to me, a white, well-educated, upper middle class woman, a nurse…..this mom turns to me……..

This  haggard , tired , no teeth in her head, mom turns to me and kisses me full on the mouth.  This mom cries with tears of pain and joy.  This mom repeats over and over again about how thankful she is that we were there to take care of her son.  How we helped her and how God sent her to us.  I am so very thankful for this day. The day my son’s life was saved.

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

This nurse is so very thankful that this mom was sent to me.  This mom who showed me what being thankful really means.  Her and he son was sent to us…..we were not sent to her.  And for this…. I am so very thankful.

RR

*Fictitious/ composite story


Posted in NICU, nursing | Tagged: , , , | 7 Comments »

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