Purdue University
Medical Sociology, SOC 491C
Winter 1987
Grade – 10\10
Teacher’s comments: Excellent and sensitive discussion of a complex topic
Medical Technology: What’s the Problem?
Medical technology has not gone too far; the way in which we use that technology is the problem. There is a lag involved between scientific technology and the ethics involved in its humanistic use. We can physically keep a person alive with life support systems, but society has not yet provided a moral code for doing so; there are no norms or guidelines for medical practitioners to go by.
The science involved with the technology is actually the easy part; whether you’re talking about an antibiotic to kill a germ or a machine to force air into motionless lungs, the principles are concrete and appear to be quite humanistic. The ethics that become involved with science is very complex and very controversial.
Another major problem is the fact that the doctors who order this technology are no further advanced (and possibly further behind) than the rest of society. Medical school does not prepare doctors to deal with these delicate issues. Doctors become nomophobic (an irrational fear of the law) in medical school; they make decisions about the use of technology from a standpoint of fearing a lawsuit. This leads to the problem of medical technology going too far; doctors end up over-treating dying patients simply to avoid litigation. Technology should be used to help a patient.
By practicing defensive medicine doctors see the law as primary and ethics secondary. Legal thinking is to protect themselves; their goal, however, is to benefit the patient. Ethics goes beyond the law; many of us are not trained in ethics as a part of our education, but the fact that doctors aren’t is hard for me as a nurse to cope with.
The American Heart Association has said that CPR’s use on a terminal patient is a violation of his/her right to die with dignity.
The Vatican has spoken to this issue in its 1980 “Declaration on Euthanasia”. Roughly quoted the Vatican said: No one need to undergo treatment when its use would only secure a precarious and burdensome prolongation of life. If treatment doesn’t offer a reasonable hope of success if it only prolongs dying, it is worse than useless; it is an indignity against our humanity.
I can think of an example that will illustrate a case where interventions became intrusive. I was a new graduate nurse in an intensive care unit; I was assigned to a patient who had been in the unit for a month now with metastatic cancer. He weighed 72 pounds, was respirator-dependent, was being fed through a needle in his vein, and was in constant, excruciating pain. I had been aware of this patient’s case, but this was the first time that he had been my patient. I was afraid to have him as a patient because I feared that I could not ethically refrain from being honest with the family. When I first went in the room to care for him his blood pressure was 50\0; he was already on drugs to force him to have blood pressure. I called his wife and told her that he did not have enough blood pressure to maintain his life and the medications were at their maximum. I asked her if anyone had discussed emergency measures with her. She said no, but that she was too upset to bring the subject up herself; she begged me not to do anything to make him live any longer in this horrible way. I told her that she had to sign a paper to prevent his being resuscitated.
I feared the loss of my job for doing what the experienced nurses and none of the doctors had done; I was honest about what we could do with our technology and what we couldn’t do to help this patient. I called the respiratory specialist (MD) to tell him that the wife was on her way to sign a DNR (do not resuscitate) for her husband. He said, “Gee, thanks, I’m glad someone finally took care of that”. I had prepared myself for being told that I’m just a nurse and had no right, to be honest with the wife. I then called the family doctor to let him know and he said, “Boy, I’m glad you took care of this; you know I’m not trained in these matters”.
Can you imagine the doctor’s defense if the wife were to sue for unnecessary cruelty to her husband? The doctors would say that they used the technology even though it would not help the patient and would prolong his suffering because they feared being sued for not using them – what a flimsy defense! I believe that doing what is ethically appropriate and goes along with the patient’s wishes is not only humane but serves as the best defense.
I think that interventions are intrusive whenever the patient is not fully informed and in charge of his/her care. I have seen many little old women from nursing homes come to my CCU saying that they don’t want all this stuff done to them. Their families tell the doctors that they want everything done to save Grandma. (They don’t know what “everything” means). It is assumed that grandma is senile, (even though my neurological assessment tells me otherwise) and they proceed to treat the patient telling her that they are only doing what is best for her. They (the family and the doctors) make Grandma feel guilty for not cooperating with all this generosity.
I recall a recent occasion when I acted as a patient advocate for an older woman and was able to elicit the assistance of a resident to see that we respected her demands. I was reprimanded by my head nurse; how dare I rock the boat and deprive this hospital of the funds collected for grandma’s care and for the opportunity for the doctors to practice their skills on her.
The manner in which DNR subjects are brought up to the patients and the families leaves a great deal to be desired. For one thing, we usually bring up an extremely difficult subject with people who are experiencing a major life crisis; the loss of their own life or that of someone whom they love. If you ask a family, “If your mother’s heart stops beating do you want us to help her”? could only elicit a response of “yes”. On the other hand, if you explain the terminal prognosis and that no technology can make the patient better and then ask, “What do you think she would want us to do for her?” The family will more than likely say to make her comfortable in her last days.
Some families may misperceive a DNR order as meaning no care; an order called, “comfort measures only” may be more psychologically palatable.
I think that health professionals have a duty to decrease the power disparity between the patient and staff and use their knowledge and experience to better meet the PATIENT’S needs; we should think in terms of the goals of the patient NOT those of the staff which may be to cure cure cure. The patient’s need may be to obtain support and comfort to cope with their death; I think we should be non-judgmental in assisting our patients.
Patients should be made aware of all their rights and options involved in their care; professionals should be held liable to respect their wishes.
The solutions to these very controversial issues are many as I see them. I once worked in an oncology unit where the subject of death and treatment choices were discussed on admission by the nurses. This worked well because the nurses had the support of the doctors in regard to putting patients in charge of their care. The nurse would document in her notes a patient’s wishes; the chart IS a legal document so it can be referred to later for reference if the patient becomes unable to direct his/her care; the family can fall back on the patient’s wishes without guilt and the staff can feel free of liability.
Because nurses spend more time with patients and are more educated in the social and psychological sciences, I think they are the natural ones to deal closely with these matters. Patients frequently feel free to talk to nurses; I have had many intimate relationships with my patients because they felt free to discuss difficult subjects with me.
Nurses are in an excellent position to do research on these issues, and I think they should do so and go public with their findings. There are literally no issues that aren’t discussed on TV, why not the issues involved with technology and its proper use.
Being honest and using language that a patient can understand cannot be overemphasized; frequently doctors leave the room, and a patient will say, “What did he/she say?” Education of doctors is definitely lacking in training to enable them to deal with humans and communicate compassion. I recently heard on TV that a leading medical school was changing its entrance requirements to include an assessment of qualities relating to the ability to show concern to patients. I found this very promising.
Living Wills are not fully understood by doctors; they don’t seem to feel secure in feeling protected from liability with them. I have had patients with living wills prepared; they come to the hospital at death’s door, unable to speak for themselves and the family says they want all the technology used; the docs go ahead and use the technology.
At a seminar on this subject that I recently attended, the speaker recommended appointing a representative who would speak on your behalf if you were too ill to do so. You could discuss ahead of time the various issues in current technology. The speaker specifically and emphatically recommended NOT using a lawyer to fulfill this role; he said you could even spare your family by using a friend. This spokesman and you will prepare a legally binding document to be used if it ever becomes appropriate.
Twenty states now have N. D. A.’s (Natural Death Acts); these are a collection of legal documents recognized as a way for a competent person to express their wishes in advance. These documents guard against civil or criminal liability of health professionals; they also hold the doctor liable if he does not comply or transfer to a doctor who will comply with the patient’s wishes.
Recently, nurses are becoming involved in many areas of health care which involve non-traditional; they review charts to check DRGs and audit billing. Why not have nurses specialize in discussing and implementing a patient’s wishes regarding technology?
Of course, doctors need to become comfortable with death; this will be a major feat. The acceptance of death as a part of life is not a simple teachable concept; it would probably need to be filtered into all their education.