Hasten end so wife won't doubt DNR decision????

[markm739]

A post which discussed end of life issues over on the long term care forum got me thinking about something which occurred yesterday in the ICU unit where I am on orientation. I have reposted it here to see what you all think.

My preceptor and I cared for an end-stage COPD pt. 2 days this week. He was on BIPAP with terrible labored breathing, and I saw his LOC decline significantly during the day on Day 1. Day 2 a.m. he was unresponsive most of the morning; about noon, he was able to squeeze my hand weakly upon command, but had no other response to anything except pain at any other time.

My preceptor went in and talked to the wife about his code status and the potential use of a ventilator, which he might never come off of; this all resulted in her saying that the pt. had previously stated that he didn't want to be put on machines. When the doctor came in about 1300, he was officially made a DNR.

Now, I know this is a commonplace and commonsense scenario taking place regularly throughout this country, and that the wife needed guidance as to what to do so as to not prolong the suffering of her spouse of 51 years. It was the next thing which happened which I am looking at with a critical eye in light of the discussion of end of life care issues.

When the md wrote the DNR order, we also revamped his entire med list to reflect the new approach; again, common sense. Our unit has a formal deescalation protocol, but this was not being implemented, as this man had not been on a vent.

The new med list included morphine, of course...it was 2-4 mg, can't remember the frequency, probably q 1-4 hours. It was not the morphine drip at 10 mg/hr that's on our deescalation protocol.

At 1700, my preceptor came up to me and asked me how I felt about giving this guy morphine. The pt. was resting quietly in bed with no agitation or signs of pain or increased vitals. I asked him why, since there seemed to be no immediate indication for the morphine; he said that if this guy were to hang on too long, let's say, 3 or 4 days, the wife may start to doubt her DNR decision, and that would just add to her misery. I said, "You mean, give him morphine to slow down his breathing so he won't hang on 3 or 4 days?" My preceptor nodded. This was a new concept for me, as there seems to be quite a difference between not engaging in futile treatment and actively giving drugs to hasten the end. No one would want this COPD guy to suffer any longer than necessary, but actively giving him morphine for RR effect is a little on the proactive side, it seems.

My preceptor walked over and indicated he was giving the morphine; when I left at 1900, the gentleman's RR was down to 8.

I was thinking about this last night, and suddenly thought to myself, "How would I feel if I knew my own husband's end in this ICU was hastened by possibly a couple of days by a nurse who felt it would be detrimental to my mental well-being to let my spouse 'hang on' (in other words, die without intervention), and that this decision to consciously slow down his breathing to hasten his end was done without my consent or knowledge?"

I am becoming increasingly more uncomfortable throughout the day as I contemplate what happened. I know that what happened makes absolutely no difference to the pt.'s long term welfare; it's just that the wife had no say in this, it is dangerously close to euthansia (if not equivalent), and is the stuff lawsuits are made of. Also, when I apply the "do unto others" rule, it falls a little short.

Since I am new on the scene, I am wondering if the problem is that this is a common practice that no one talks about, and that I am just naive about what really goes on. My preceptor's motives were not bad (the euthanasia movement's aren't either), but this really blows away the idea of informed consent to medical treatment. I imagine that all sorts of things go on in ICUs across the country that no one would admit to, but I would really like to get some reactions from seasoned ICU nurses and nurse ethicists as to whether this is common practice, this guy is unusual, or I am naive enough to still be hanging on to nursing school habits and ideas, and am too "black and white" in my thinking.

ICU Newbie

BSN May 2005

NCLEX survivor July 2005

[NRSKarenRN, BSN, RN]

however, i am having a problem with ""you mean, give him morphine to slow down his breathing so he won't hang on 3 or 4 days?" my preceptor nodded. ....." the patient needs the morphine so as not to needlessly suffer in the end, not to hasten it for the wife's comfort.

the preceptor who thought that medicating the pt would cause his death, and the fact that she decided to give the med based on that are two glaring examples of why this nurse "needs some inservicing."

thanks for adding those points i missed late last night. :imbar

that's what so great about this bulletin board: the collective wisdom of it's members!

some times when i'm orienting students/new employee's what i meant to say and what i did say did not adequately explain concepts trying to get across.

i'm hoping that maybe the precptor had trouble too communicating clearly ---otherwise agree inservicing recomended. i would discuss with your preceptor what your concerns are to make sure you understood preceptor correctly.

if their replies are the same, discuss this issue with unit educator or manager.

check out facilities policies on terminal care too. just might be time for an inservice to entire unit.

kudos for questioning and not just accepting this situation. you'll learn in nursing that patient's lived experience is the best teacher. try to attend any and all inservices on pain management and palliative care as they are so useful in everyday practice. the ethics disscusions that occur in many of this courses really help to see others viewpoints and issues you need to be mindful of when caring for patients.

good luck in your career. :balloons:

[markm739]

Greetings to all!

I am amazed at, and grateful for, the insight, wisdom, and even courage which can come from a collective effort such as this! I really appreciate your thoughtful and comprehensive replies more than you know.

I was off for 2 days after this incident, and go back tomorrow (Saturday.)

I may check to see if the pt. is still on our census. One thing I need to check is what dose of morphine was actually given to the patient when my preceptor walked in there, as he didn't tell me. I say that because of an odd conversation he had with me a couple of weeks ago.

We had a patient who was breathing over her vent, and he said she needed to slow down, and that it probably meant she was in pain. That was reasonable, and her order was for 2 mg of morphine prn. This didn't help her, and when it didn't, he said that I needed to learn how things really work up there, and proceeded to say - not exactly in these words, but this is what it amounted to - that the nurses up there pretty much use the drugs available in the Diebold as they felt was needed - in other words, titrating to effect

rather than sticking to the dose written on the MAR. He did say this verbatim: "For example, you'll have someone come back for more of a drug out of the Diebold.....ooops, they dropped the last dose!" ...giving me the eye to indicate that the nurse was lying about the reason for overriding the Diebold and that she was actually giving the amount of the drug she felt necessary.....he then proceeded to say, "But on the MAR, they just cross off the dose as written."

When I asked a question, he looked at me and said, "You know, I think you'd better forget what I just said." I said, "But you just said it!" He said, "Well, forget I said it."

The first day that I had the aforementioned COPD patient in my original post, he was extremely agitated in the a.m. He was pulling his vent tubing off his mask for the BIPAP constantly (we had to restrain him, finally), and was moving around in bed enough that he was in danger of falling. We did not have any sedation orders, so I thought I would call the md for some, but he was so agitated that I was wishing I could give him some Ativan immediately, so I went up to my preceptor, and, based on his previous little "unspoken protocol" conversation he told me to forget, asked him, "That guy need some sedation NOW; do we have an unspoken protocol to go ahead and give him some Ativan?"

He proceeded to look at me and act as if the conversation of the other day didn't happen, and acted all self-righteous about it..."We don't HAVE unspoken protocols! That is a controlled substance....." He later reiterated, saying that I could lose my license over that....yet, I was just trying to respond in kind with how he tried to describe to me how things "really work" on the unit.

Another incident happened where we had a terminal pt. - 92 year old stroke pt. w/brain hemorrhage who came in the night before and would soon die - who had initially been put on a vent. It was decided by the family, since the bleed on CT was showing up in fully half her brain, and she would not recover, to take her off the vent and let her go naturally. We started our unit's formalized deescalation protocol; it stated that a morphine drip would be started which would run anywhere from 2-10 mg/hr.

Well, my preceptor said it should be started at 10 mg/hr. We did this. The daughter came out and kept asking us about every little movement her mother made, such as when her mouth moved a little - "Why is she moving her mouth like that?" I didn't mind this, as I knew it was a s/s of emotional distress on the daughter's part, and that she mainly needed reassurance; when she did this, I would go in and assess if anything was really wrong (there was usually no change), and then just give them both a little concerned TLC and a hug, as this was what I felt the daughter needed.

My preceptor later came and told me he turned the morphine drip up to 15 mg/hr so that the the mother would quit the movements which were upsetting the daughter (and there really weren't many, she was out of it), to create the impression to the daughter that everything was ok. Now, the argument could be made that the slight movements she made might indicate some discomfort, and that we were titrating to pain.....but, they seemed to me just to be reflexive, mainly consisting of occasional mouth movements where the ETT tube was touching her mouth (she was on a T-piece at this time.)

I say all this to say that this preceptor has a history of giving drugs as he pleases, and saying that this is how everyone on the unit does it; his backpeddling on the "nurses are walking around on this unit with extra drugs stored in their pockets that they use when they think they need them" was a little strange to me. So, I really don't KNOW how much he gave the pt. because of his history exhibited in both statement and practice! He may never tell me, as he may smell a rat if I come back and ask him how much morphine he gave that guy.

NrsKaren, I appreciate the resources you posted, and have looked them up; this is a great way for us to learn from each other. I am interested in hospice nursing, so this may be in my future.

Siri, I understand your reaction, as it is possible that his motives amounted to what you said, although one may argue that euthanasia may be the correct term (which can be argued to be synonymous with murder anyway.)

I certainly wouldn't want my own spouse to be subject to this without my knowledge.

I think the idea of this preceptor needing some inservice has hit the nail on the head. His ideas and practices have me totally confused on how far actual practice, in the ICU at least, differs from what we were taught in school - esp. pharmacology!! I really had medication administration drilled into me in clinical, and it became an area I was precise and competent in; to get out here and find out that ICU nurses do what they feel is best and carry drugs around in their pocket to use the amounts they feel appropriate despite orders, makes me wonder how safe this place and its patients are (and the whole hospital, for that matter.)

I appreciate the encouragement to question things and even approach ethics committees. I think, after hearing from you all, I will be more vocal in my questionings and objections.

Thanks!

ICU Newbie

[P_RN, ADN, RN]

What you are describing extends way beyond the scope of practice for an RN. You need to report this to someone who will immediately get the proper people involved. It could become a "he said, she said"...thing.

I have seen a lot of nurses caught in drug diversion with the history of "ooops it dropped, ooops the syringe got contaminated." You are in a position right now to be victimized by association.

We had this very scenario last month with my DH mother. She had parkinson's and thus didn't move a whole lot. She also had copious secretions, sepsis and system shutdown cascade. What I didn't understand was the doctor's hesitancy to order MS and then the nurses' hesitancy to give it.

After a family meeting we explained to the doctor we understood. She passed away quietly the next day.

This wife doesn't need to be in the dark. She needs to be included in the WHOLE decision. She needed explanation that DNR doesn't mean suffer. MS is indicated for comfort.

[markm739]

"You are in a position right now to be victimized by association."

You really have me thinking about this one. My spouse and I were discussing the meaning of this, and it could be 1) guilt by association with this unit

2) Being in a position to be influenced by nurses who think this way

3) Being ridiculed for being so naive as to think that anyone in the ICU would actually think that the 5 medication rights were something to be adhered to...primarily speaking of right dose here.

I actually have thought about transferring out of this unit.....this may add to my rationale for doing so. It is true that it could become a "he said, she said" thing, as this nurse is very much respected by management.

ICU Newbie

[Tweety, BSN, RN]

I'm a bit distrubed by your posts. He's practicing medicine without a license. I've heard of nurses giving "nurse's doses" and that's wrong.

Another thing to consider is this person might actually be a drug abuser and not giving the meds to the patients.

Either way BIG RED FLAGS for you to discuss with your manager, ethics committee or someone before you get way in over your head. It might be "the way we do things here", but you stick to your principals. It might be very uncomfortable, it might label you with your coworkers, but right is right and wrong is wrong. No grey areas with passing narcs.

If ordered pain medicine is ineffective, you call the MD. ICU nurses aren't more licensed to prescribe narcotics than anyone.

As was said above, if it is discovered he gave an overdose, and it's discovered that you knew about it and didn't use the chain of command, trust me on this the stone cold faces of the Board of Nursing will ask you "why didn't you use the chain of command" and you will not have a leg to stand on.

Good luck!

[Nurseinthemaking]

I saw this exact same thing happen in clinicals. Little different scenario, but same thing.

Patient was in the hospital but under hospice care. They were working together but battling the Morphine thing. Hospice was saying give it no matter what, even if he is showing no signs of pain. Med Surge Nurse said NO, I will not do this, they had a huge meeting over this and battled out if the patient needed this then why was he even in the hospital. It boiled down to the wife, refused to have him at home, but wanted hospice involved. Alot of people were calling her the Drama Queen. This was really hard for me to watch and listen to, but what I learned was that, there are different styles of nursing.

Hospital Nursing = Let's get them better and get them out of here.

Hospice Nursing = Let's keep them pain free and let them die a gracefull death.

Me being new at this as well, I am not sure I would feel any different then you.

[austin heart, BSN, RN]

Wonderful post from NRSKarenRN!

I do think that ICU nurses look at treating their patients differently than most floor nurses and please this is not meant to be a derogatory statement. But I could never imagine doing what your preceptor has discussed with you. It is always important to discuss your feelings and issues regarding the patiants care with the MD so that the two of you are on the same page and the appropriate pain management medications can be ordered. The key word being ordered.

Have you discussed your preceptors statements with your unit manager. Since you are still on orientation you could go into it with the "so and so told me that this is the unit practice and I am unsure of these protocols and wanted to discuss them with you further as you are my immediate supervisor...."

[Daytonite, BSN, RN]

To OP: I don't feel your preceptor did anything wrong. We had lots of end stage COPD'ers on our stepdown unit and gave Morphine to help them with their breathing. Without it, they are extremely restless, confused and just look like they're in agony. There is nothing worse than a patient who feels they are choking or smothering to death except watching it happen. I might not have given the Morphine if the patient seemed quiet and peaceful. However, at the first sign of discomfort I'd be going for the med cart if the patient was no longer able to ask for it.

[pricklypear]

What a great thread!! NRSKarenRN - What a wonderful post, and great references.

To the OP - I just have 1 thing to add and 1 thing to reinforce. First, I have only seen one family reverse their original request for DNR status. One in almost 6 years, and many dying patients seems, to me, like a small percentage. I just wanted to make it clear that I don't think it's too common to have a wife "change her mind" if her husband "hangs on too long." People understand a lot more than we give them credit for. It's hard to have to make that decision, but once made, they usually see it through.

Secondly, I think your preceptor is doing you a huge disservice. You sound like you have very sound ethical reasoning. Listen to YOURSELF, not your preceptor. You have picked up on the errors in his practice. Yes, you have an obligation to keep patients comfortable, and to make them as comfortable as possible, as soon as possible. But you must ALWAYS function within your scope of practice. I don't care what the "unspoken" rule is on the unit (believe me, I see it too), it won't matter when your license comes before the board. I won't comment on the morphine issue except to admit that I am very liberal with it for dying patients. Not to hasten death, but to ensure comfort. When a body is in the process of dying, pain and discomfort can be more difficult to detect. I would rather err on the side of giving possibly uneeded MS, than allow someone to suffer in their last hours. But that's just me.

[markm739]

To Pricklypear - What you said about families hardly ever reversing DNRs makes sense. I'm sure the wife wouldn't reverse this guy's, as bad off as he is.

"But you must ALWAYS function within your scope of practice"

I am glad to find out that there are others in this world who don't consider that a mere nursing school habit. It is encouraging to know that others would question what is going on out there, and would actually care about doing what is right. Thanks.

With regard to ethical reasoning, I think it really hit me what was happening with him when I realized it violated the "do unto others as you'd want done to your own family" rule, and also that all that was drilled into us in nursing school about informed consent and the volitional rights of patients. Of course, I really wonder if he considered that what he was doing was in the realm of euthanasia.

One more strange thing happened with this guy. He started out the conversation where he discussed the rationale for the morphine by saying that he wanted to see how I felt before giving it, because another preceptor/orientee pair on the floor had an incident where the preceptor did something, and the orientee felt it to be an ethical problem; the preceptor said that the orientee went to someone else without even talking to the preceptor about it and lodged a complaint; my preceptor didn't think the orientee handled it properly, so I think he was preempting a similar occurrence by attempting to raise the issue with me.

Two things come up about this. First of all, this shows he was aware that what he was doing was morally debatable. Secondly, I would guess that the other orientee who did this was probably too intimidated by her own preceptor to directly address it with them. This can be a problem on this unit; we have 15 orientees, and the types who are preceptors are not exactly touchy feely friendly types, they are kind of hard driving individuals who are very certain of their own ideas and practice because of the vast experience they have. It is harder to correct someone who is the primary source of job performance data about you to management. This makes orientee's positions in these kind of situations more precarious.

To all who have encouraged me to go to ethics boards or management: I guess it is true that one would need to be prepared to be branded as a do-gooder or whistle-blower if they did this. I wonder how much management goes along with this kind of thing; I mean, if they are presented with it, they obviously have to respond to the outward significance of it, but are they really thinking inside, "I wish she hadn't done this, we know it goes on, but prefer to look the other way?"

Any charge nurses or nurse managers out there able to comment? Have any NMs had whistle blowers on their staff? Is there anyone out there who blew the whistle, and would like to tell us how it went?

ICU Newbie

[gwenith, BSN, RN]

You absolutely HAVE to discuss this with your preceptor first before going to management. Ig you went straight to management you are skipping over a neccessary step in the greivance process and it could backfire on you. You can do it in such a way that it does not "tip" the person off that you are going to speak out against them.

I have read your posts and I really feel that although there could be some ethical questionable practices equally there could be a lot of miscommunication with you reading things the wrong way.

[patwil73]

Do nurses give meds on their own? Sometimes yes, but the case should always be an emergency -- example I have given ativan for a pt in sustained seizure (however, I had someone calling a doc at the same time), same with dramatic decrease in BP, I hung dopamine. These emergencies required immediate action and were done in concert with my charge nurse. So to give meds without orders there really needs to be an emergency and should always be done with a charge nurse.

If you feel the pain meds are not effective there should always be time to call the doc and get titration orders. The taking extra meds out and lying about the reason is plain out wrong. That said people who are dying often require vastly different amounts of pain control and the use of the medication may mask signs of pain such as increased HR (I often ask family members what the patient does or looks like when in pain) I have given pain meds because the family thought the patient was in pain even though I could not find any observable sign of pain (however, the meds was within the orders to be given)

As for talking with your preceptor, please do. People have different ethical guidelines To put this bluntly I agree with what he said, but not how he is doing it. I think we keep people alive way too long because we are scared of giving too much medication. I have personally had 4 families withdraw DNR because the pt was hanging on and they thought a miracle was coming - once was during a code, she flat out ordered us to ignore the dnr and start cpr. That is why I always get liberal pain medication orders from my doctors when I have a pt actively dying. The question you have to ask is how comfortable you are giving meds that you know might hasten death, can you or not, if not you might consider less acute pts because with high acuity you will be presented with that situation over and over.

Hope this helps,

Pat