OT: End of life, Family conflict, damned if you do and if you don't, thought?

[etu]

I sympathize with your situation and respect your concern for your father in law. However don't forget the living. The dying process is more often about the family than the person, especially when their mental faculties are compromised either from chronic deterioration or their acute condition. I think it's important to remember what your father in law would have wanted not for himself but for his children. Last thing would be for their to be conflict and a rift over this death. I would support your wife, but also avoid encouraging any resentment. Most of us idealize a death surrounded by family and friends who celebrate our life and serve to affirm that we left a positive legacy.
I recently had the privilege of caring for a Battle of Bulge veteran who passed. When the eventual outcome was clear, our focus was on the family and making sure the process of closure was as least as painful as possible and without distractions. IMO a great deal of the responsibility for these case rests with the physician who has to develop trust with the family and then be unequivocal about the prognosis. The latter can be uncomfortable to do, but part of our job is to unburden the family of any guilt or responsibility over the dying process. Family member should not feel like they are the ones withdrawing support or "letting" their loved ones die. Unfortunately sometimes the underlying family dysfunction is impossible to manage smoothly. In these cases, mercifully modern medicine can't hold off death forever.
I have found that the key to the process is the trust that we build at the initial encounter. Since there is already friction between your brother and the current inpatient team, I wonder if there is a primary care provider or someone else who has cared for your father in law longitudinally as an outpatient that your brother knows and trusts. That person could be help your him allow this process come to a close.

[Rusty Luggs]

Originally Posted by Kirk007

..... Yet, continuing to say nothing results in a continuous loop in my mind of the saying that all it takes for evil to succeed is for good men to do nothing.....

This one thing strikes me from the original post.... Is everyone who disagrees with my strongly held beliefs "evil"? Is the only "right" decision the one I would make? Or the one the majority of people would make?

Might be ill informed, emotionally driven, immature, insensitive to other peoples views, maybe even stupid, but evil? I think if I would work on getting that idea out of my head before I did anything.

[Aaron O]

Originally Posted by Rusty Luggs

This one thing strikes me from the original post.... Is everyone who disagrees with my strongly held beliefs "evil"? Is the only "right" decision the one I would make? Or the one the majority of people would make?

Might be ill informed, emotionally driven, immature, insensitive to other peoples views, maybe even stupid, but evil? I think if I would work on getting that idea out of my head before I did anything.

Kind of agree here...your brother in law is losing a father. It's not the choice I hope I'd make, but he's probably trying to do what he considers the right thing. He might be rationalizing his own feelings into what he thinks is right, but it's a tough choice I never want to be in. It's not the choice I hope I'd make, but it's a tough situation, and I'd be loathe to use absolute terms.

I'm extremely close with my dad...I love the heck out of him...and it's easy for me to judge on the internet without emotion. I don't know what I'll be thinking if it's ever my turn...and I know darn well what my dad's choices would be.

[fuzzalow]

“The only thing necessary for the triumph of evil is for good men to do nothing.” is a favored Edmund Burke quote of mine and one that IMO, is useful to instill activism and responsibility in civic society.

Originally Posted by Rusty Luggs

This one thing strikes me from the original post.... Is everyone who disagrees with my strongly held beliefs "evil"? Is the only "right" decision the one I would make? Or the one the majority of people would make?

Might be ill informed, emotionally driven, immature, insensitive to other peoples views, maybe even stupid, but evil? I think if I would work on getting that idea out of my head before I did anything.

No, you are using the quote far too literally, oversimplifying it's sentiment and furthering its misuse into a comfortable, if misguided, polarization between your views and of other views. There's no such thing as black and white along the gradient of modern society, it's all a continuum of grey.

Although evil may still apply as an appropriate term to the most egregious assaults against fundamental tenets of society: for example such as the elevation and propagation of mistruths and/or the delegitimization of 1st Amendment free press and/or delegitimization of the co-equal branch of the judiciary.

No drift intended but nonetheless related to writing from the OP.

FWIW, if this is somehow a term applied to the BIL, I'd say it was also misapplied. Evil must also confer intent and I do not view this as driving the BIL motives. I rather see it as confusion, conflicted emotions and the bewilderments of human frailty. I would try to be more forgiving as we cannot really know that in the same conundrum any of us could do any different or better.

[54ny77]

such a good thread. excellent comments by all.

end of life discussions taking place more & more each day, it seems.

so many loved ones depart unexpectedly or eventually (via prolonged illness).

[carpediemracing]

My dad died Oct 2016. He was admitted into program the prior Saturday (home hospice so basically a nurse came to verify that he seemed appropriate for hospice care). First actual hospice visit was Tuesday morning. My dad died that Tuesday afternoon.

So my experience with hospice was brief.

However, the one thing that I took away from hospice vs hospital care is that hospice is an acknowledged end of life kind of care. The emphasis is on comfort and dealing with the surviving family. Hospital care emphasizes prolonging life at any virtually any cost.

[Kirk007]

Originally Posted by Rusty Luggs

This one thing strikes me from the original post.... Is everyone who disagrees with my strongly held beliefs "evil"? Is the only "right" decision the one I would make? Or the one the majority of people would make?

Might be ill informed, emotionally driven, immature, insensitive to other peoples views, maybe even stupid, but evil? I think if I would work on getting that idea out of my head before I did anything.

Yeah no worries Rusty evil is certainly not the right adjective it was just a handy phrase that I wanted to more or less accurately quote to describe the discomfort I feel with the idea of staying silent in the face of a situation that you have a stake in and that poses an ethical/moral dilemma.

And as others like Aaron have suggested I recognize my primary role of support for my wife rather than a direct participant, at least in the absence of an extended family discussion.

We recognize the emotional struggle for BIL and feelings of understanding compassion and kindness for him are certainly there, but frankly he's been a self centered jerk towards his siblings and nephews for a long time, so there's already pre-existing emotions that are exacerbated by the feeling that father in law should be allowed to pass without extraordinary measures, as was agreed to by the siblings when the Physician's Directive was executed under less stressful, emotional times. It is the backsliding from that directive that is causing further friction. BIL knows how we and other family members feel on this and was reminded directly by his sister (my wife) yesterday, and he has been counseled by at least 3 doctors, and the head of skilled nursing at the memory care facility. But he has been in denial of this day for years. He holds the cards and the responsibility, he has isolated himself and is dismissive of the counsel of all others. As I believe Angry Scientist pointed out, he will have to live with his decisions.

We have made our peace with FIL's passing; we have said our goodbyes. All that is left is how much further suffering and sadness we all endure, particularly if against all odds FIL survives this challenge and we go through one or more repetitive cycles of this crap.

[Climb01742]

Originally Posted by Kirk007

It is the backsliding from that directive that is causing further friction. BIL knows how we and other family members feel on this and was reminded directly by his sister (my wife) yesterday, and he has been counseled by at least 3 doctors, and the head of skilled nursing at the memory care facility. But he has been in denial of this day for years. He holds the cards and the responsibility, he has isolated himself and is dismissive of the counsel of all others. As I believe Angry Scientist pointed out, he will have to live with his decisions.

This may be the crux of the situation. Your role may be as a witness. Be there for your wife but otherwise you may only be able to watch. It's the BIL's drama and his karma and his issues to work through. Watching someone you love in pain is damned hard. Sorry you're going through it.

[Pastashop]

007, I looked through the thread once more and didn't see it brought up, so... I mentioned this thread to a doctor friend and was told that every (big) hospital has an ethics review board, which you can engage in this type of situation. Is this an option?..

[OtayBW]

Originally Posted by Kirk007

BIL knows how we and other family members feel on this and was reminded directly by his sister (my wife) yesterday, and he has been counseled by at least 3 doctors, and the head of skilled nursing at the memory care facility. But he has been in denial of this day for years. He holds the cards and the responsibility, he has isolated himself and is dismissive of the counsel of all others.

This is as much of a shame as dealing with your FIL's condition. IMO, your BIL is creating a toxic situation that will likely linger to his own detriment and that of your family long after your FIL is gone.
Hope you and your wife can get some detachment (not quite the right word...), and have a clear mind about all this moving forward.

[jumphigher]

Sorry to hear about your situation, OP. I feel the same way, extending the life of someone in that state is not helping them in any way imo, and probably prolongs a lot of suffering. Sucks. I wish you the best.

[gordosburritos]

Really tough situation. I deal with critical care/death as part of my job as a heart doctor and my wife is a palliative care physician. A couple of ideas:
1. I would request a palliative care consult if available. This is separate from hospice referral. One of the jobs of palliative care teams is to work with families to help bring them together and get on the same page. They have the time and more importantly the expertise that most physicians/nurses don't have. It is a major part of their job and they're usually pretty good at it.
2. Ethics review if there is a true concern for medical futility. I am not sure if the situation is truly futile from reading this thread but could be looked into. Realize of course this will drive a wedge into the family rather than trying to pull folks together.
3. Find out ways to support brother in law. This is likely the most challenging but may help build a connection to better understand his viewpoint and possible keep future events like this from happening. If he can move past the him vs. everyone mentality he may be more open to shared decision making.

not easy. best of luck to you and your family.

[Chris]

Originally Posted by Pastashop

007, I looked through the thread once more and didn't see it brought up, so... I mentioned this thread to a doctor friend and was told that every (big) hospital has an ethics review board, which you can engage in this type of situation. Is this an option?..

I am the Chair of the ethics board at our hospital. This situation is not unusual and we often sit with all of the family members and physicians involved to discuss the current status of the patient and realistic expectations. It often helps the person who has unrealistic expectations to come to terms with the reality of the situation in a fairly supportive environment. Good suggestion.

[gngroup]

My only comment (and I didn't read through all of the posts yet), would be that you and your wife should at the very least communicate your feelings to him (perhaps very delicately). Beyond that, it's hard to know the outcome with certainty but at least you will have spoken up and that alone may lend itself toward keeping the familial relationship amicable going forward. Tough situation. Sorry to hear about it but best of luck.

edit - Just read that you have done this already. Hopefully BIL comes to the conclusion everyone is pointing him toward very soon.

[Jeff N.]

Originally Posted by Kirk007

Out of respect for the collective wisdom, life experience and kindness of so many on this forum whom I've come to know electronically over the years, I seek any counsel that you may offer; perhaps some of you have been through this and made it through to the other side relatively intact.

Situation: 92 year old father in law, in year 10 of dementia, hospitalized 11 days ago with pneumonia, UTI and septicemia. Hanging on by a thread with multiple antibiotics and IVs. Barely eating.

Brother in law is Guardian and has Power of Attorney for medical decisions. Living will in place. Physician's Directive in place directing antibiotics for comfort only, no tube feeding. Brother in law thinks he can be saved, and now trying to go back on the Directive, which he executed a few years ago as guardian.

Wife (and me and the rest of the family). Adamantly against extraordinary life extending measures, believe this man has suffered enough and current efforts by brother in law are extending suffering and are being made for his own interest/inability to accept death. Brother-in-law is very angry, nasty lashing out at everyone and anyone, including health care providers as not doing enough to save his father (long pattern of narcissistic behaivour here). Acting independently, not seeking input from other family members and ignoring counseling of at least 3 doctors.

I am torn as to what to do, if anything, as is my wife. On the one hand we believe her father to be suffering and her brother's conduct, while in some ways understandable nevertheless is inhumanely selfish and contrary to his duties as Guardian to do what is in the best interests of his father. His conduct is deepening the gulf that already exists between him and his sister, and me and other family members.

If we say nothing, father-in-laws suffering may continue through the "miracles" of modern medicine.

If we confront, even gently and with kindness, brother-in-law, the likelihood of him hearing and reconsidering his path is remote. Far greater is the likelihood that he lashes out even more at the family and the family relations deteriorate even further. Yet, continuing to say nothing results in a continuous loop in my mind of the saying that all it takes for evil to succeed is for good men to do nothing.

This is sadly a lose, lose situation I think. The biggest loser short-term at least in my view is my father in law whose suffering is needlessly prolonged. For my wife, this is her only living brother and as the conflict continues she loses him as well, but the relationship is not, as of yet irreparable (but it could become that). Ultimately her brother stands to be the biggest long term loser as he drives the rest of the family away from him. Never married, too self centered for the give and take of any relationship, he is on the path to a lonely future.

All of these outcomes suck, for everyone. And so my (our) dilemma - keep quiet unless asked or speak up (wife very conflict avoidant as her brother gets verbally nasty)? Third party intervention? How far do you go (trying to hold my litigator training at bay)?

Again if anyone has gone through a situ like this and had a good outcome, I'd love to hear how you did it.

Grazie mille,

Greg

As an R.N. for 36 years, 10 years spent as an ICU R.N., I've seen this kind of situation far too many times: a do-gooder family member who insists on everything being done to keep their "loved one" alive and suffering when the prognosis is extremely poor at best. We used to call it, "whipping a dead horse" behind closed doors. Unfortunately, if you aren't the responsible party there's really not much you can do except having one or more of the docs try to talk some sense to your Bro-In-Law or some kind of ethics committee intervention. If he continues to be unbending...well...