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

[RNAnna]

Let's hear it for being a "do gooder"! I would rather be labled as a "do-gooder" than go against my pricipals, beliefs, and the law where people's lives are concerned. I know and understand the need for Hospice care and comfort measures - I administer them myself. But I am not, as some nurses have told me, going to hasten the end of their lives just because it might be easier on the family. It's just not right.

As to a He said, She said issue, you can use this thread as documentation of what you observed about your preceptor. I see nothing wrong with going to your manager and discussing this with them. If your manager comes off as being less than concerned, it is time to get out. As nurses, we are not supposed to play around with drug orders or dosages. It is not in our scope of practice and it is against the law.

In this situation, I would have to say that you should think about your own license and take appropriate action. It would be interesting to see how much of your preceptor's drug practices are documented. There are a lot of people who think that they are doing good in the world who are actually taking away something from others. In this case, the preceptor took away the family's time with the pt and their natural grieving process.

RNAnna

[mtymom]

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.

I whole heartedly believe in using MS for comfort at the end of life. Both of my parents died of cancer. My dad had lung cancer and my mom had ovarian cancer. We had hospice come in and we gave them MS as often as possible. We did not wait for signs of discomfort. When someone is in pain and becomes restless from it it is very difficult to get them calmed down again; especially if they are dying anyway. Both of my parents were able to die peacefully because of this. I agree, however, that the wife should have been informed and been allowed to make the decision. The doctor should have also been contacted. He could have given a verbal order to give the MS routinely for comfort.

On another note I had an uncle who was dying from cancer. He was not in the end stages where he had a lowered LOC but he was in a lot of pain. His wife refused to let them give him MS. He ended up committing suicide because he was in so much pain. Just my opinion.

[chadash]

Greetings to all!

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?" ...

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.

ICU Newbie

This is creepy and spooky!

[bluesky, BSN, RN]

His wife refused to let them give him MS. He ended up committing suicide because he was in so much pain. Just my opinion.

Gosh, what a sad story.

[pricklypear]

I whole heartedly believe in using MS for comfort at the end of life. Both of my parents died of cancer. My dad had lung cancer and my mom had ovarian cancer. We had hospice come in and we gave them MS as often as possible. We did not wait for signs of discomfort. When someone is in pain and becomes restless from it it is very difficult to get them calmed down again; especially if they are dying anyway. Both of my parents were able to die peacefully because of this. I agree, however, that the wife should have been informed and been allowed to make the decision. The doctor should have also been contacted. He could have given a verbal order to give the MS routinely for comfort.

On another note I had an uncle who was dying from cancer. He was not in the end stages where he had a lowered LOC but he was in a lot of pain. His wife refused to let them give him MS. He ended up committing suicide because he was in so much pain. Just my opinion.

I think there are too many misconceptions regarding the use of narcotics for dying patients. It takes much more morphine than people think to actually depress respirations enough to cause or hasten death. I think (and have witnessed) people being "afraid" to give it regularly, and in sufficient amounts to actually ease pain or air hunger, for fear of causing death. Also, too many people (IMHO) wait too long to administer PRN doses. Like you said, waiting until S/S of discomfort actually manifest themselves. By then, it's too late. Even if there are no scheduled doses, there's nothing wrong with using PRN doses in a scheduled manner. I'm glad your parents had someone like you to ensure they got adequate relief from suffering in the end. And BTW, what happened to your uncle happens frequently, unfortunately. Why someone would rather see someone suffer then see them get "drugs" is beyond my comprehension.

Sorry this is sort of off topic:imbar My biggest problem with the OPs preceptor was his idea to try to "hasten" the patient's death to keep the wife from possibly changing her mind. I don't think he could have actually "hastened" anything short of administering a HUGE dose, but it was the idea that bothered me. And exposing a new nurse to that kind of thinking bothers me as well. Letting a new nurse believe it's OK to misuse medication, give "nursing doses" and generally practice outside of their scope is setting them up to lose a license they worked very hard to get.

[Daytonite, BSN, RN]

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. . .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. . .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

This person's preceptor was stung once before. Indicates to me that he is a sensitive person and doesn't like conflict. A lot of nurses find themselve in the role of a preceptor and don't particularly want to be there. However, look at your official job description where you work. The role of preceptor is in there for all RNs. So, whether they wanted it or not, they got it. 15 orientees on one unit at one time is A LOT! That alone has probably put a lot of stress on the unit staff. When you precept someone your work is much more complicated. The preceptor has to slow down so the orientee can catch up while they are learning, yet still get all the patient care done. If you've ever done precepting, you would know it's very stressful on both the preceptor and the orientee. I don't know why your unit would have orientees who are afraid of their preceptors. Nursing students are precepted all through nursing school by instructors. The only difference in an employment situation is that your preceptors are other staff--many of them not trained specifically as educators. They are just good nurses who management wanted to step up to the job. Who are they going to get to precept a new grad, some schmuck nurse who everyone knows is a screw up or one of the nurses who is efficient and gets things done right? Attitude is the wild card in all of this. Part of making ones way in the world is to learn how to communicate and get along with peers. I'm willing to bet that every orientee on your unit has had some exposure to assertiveness and communication skills. The reason that is introduced to students is for the very situation you talk about with these preceptors and orientees. It is one of the survival skills we all need to get along in the world, not just in nursing. Well, this is the time to review them and start practicing and putting them into action because they are skills to be mastered just like learning to start an IV or place an NG tube. A good manager is going to know her staff. This manager is going to know when one of these "good" RNs who has been roped into precepting is being unreasonable in their assessment. As a manager I wanted facts on an orientee who wasn't doing well. Any emotional venting by the preceptor was taken as just that--venting. A orientee either knows how to draw up medication into a syringe and inject it IV or they do it wrong. Now, if you are suggesting that some of the preceptors are willing to lie about something like that, then I would say your unit has a big problem. However, I don't think that is what you were meaning.

I haven't had any whistle blowers among the nursing staff. We did, however, have a huge incident involving a doctor that was abusive to nursing staff. One of my buddy managers was involved in it and for almost two years while this guy was investigated every thing was hush-hush. My friend was told to say absolutely nothing to anyone about her testimony and questioning at the many hearings (with lawyers present) that were held for this guy. She was told it would jeopardize and weaken the hospital's position as, we all found out later, they were trying to get him removed from the medical staff. Once the final decision was made, the story was on national TV on one of the news magazine shows which is where most of us finally got the entire story. I'm sure it was most embarrassing for the hospital since we all learned at that time that it wasn't just nurse harrassment that was involved, but a power struggle between the doctors and the hospital administration. Nurses had been complaining about the way this doctor treated them for some time and felt they had been ignored and many told stories later indicating that they felt they were forced out of their jobs. The fact is that when something is serious enough to involve lawyers on some level, the first thing the lawyers tell everyone involved is to clam up and stop talking about it while they are trying to resolve the situation. Quick decisions are never made on these kinds of situations, it takes time to come to final conclusions. Some people can't put up with the pressure of that and their emotions inflate to the point of making them ill. Some of the things this doctor did were absolutely way out of line. My experience with this and with other situations I was personally involved in taught me the importance of confidentiality. Managers are in a very precarious situation. On the one hand they are privy to some of the most outrageous behavior on the parts of some employees and doctors that you could ever imagine. On the other hand you have to fight the temptation to blab about it because some of these things are such juicy discussion items. However, to do that only feeds the gossip mill and inflates the situation. This is why, when I read a lot of the posts on these forums of people who are complaining about co-workers doing terrible things and no one is doing anything about them, I have my management background to fall back to telling me that management may know, but cannot comment on it.