Month: October 2018

Talking to Patients

nancyvalko medical, mental health, nursing, ventilators/life support

As I have related before, back in the early 1970s when I was a new ICU nurse, I was teased for talking to comatose patients. I was even asked if I talked to my refrigerator. I explained that if hearing was truly the last sense to go, it made sense to talk to the patients and explain what we were doing just as we would for any other patient. The other nurses thought this was ridiculous-until “Mike”.

“Mike” was a 17-year old boy who was admitted to our intensive care unit in a deep coma with massive injuries caused by a terrible car crash. The neurosurgeon on duty pronounced, “He won’t live until morning and it’s a good thing, because he’d be a vegetable.” I was shocked that he said this in front of “Mike”!

But “Mike” didn’t die. I kept talking to him and eventually he could even move a finger on command. But he would not respond to the neurosurgeon, even with tests to see if he would move with pain stimuli.

Later on, when “Mike” was able to breathe on his own, he would even say “Hi” for me on command but it was only after I repeatedly begged that Mike finally said “Hi” to the neurosurgeon. The neurosurgeon called this a “miracle” but shortly after that, Mike was transferred to a nursing home. None of us ever expected to see him again.

However, about 2 years later, a handsome young man strode into our ICU and asked “Do you remember me?” It was Mike! He said he had driven 60 miles to tell us thanks for saving his life and we all dissolved in happy tears.

I told him that he wouldn’t remember this, but he would move and say “Hi” for us nurses but not for the neurosurgeon. Mike got very serious and said “I remember him calling me a vegetable and I wouldn’t move for him!”

After that, every nurse on our unit was told to talk to every comatose patient as if he or she was totally awake and soon we found more patients who unexpectedly woke up or improved.

And no one ever teased me about talking to “comatose” patients again.

Throughout the decades since, I have talked to other patients who were considered comatose or otherwise unconscious, not just to patients with a major brain injury but also to patients approaching death and to patients sedated while on a ventilator for breathing. I’ve always considered this talking and explaining just basic respect for every patient. I was pleasantly surprised when I followed up with patients and families after they left our ICU and found many who remembered and told me how much this had helped them.

“OBSERVATIONS FROM ICU PATIENTS WE THOUGHT WERE ASLEEP, BUT WERE NOT”

So I was thrilled to see this title for a new Journal of the American Medical Association (JAMA) learning audio for doctors with stories from patients about what they experienced in an ICU while their treating doctors and nurses thought they were “asleep”.

In the audio, most of the patients were on sedation while on a ventilator and assumed unaware. One such woman related how she became so angry at her doctor’s attitude that she wanted to throw something at him and was frustrated when she couldn’t. Another man related how painful it was when the electrodes checking for his level of sedation were used without explanation or warning. Another complained about hearing nurses talking about her mom and dad poorly and their lack of empathy.

But there were also good stories about nurses or doctors taking the time to explain what was happening, talking as if the patient could hear everything and helping patients communicate without words. One doctor told about how his own father was in a hospital for an extended time and his dad remembered hearing the doctor talking about all the things he couldn’t do instead of what he could do. This doctor says that his father’s discouraging experience made him a better doctor.

The audiotape also explains how difficult it can be to not over- or under-medicate people, especially when it comes to pain, confusion and anxiety. The audiotape recommends that health care professionals try to avoid long acting drugs with potential side effects and continuous medication infusions and to use simple tools to assess delirium, confusion and anxiety.

The audiotape also recommends that health care professionals “treat patients like real persons”, “take the time to explain”, “be careful to assess level of awareness”, “realize that every action and word have real consequences” and that the “human element” is the most important.

CONCLUSION

Being in an ICU can be especially stressful for patients and their families and I hope this information is helpful. Medicine can do wonders today but it is the human connection that provides the best environment for healing for both patients and their families.

My Review of “Gosnell: The Trial of America’s Biggest Serial Killer”

nancyvalko abortion, culture, law, medical ethics

I just saw the movie “Gosnell: The Trial of America’s Biggest Serial Killer” and was moved to tears even though I already knew much of the story about the notorious Philadelphia abortionist who ran an outrageously filthy clinic where he executed late-term babies who survived abortion by callously cutting their spinal cords. I also knew that some of the women died, suffered serious complications or contracted diseases from dirty instruments during the 30 years Dr. Kermit Gosnell ran his politically protected clinic.

This PG 13 movie scrupulously avoids sensationalism but through great acting, writing and accurate depictions of the clinic and Gosnell himself (actual pictures were shown at the end of the movie), the enormity of the evil cannot be ignored.

The movie starts much like an episode of “Law and Order” portraying a drug bust but then expands as police raid Gosnell’s abortion clinic for evidence of illegal prescription drug sales and find even greater problems. After the initial reluctance to prosecute by the District Attorney because the case involves abortion, a courageous assistant district attorney puts her job on the line to prosecute Gosnell.

The trial of Gosnell is riveting, especially when an expert witness abortionist describes how to correctly perform a late-term abortion that is unnervingly similar in callousness to Gosnell’s. The testimony of girls as young as 15 when they were trained by Dr. Gosnell to be his unlicensed assistants is also devastating as they describe an aborted baby swimming in a toilet or another struggling to keep breathing. The trial is very contentious but a stunning development late in the trial determines the result.

I highly recommend seeing this movie that even opened the eyes of people like Ann McElhinney who was neutral on abortion until she worked on this film.

CONCLUSION

Although one of the most shocking aspects of the Gosnell trial was his cutting the spinal cords of babies who survived abortion, Kermit Gosnell was not the first known abortionist to deliberately end the lives of babies who survived abortions.

In 1999, nurse Jill Stanek was shocked to discover a live baby boy left to die after an induced-labor abortion  and found this was a common practice in her hospital. Her courageous testimony led to the 2002 “Born-Alive Infants Protection Act” which extended legal protection to infants born alive after an abortion.

However, the lack of legal enforcement power in this Act led to the current “Born-Alive Abortion Survivors Protection Act that not only requires physicians and abortion facilities to afford “the same degree” of care to a baby born alive during an abortion that would apply “to any other child born alive at the same gestational age,” including transportation to a hospital, but also mandates fines and the possibility of imprisonment for medical professionals found to be noncompliant.

This bill was passed in the US House of Representatives this year and sent to the Senate where (because of procedural hurdles), it might need 60 votes to pass and be signed into law by President Trump.

Although it might be difficult to pass the Act now because of the political entrenchment of abortion supporters in the Senate, passing this law would provide at least one fitting endnote to the horrors of Dr. Kermit Gosnell’s clinic.

American Academy of Family Physicians Urges the American Medical Association to Drop Opposition to Physician-assisted Suicide

nancyvalko assisted suicide, Compassion & Choices, conscience rights, Living wills, medical ethics, terninal/palliative sedation

Compassion and Choices, the former Hemlock Society and now well-funded promoter of assisted suicide and other death “choices”, is celebrating the new resolution by the American Academy of Family Physicians (AAFP) to oppose the American Medical Association’s (AMA) long-standing opposition to assisted suicide.

The AFFP, the second largest component society of the AMA with over 131,000 members, just approved a new resolution adopting a position of  “engaged neutrality toward medical-aid-in-dying (aka physician-assisted suicide) as a personal end-of-life decision in the context of the physician-patient relationship.” (Emphasis added)

But as Dr. Rebecca Thoman, campaign manager for Doctors for Dignity for Compassion and Choices explained when the Massachusetts Medical Society adopted the same policy in 2017:

A “‘neutral engagement’ position is even better than a simply neutral position. It means if Massachusetts enacts a medical aid-in-dying law, the medical society will offer education and guidance to physicians who want to incorporate medical aid in dying into their practices.” (Emphasis added)

Now, yet another physician-assisted suicide bill is expected to be introduced next year in the Massachusetts legislature.

The AAFP resolution also stated that:

“By supporting the AMA’s opposition to medical aid in dying, some members feel the AAFP is telling them that they are unethical”

and that

“the American Academy of Family Physicians reject(s) the use of the phrase ‘assisted suicide’ or ‘physician-assisted suicide’ in formal statements or documents and direct(s) the AAFP’s American Medical Association (AMA) delegation to promote the same in the AMA House of Delegates.” (Emphasis added)

CONCLUSION

In 1994, Oregon became the first state to pass a physician-assisted suicide law. This came after the Oregon Medical Association changed its position from opposition to neutrality. 21 years later and after multiple failed attempts, the California state legislature approved a physician-assisted suicide law after the California Medical Association changed its opposition to neutrality.

The unfortunate message sent-and received- was that if doctors themselves don’t strongly oppose physician-assisted suicide laws, why should the public?

Still, it was a surprise that in June 2018, the American Medical Association House of Delegates rejected the AMA’s Council on Ethical and Judicial Affairs (CEJA) strong report recommending that the AMA continue its long standing policy opposing physician assisted suicide. Instead the delegates “voted 314-243 to refer the matter back to the trustees for further deliberation”.

With the crucial help of a supportive media, Compassion and Choices started this momentum towards acceptance of physician-assisted suicide and other death choices like VSED (voluntary stopping of eating and drinking), terminal sedation and withdrawal of even spoon-feeding, affecting not just doctors but also nurses and other health care professionals and institutions.

In addition, Compassion and Choices also opposes conscience rights, even stating that  the new Federal Conscience and Religious Freedom Division:

“is not about freedom; it’s about denying patient autonomy. Under their proposed rules, providers are encouraged to impose their own religious beliefs on their patients and withhold vital information about treatment options from their patients — up to, and including, the option of medical aid in dying. And your federal tax dollars will be used to protect physicians who make the unconscionable decision to willfully withhold crucial information regarding their care from a patient and abandon them when they are most vulnerable.” (Emphasis added)

However, here are a few ways any of us can help turn around this dire situation:

When the most basic medical ethic of not killing patients or helping them to kill themselves can be discarded in favor of “choice” or “quality of life”,  none of us of us can afford to be neutral- or silent-on this life or death issue.

No Suicide Discrimination!

nancyvalko assisted suicide, medical ethics, suicide

When I was asked by my late daughter Marie’s best friend to join her on a family and friends fundraising walk for suicide prevention last Sunday, I hesitated.

I was in the process of reading yet another disturbing article about assisted suicide, this time a Journal of Clinical Psychiatry article titled “Working with Decisionally Capable Patients Who Are Determined to End Their Own Lives”  and I found it outrageous that the suicide prevention groups I know exclude potential physician-assisted suicide victims.

As a nurse, I have personally and professionally cared for many suicidal people over decades including some who were terminally ill. To my knowledge, none of these people went on to die by suicide except one-my own daughter.

Almost nine years ago, my 30 year old daughter Marie died by suicide using an assisted suicide technique she found after searching suicide and assisted suicide websites and reading assisted suicide supporter Derek Humphry’s book “Final Exit”.

Marie was a wonderful woman who achieved a degree in engineering despite struggling off and on with substance abuse and thoughts of suicide for 16 years. She was in an outpatient behavioral health program at the time of her suicide. Her suicide was my worst fear and it devastated all of us in the family as well as her friends. Two people close to Marie also became suicidal after her death but were fortunately saved.

For years before and after Marie’s death, I have written and spoken to groups around the country about the legal and ethical problems with assisted suicide as well as suicide contagion  and media reporting guidelines for suicide.

So it was with mixed feelings that I participated in the suicide prevention walk but now I am glad I did.

“WORKING WITH DECISIONALLY CAPABLE PATIENTS WHO ARE DETERMINED TO END THEIR OWN LIVES”

I finally finished reading this article after the walk and found that while the authors of this Journal of Clinical Psychiatry article insist that they are only discussing “decisionally capable” people with “advanced medical illness”, they write:

“The 24% increase in US suicide rates from 1999 to 2014 has led to greater efforts to identify, prevent, and intervene in situations associated with suicidality. While the desire to kill oneself is not synonymous with a mental illness, 80%–90% of completed suicides are associated with a mental disorder, most commonly depression. Understandably, psychiatrists and other clinicians face strong moral, cultural, and professional pressures to do everything possible to avert suicide. Hidden within these statistics are unknown numbers of individuals determined to end their lives, often in the context of a life-limiting physical illness, who have no mental disorder or who, despite having a mental disorder, were nevertheless seemingly rational and decisionally capable and in whom the mental disorder did not seem to influence the desire to hasten death.”

Tragically, the authors also state:

“In reviewing the either sparse or dated literature in this field, surveys from the United States and Canada support that most psychiatrists believe that PAD (physician aid in dying, a euphemism for assisted suicide) should be legal and is ethical in some cases and that they might want the option for themselves.”

And

“Although we see ‘assisted death’ as an option of last resort, we instead ask whether on certain occasions psychiatrists might appropriately not seek to prevent selected decisionally capable individuals from ending their own lives.” (All emphasis added)

This flies in the face of long-standing professional suicide prevention and treatment principles.

Notably, the article ends with an addendum, the 2017 Statement of the American Association of Suicidology (AAS): “Suicide is not the same as ‘Physician Aid in Dying’”

That concludes:

“In general, suicide and physician aid in dying are conceptually, medically, and legally different phenomena, with an undetermined amount of overlap between these two categories” but “Such deaths should not be considered to be cases of suicide and are therefore a matter outside the central focus of the AAS.” (Emphasis added)

WHY I AM GLAD I WENT ON THE SUICIDE PREVENTION WALK

The Sunday walk was sponsored by the American Foundation for Suicide Prevention (AFSP), a group that I discovered states it is trying to “Develop an updated AFSP policy position on assisted death (other common terms include physician assisted suicide or Death with Dignity Laws)”

The next day, I was able to contact a policy person at their Washington, DC office and, unlike other suicide prevention group representatives I have contacted in the past, I found this woman surprisingly interested and receptive to the idea that we should not discriminate against certain people when it comes to suicide prevention and treatment. She even asked for my contact information.

Of course, the AFSP may decide to exclude potential assisted suicide victims like other organizations have done but at least I tried and that’s the best tribute I can give to my daughter now.