Ethical dilemma

[GooeyRN]

On friday, I was taking care of a very elderly person, who was knocking on death's door. Pts respirations were 5 per minute. Pt has had these breathing episodes a few times over the last few days. Family stated pt was in pain, and that I should give pt a pain shot, since it was time. (Dilaudid, 1mg IM)

Patient was not able to communicate if they were in pain. Pt was not showing any outward signs of being in pain, but I also had the feeling that pt was either in pain, or very anxious. It was hard to tell. It was my gut feeling that pt was not comfortable. The patient has been receiving the same dosage for several weeks. There was not an increase in the dosage or frequency of the med.

I explained to family, that if I were to give the Dilaudid, pt may stop breathing. It was not absolute, but there was a chance.

I can not give more details about the situation, but the family was TOO okay with this. They actually made a comment about me euthanizing the pt. I can not say the actual comment they made, since I do not want to give too much info.

The primary doc was aware of the situation, and wanted me to give the Dilaudid. He even came to the floor, since I called him several times about it.

What would you have done?

[jill48, ASN, RN]

I would have given it too. The family said out loud what many of us are saying in our heads but do not let others hear. Always trust your intuition. We are nurses because of this intuition and because we want to relieve the helpless of their pain; and that is what you did. So, good job to you! Please continue to always care as deeply as you do now.:nuke:

[Hoozdo, ADN]

i also feel perfectly comfortable with giving the pain ,meds. i would not feel comfortable not giving them and then going home and thinking about the poor pt. in discomfort.

[color=#483d8b]if the pt. is going to die, let them die in as little pain as possible. several times in icu we titrated morphine for comfort. families were made aware it depressed resp. and were ok with that. it's humane.

absolutely! i have worked in icu a skosh over a year and have had to do this many times. i have no qualms about it either. if it were a family member or myself in that hospital bed, i would definitely want the morphine even if i had depressed respirations. there is no reason to suffer, in particular if you are a dnr.

[DDRN4me]

Always go with your gut. you know what is best for your pt; and even if the family seems to be trying to influence, you know what you need to do for your pt. who knows he may be hanging on to spite them!

[mandykal, ADN, RN]

I think that it's an instinct for most nurses at a point of their career, most likely at the beginning of their career to be in this type of ethical dilemma. I remember my own....

I was an 11-7 new nurse providing comfort care to hospice pt. I was also inexperience. I had a PRN ativan and MS sub-Q order that I was afraid, but my gut told me that it was my shift that she'll be going. Called the family as a courtesy, gave the meds...She did past comfortably with family @ side.

The only support I had was my supervisor. I can recall checking the dose ALOT!

Since that episode, everytime I have a patient with something new to me I will alway refresh my studying when I get home. Now I have many experience, that was the last MS subQ order I've seen....it's now MS SL... less invasive. ..I totally understand pallative care now.

I think it's a horrid situation when you take your job home thinking about an ethical dilemma recaping and thinking about your performances, questioning.....that's what gets me tossing and turning.

[Jolie, BSN]

Gooey,

Thank you for taking such thoughtful and considerate care of this patient and family. It is truly refreshing to hear that you gave such thought and consideration to the best interests of the patient, and the surrounding moral and ethical issues. I would be honored to have you care for me or a family member any time.

I recently made the decision to admit a family member to hospice. She was unresponsive and while we had had "theoretical" conversations about death and dying in the past, her situation did not quite fit the scenarios we had discussed. Given her condition, I had no qualms about making the decision to discontinue therapeutic treatment and opt for hospice. Her doctor and the hospice team made certain that she had generous orders for morphine and ativan, and I requested that they be administered as often as allowed. I silently wondered if anyone involved in her care questioned my motives in making that request, but don't think so. She had already suffered immensely, and I simply wanted her to be comfortable and peaceful in her final days. Extending her life a few hours or minutes at the expense of comfort was simply not acceptable to me.

Perhaps my view on the subject is colored by my own experience with pain. I have an extremely low pain tolerance, and can vividly recall situations when it has been inadequately treated. I would never want a loved one or anyone to suffer like that.

My family member passed away peacefully, and I will be eternally grateful to everyone who made her comfortable in her final days. I am certain that this patient's family feels the same way.

That you have questioned this situation shows your high moral, ethics, and level of professionalism. But please know that you did the right thing.

[RNOTODAY, BSN, RN]

I would have given it. The dilaudid was prescribed for a reason, and you said that you felt pt was "uncomfortable"..... and in a pt that cannot communicate to you, with a hx of pain .... yes, I would have given it... despite side effects (which in this case happened to be resp arrest in a terminal pt), and despite the family's acceptance or non acceptance of it.

[Dixiecup]

do some research on the 'double effect'. It rationalizes this quite well.

[adrienurse, LPN]

What you are talking about is what is known in the books as "double effect" or analgesia treating pain but lessening respirations. If the person is already on their way towards death, you are not causing it no matter how shallow and slow respirations get. It is an ethical debate, but you have to look at the big picture. Dying is painful and distressing. Analgesia is a justifyable treatment for this.

http://en.wikipedia.org/wiki/Principle_of_double_effect

http://www.hospicecare.com/Ethics/fohrdoc.htm

[GooeyRN, ADN, BSN, CNA, LPN, RN]

Thanks everyone. You guys made me feel so much better!

[burn out]

On this issue I believe you have to let your conscience be your guide because you are the one that has to be able to sleep at night. There has been a time or two when I knew that the patient was dying and really couldn't see any other reason to give the med...no clues of discomfort and the family wants pain med given. I felt like I was interferring with a natural process and the med would be the cause of death...I couldn't give it but I did call my supervisor and told her that ethically I could not do it but I would not stand in the way if she felt like giving it. She was very understanding and came and gave the med, the family was satisfied, the patient died, and I could sleep at night.

Sometimes I wonder with how these orders are written -like prn without any hour frequency- when is enough pain med enough?

[DutchgirlRN, ASN, RN]

We have to remember the pain medicine didn't kill the patient, the cancer/terminal condition did. We only keep them comfortable in the end, and what an honor that is. People should die in comfort.

Despite your reservations about the family, you did what was right for the patient - you followed you gut that the patient needed pain medicine and you gave it. You didn't give it for the convenience of the family.

Tweety how wonderfully and compassionately you have stated the absolute truth!

[miko014]

Sometimes I wonder with how these orders are written -like prn without any hour frequency- when is enough pain med enough?

Isn't that illegal? We can't give a med order without a frequency - it has to be say, q2h prn or something.

Speaking as someone who has worked with hospice/palliative/cancer pts for 5 years, I would most definately have given the drug. I would, however, have questioned the route. Dilaudid IM for weeks? No way, Jose! That isn't comfort! I would have asked for something SL or else gotten it switched to SQ and started a butterfly.

This pt had been on dilaudid for weeks - had she been conscious, she might have been able to tell you that she was still in pain - the dose probably would have needed to be increased. That being said, 1 mg would not hasten anything. What we tell the families is that pain meds will not kill the pt, but they may help relax them enough that they are comfortable enough to let go. And with resps of 5, she wasn't long for this world anyway. It can be scary at first to give pain meds to a person who is that fragile, but don't worry! You did the right thing!