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Canada - Flu pandemic plan would deny intense care to very sick, aged

AlaskaDenise

In Memoriam
http://www.canada.com/ottawacitizen/news/story.html?id=bda89416-438b-4ac2-9147-0d4de13517fa

Ontario strategy directs scarce resources to patients more likely to survive

TORONTO - Ontarians more than 85 years old, as well as patients who are extremely ill and unlikely to recover, won't get aggressive medical care aimed at saving their lives during a pandemic, according to the province's emergency plan for dealing with a widespread influenza outbreak.

(remainder of the story by subscription)

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Re: Flu pandemic plan would deny intense care to very sick, aged

Re: Flu pandemic plan would deny intense care to very sick, aged

http://www.hamiltonspectator.com/NASApp/cs/ContentServer?pagename=hamilton/Layout/Article_Type1&c=Article&cid=1164581412059&call_pageid=1020420665036&col=1112876262536

Pandemic plans must include all

<TABLE cellSpacing=2 cellPadding=2 width=299 align=right border=0><TBODY></TBODY></TABLE>
By Jan Burke-Gaffney, Dundas
The Hamilton Spectator(Nov 27, 2006) Letters @thespec.com

Re: 'No pandemic care for elderly' (Nov. 21)

The pandemic plan put together by the experts may be driven by ethics. It certainly isn't driven by morality. Do these treatment decisions really reflect the values we hold as a society? You may have raised your family, paid your taxes, gone to war for your country and donated to your favourite charities. You're too old now. You will not receive critical medical treatment.

You may be the beloved son or daughter who brightens the lives of your family, who always brings a smile to your co-workers, who contributes with kindness and gentleness in a cynical world -- but you have a disability.

You're not smart enough, or stable enough. There will be no treatment for you either.

You may be a thief, a rapist, a petty tyrant or a bully, but you are healthy and young. You will receive critical medical treatment.

I don't mean to be flippant. It's a terrible task to have to create flu pandemic rules for the whole province. Perhaps that's the problem; trying to manage something that is unmanageable. We mustn't play God.

We will make terrible mistakes and perhaps sacrifice our humanity in the process.

In 1918, the Spanish flu virus swept the world and more than 50 million died. No one knows whether a pandemic strain -- if it ever emerges -- will be similar enough to the ones we now know about that any vaccine will offer full protection. We don't even know if the bird-flu strain is the right threat to focus on.

We have to do something to prepare: work on a vaccine, produce enough doses to protect people, have a plan for public hygiene and so on.

These are humane efforts. Denying people critical medical treatment based on their age and impairments will not protect us. Societies that select and discard people are not societies we have ever admired or wanted to emulate.

I do not envy the task of Dr. Michael Christian and his team. They are wrestling with worst-case scenarios that will result in unspeakable tragedies. Please don't make it worse by excluding certain people from their share of hope and their place in humanity.

.
 
Re: Flu pandemic plan would deny intense care to very sick, aged

Re: Flu pandemic plan would deny intense care to very sick, aged

DeNial is not a river in Egypt....
 
Re: Flu pandemic plan would deny intense care to very sick, aged

Re: Flu pandemic plan would deny intense care to very sick, aged

Alaska:

I respectfully disagree. Effective triage is the cornerstone of emergency medicine. When we have scarce resources, it is ethical and highly courageous to utilize them in a manner which delivers the maximun good to those most likely to recover.

I believe that it is moral and ethical to focus scarce resources on those elements of society, most likely to be able to rebuild it and repopulate it.

I have several courses of Tamiflu. If there is a serious CFR, I have considered that my best choice might be to donate my time to caring for those who are ill, but may recover and donating my Tamiflu to their recovery.

Triage has been the cornerstone of medical ethics and decision making for hundreds of years. It is truly merciful and has sustained us in dignity and compassion.
 
Re: Flu pandemic plan would deny intense care to very sick, aged

Re: Flu pandemic plan would deny intense care to very sick, aged

Simply replace all the references to pandemic care with the words 'insurance coverage'. We are already in the situation the outraged columnist is describing. The only alternative being proposed by the columninst is to let everyone have a more equal chance of dying so nobody has to make any hard decisions. Well, as my mom said, 'Not deciding is also deciding.'
 
Re: Flu pandemic plan would deny intense care to very sick, aged

Re: Flu pandemic plan would deny intense care to very sick, aged

Think of this as front lines in a war. Decisions must be made when soldiers are brought in from the battle fields as to who will get most of the available resources, including time by an attending medical person. If there is zero chance of survival, then making a person as comfortable for the inevitable must be the priority. No one likes these kinds of decisions, but they are made everyday. At some point this is going to become a choice of Great Aunt Nell and four other people. So, ethically, how can you choose one when it means the deaths of several others? Especially if Aunt Nell is going to die anyway?

A better choice is to care for immune compromised and elderly patients in homes. They along with children and pregnant women should be isolated as much as possible to prevent infection in the first place. Knowing they will probably be passed over if they do get sick should be made public now. It will help wise decision making by care givers later.
 
Re: Flu pandemic plan would deny intense care to very sick, aged

Re: Flu pandemic plan would deny intense care to very sick, aged

No one wants to think of a loved one not receiving all possible medical treatment possible. Worse yet, no matter how it is phrased, we always either admittedly or even unconsciously place ourselves as a venerable patient who is in need of that sort care. I know that I make it very personal and up in my face when considering the facts initially, it is a part of us as humans.
<o:p> </o:p>
The way the article was presented, that if a person is sick and there is no possible way of survival, that support services will not be available. Yet the article did not say that there would be no more help. Instead of life sustaining measures there will be if at all possible as much compassionate assistance and support possible for the person while they are alive. This will mean so much more than extensive heroic measures that will only cause more pain and suffering and prolong not the living but the agonizing DYING process. Many have only seen what it looks like on fictional TV to have CPR done. It never shows the broken ribs, torn muscles in the chest cavity, the burn marks that can occur from a defibulator, the raw throat from the incubation of a tube down the throat, the hurricane force of air from a C-Pack ventilator, all this on top of the severe agony of the potential pandemic disease. Even if the person does survive, their quality of life may be severely restricted and hampered with untold multiple complications and compromised systems. It is not a joyful and happy ever after ending - far from it.
<o:p> </o:p>
As a thanatologist I have often seen the medical treatments that have been performed to try to save a life and it is not a jolly situation that the patient experiences during the medical crisis or during recovery if that that does happen. Aggressive medical treatment does not guarantee recovery or even a more comfortable death. Medical science has come a long way to help sustain life but at what cost to the person who is suffering. There needs to be compassionate and loving care provided to all persons with dignity for all concerned.
<o:p> </o:p>
It is not an easy decision to make to say no more treatment that will prolong life. I seriously doubt after having been involved in numerous situations both personally and professionally that few what to ?play God? far from it. Yet for many involving a sick person in aggressive advanced medical treatments is also considered playing God as well.
<o:p> </o:p>
In a pandemic situation, that we will face at some given point, will call for prudent and compassionate consideration. If I am so sick that there is little to no chance that I will recover than I will want to have all the compassionate not aggressive medical treatment that I can receive, even if in my dying that could only mean that someone will be willing to hold my hand and journey with me those few hours, days or even moments as I cross over from this living experience to that which will occur afterwards. Most people who are critically and terminally dying do not want to have extraordinary painful, invasive actions taken, instead they want a peaceful presence of a caring person to be with them.
<o:p> </o:p>
The scariest part of death event for many is not the death event itself, but the dying process. We, who are not currently dying, fear most the thought of the loved one not being with us any more in the manner we are accustomed to. It is self interest motivation. Once we can focus on the well being of the person who is actively dying, then the issue needs to be ?what is the kindest acts of care we can provide this person?. Major invasive, prolonged and most likely non-effective aggressive treatments are not what will provide the most caring and loving support to a person who is dying.
Please understand I am NOT suggesting that no treatment be offered to a dying person, instead I advocate that the most aggressive INTENSIVE compassionate palliative treatment be provided.

The title of this article first mentioned is an emotional and attention grabber. It does not help to have high intensity verbage when considering the best and msot compassionate care for a ternimal person.

TM
 
Re: Flu pandemic plan would deny intense care to very sick, aged

Re: Flu pandemic plan would deny intense care to very sick, aged

Thoughtful comments, all. I have a question for T Modesto. How will average people react in the trenches once a pandemic with a high CFR starts.

I have for, the most part, been insulated from the dying process. I think most of us have been as well. How will care givers at home know when it is time to switch from lifesaving measures to final compassionate preparations. Is the transition obvious? Can the home care givers make the psychological adjustment in time? Any recommendations for mental preparations for a possible future during a pandmeic where everyone will be affected by the dying process?
 
Re: Flu pandemic plan would deny intense care to very sick, aged

Re: Flu pandemic plan would deny intense care to very sick, aged

If I receive Tamiflu, I'll save it for my adult daughter and her young husband. They are our future. Young people should not feel guilty about their desire to survive. Of course you do!

And if there turns out to be plenty of meds, then I'll want some, too. But not if it's in short supply. I'll stay home, away from people. Regarding caregiving, Hospice provides very helpful information on how to care for terminally ill patients.
 
Re: Flu pandemic plan would deny intense care to very sick, aged

Re: Flu pandemic plan would deny intense care to very sick, aged

An obvious transition is , for example, when the person is becoming blue (blue lips, blue nails, and last dark blue skin as in 1918), breathes quickly, with the muscles of the neck. ( if there is not O2 or intensive medical treatment at this stage, it is almost bad , to late )
I think that that will be very hard to support for a nonmedical person, and for a doctor too.
The main thing is that the patient does not suffer, does not feel that it cannot breathe any more.
 
Re: Flu pandemic plan would deny intense care to very sick, aged

Re: Flu pandemic plan would deny intense care to very sick, aged

Excellent questions! <o:p></o:p>
<o:p> </o:p>
There is a great deal of debate as to how Western society individuals will deal with mass fatalities. From what I have seen from the examples of 9 -11 and Katrina, I seriously doubt if Western Culture will fare well in their ability to cope. Unfortunately, most people do not know how to do dying, death, mourning and bereavement much less grief very well.<o:p></o:p>
<o:p> </o:p>
I have been in conversation with Florida1 and the idea has been approached as to having a room on the forum to discuss these sorts of questions. I would be willing to do if it would be of help and support.<o:p></o:p>
<o:p> </o:p>
In a pandemic the switch in the home I would think would be when the care givers see a significant change in a person?s ability to deal with the most elemental issues of self care and support. <o:p></o:p>
<o:p> </o:p>
It is impossible to tell accurately the precise time of death, it is helpful to know where a person may be in the dying process. <o:p></o:p>
<o:p> </o:p>
One way to gauge this is to consider the level of strength and activity that the person is able to accomplish or not able to accomplish. The sequence of decline generally can be considered in the following way from a healthy, self sustaining ability to that of a person actively dying. This is the general understanding of the dying process but frankly all bets are off the table when it comes to this infectious disease. This disease is not your general death trajectory model. There have been so few reports as to the sequence of the death events. Many are dying either at home or at health facilities that are not trained in recording the dying process of a patient. So what is currently the thought may not be the same once the pandemic occurs. Additionally the translations of experiences are coming from news articles with very brief and limited descriptions, not to mention translation issues. <o:p></o:p>
<o:p> </o:p>
Healthy Ability:<o:p></o:p>
<o:p> </o:p>
Standing sitting<o:p></o:p>
Able to take in solid food<o:p></o:p>
Able to care for some or all of their personal needs and responsibilities <o:p></o:p>
Alert<o:p></o:p>
Aware of their surrounds and self<o:p></o:p>
Able to identify people<o:p></o:p>
Able to remember dates, places and events <o:p></o:p>
<o:p> </o:p>
Medical Level of Supportive Care<o:p></o:p>
<o:p> </o:p>
Continual or primarily needing bed rest<o:p></o:p>
Full liquid diet<o:p></o:p>
Bland diet<o:p></o:p>
Consciousness begins to become cloudy<o:p></o:p>
Irritable at times<o:p></o:p>
Periods of drowsiness<o:p></o:p>
Easily distracted or startled<o:p></o:p>
May stumble over words or has difficulty carrying on a longer term conversation<o:p></o:p>
Difficulty discerning what they hear or see accurately. <o:p></o:p>
<o:p> </o:p>
Point of Serious Health Transition<o:p></o:p>
Can no longer hold a cup <o:p></o:p>
Sips of fluids<o:p></o:p>
May become excitable or restless<o:p></o:p>
Difficulty following instructions<o:p></o:p>
Memory becomes very poor<o:p></o:p>
Disorientation as to time, place<o:p></o:p>
Restless and agitated<o:p></o:p>
Visual Hallucinations <o:p></o:p>
<o:p> </o:p>
Approaching Death<o:p></o:p>
Difficulty swallowing<o:p></o:p>
Nothing by mouth <o:p></o:p>
Unconscious or semi-unconscious, however in historical accounts many patients never went unconscious until short period before death if then.<o:p></o:p>
Stupor when the individual sleeps the majority of the time. Significant stimuli may be able to arouse them but the person will immediately go back to sleep. <o:p></o:p>
Wishes to be left alone, this is what may be the situation in a generally expected death, however in dealing with a influenza pandemic disease as in 1918 this may certainly not be the case. <o:p></o:p>
Becomes more disassociated with current situation and loved ones. <o:p></o:p>
Enters coma state in which they are not able to reenter the state of consciousness. In a coma a person may still be able to hear even though they appear to have no connection to their surrounds. <o:p></o:p>
Breathing patters changes to that of Cheyne - Stokes respiration which is a combination of shallow breaths to volume breathing then to no breathing (apnea) for up to 10-30 seconds. <o:p></o:p>
There may also be cluster breathing also known as decreasing breathing, where there are bigger and bigger gaps between breaths<o:p></o:p>
Ataxic breathing which is very irregular. <o:p></o:p>
Breath Sounds can also occur. This may also be called the ?death rattle? and this can be very loud. There will be significant skin changes including motley or patch color changes to the skin. Bluing of the lips and face may also be a possibility. In general death experiences the person who is dying may become very pale but in the records and descriptions of 1918 the opposite was true in that the person?s skin became very dark. <o:p></o:p>
There will be a significant change in heart rate and the pulse will become weaker over time.<o:p></o:p>
There can be elimination issues as well. The kidneys generally start to shut down about 2 days before death in a general death experience but in a influenza pandemic such as 1918 elimination issues including diarrhea and vomiting may occur up to the point of death <o:p></o:p>
<o:p> </o:p>
Death<o:p></o:p>
<o:p> </o:p>
No form of response<o:p></o:p>
No movement of the body<o:p></o:p>
No pain<o:p></o:p>
Eyes fixed<o:p></o:p>
Loss of control of bladder and bowels may occur<o:p></o:p>
Jaw may slacken<o:p></o:p>
In time the temperature of the body will cool to that of room temperature. Note a dead body does NOT get cold. I t may feel much cooler to the touch because the person touching the dead body is warmer than room temperature so bodily remains will feel cool to the touch. It is similar to when you touch a table or a piece of marble. It can feel cool or some would say ?cold?. In reality it is only at the room temperature and in no way is the body colder than room temperature. Some people become concerned that the person who has died is cold. The person who has died does not feel the sensation of being cold or hot. All life-force consciousness has left the body. <o:p></o:p>
<o:p> </o:p>
CURRENT WESTERN CULTURE THANOSTIC SITUATION <o:p></o:p>
<o:p> </o:p>
Most people in our Western culture have not had much exposure to death and particularly the dying process. The average age for a first primary death (generally a parent, possibly a grand parent) experience often occurs when a person is in their mid- 30s to that of their 50s. For those who have had the death of grandparents they have often been experienced as a young child or as a distant death due to the mobility and geographical relocations for both adult children and parental figures after retirement. If it was a death experience in the early to later portion of the 20<sup>th</sup> century, young children were sequestered from the death experience. In fact from early 20<sup>th</sup> to the later 20<sup>th</sup> century there has developed a MAJOR death phobia development in Western society as a whole. Up to that point dying, death and funerals were close and intimate affairs with the person ?laid out? at home after death. Most births and deaths were at home, not in hospitals or supportive care facilities. Few people even knew what a nursing home was all about and the advent of assisted living centers was only starting to become prevalent in the 1970s and beyond. When Aunt Mary needed to have help, someone in the family or neighborhood or possibly church would come live with Aunt Mary or Aunt Mary would go live with a family member, etc.. The more we have glorified youth, the more we have run away from the sequence of life called living with a life threatening illness or advanced age. <o:p></o:p>
<o:p> </o:p>
Think of it, we are so scared of death that now most people die outside of their homes in an institution such as a hospital or a nursing home. Funerals are no longer family affair at home but are now held at a funeral home. In the past 20 years the mourning expression (the period from death through the funeral rituals) has been shortened from what was a 3-4 DAY experience to a 2.5 to 4 HOUR experience not including the repast meal at a catered facility instead of at the family home. People want to stay as far away from the whole death scene as possible. <o:p></o:p>
Mainline Christian denominations, over the course of the last century, relinquished, if not many, some of their active ministerial duties to the dying and the bereaved to professional ?others?. These professional others include the medical community, funeral directors, hospice volunteers and professional staff to name a few. Many churches / faith expression centers and clergy / pastoral teams have little or no knowledge or training concerning contemporary thanatology. There is also a lack of knowledge of how to incorporate current thanatological understandings ? as reflected in diverse cultural expressions ? into the life and ministry of many of the local churches, as well as on denominational levels of mainline Christian expressions of faith. There is also very little understanding and appreciation for the mutuality of service and care to the dying and the bereaved offered by both clergy / religious leaders, pastoral teams, funeral service directors / providers and other thanostic care providers.

I hope this will help
TM
<o:p></o:p>
 
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