Ethical dilemma

  1. 0 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?
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  3. Visit  GooeyRN profile page

    About GooeyRN

    GooeyRN has '12' year(s) of experience and specializes in 'Psych, Med/Surg, LTC'. From 'Boonieville'; 36 Years Old; Joined Nov '05; Posts: 1,735; Likes: 751.

    33 Comments so far...

  4. Visit  SuesquatchRN profile page
    0
    I would have given the Dilaudid. And I understand the family. I will not allow my loved ones to linger on in pain if I can possibly help them out of it.
  5. Visit  Tweety profile page
    0
    It's hard to gauge. But they probably were very tired and worn out of the weeks of this slow agonizing death of their loved one, and are that the point where they have accepted it, and are ready to move on, ready for their loved one's suffering to end. It might just be their fatigue talking.

    Trust you gut that the patient was uncomfortable. But also if you feel the family was trying to hasten her death unethically, use your chain of command, particularly the ethics committee if you have one. Document an incident report of their statements regardless.
  6. Visit  Gompers profile page
    0
    I would have given it. When my grandmother had terminal cancer (pancreatic, liver, and lung) and lost consciousness near then end, she was still moaning whenever she was moved and we could tell she was still in pain. The doctors and nurses informed my family that the amount of morphine they might have to give to make her comfortable might cause respiratory depression. We just said to give whatever she needed so she wasn't in any pain. That was the entire conversation. Nothing about euthenasia, nothing about misery, nothing like that. Just a mutual agreement that pain management was the number one priority in this case, period.

    I think you did the right thing. I do understand that the comments from the family made you uncomfortable, though, and I can imagine why. Talk to your supervisor about this case - for one thing, it'll help to talk about it and debrief, and for another, if there is any ethical committee action that needs to take place (to help in future situations like this) then your supervisor should be the one to set up that kind of thing.
    Last edit by Gompers on Mar 5, '07
  7. Visit  GooeyRN profile page
    0
    I did give it. But not before discussing it with the priest. (I did call him in, since the pt belongs to our parish, and the priest has been there to visit him daily) I still felt pretty sick afterwards. The pt did not die that evening, I don't know if he will still be there tonight. At the weekend mass, the priest did stop me after mass and we discussed it in quite detail. (not breaking hipaa, the priest probably knew more about the pts condition than I did) Basically, the priest picked up the same feeling about the family. But since MY intent was to make him comfortable, it was ok to give. It would have not been ok if my intent was to end his life. Unfortunatly, its a very small hospital, with no ethics group or hospice or anything like that.

    Thank you all for making me feel better about my decision to give the med.
  8. Visit  medic2crna profile page
    0
    Was this patient hospice? I can remember when my grandmother was near the end of her battle with lung cancer, I wanted her pain free. I would have given the med. This is never easy, but we as health care professionals, can sometimes do no more than to make it a little bit easier for our patients.
  9. Visit  Tweety profile page
    0
    Sometimes we give what is sickeningly referred to as the "death dose" of a pain medicine on a terminal patient. 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.

    Giving pain medicine to someone with depressed repspirations isn't a very comfortable situation. I had a situation happen once when a patient actually had rapid respirations but died within minutes after I gave morphine. Did I kill her? I don't think so. I'm perfectly comfortable with it. I've also given pain medicine to a dying paitent with depressed respirations as well.

    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.
  10. Visit  nursemike profile page
    0
    I'm against euthanasia. I have no problem with interventions to keep a dying patient comfortable, even if they may hasten death. My position almost seems hypocritical, even though it is also the law in my state (and most others, I believe.)

    It is a hard situation to deal with. Assessing pain in a non-responsive patient is very difficult, and we all know even with patients who are expected to recover fully that families tend to over-estimate their loved-ones pain. I have also seen families in the position of having to hope their loved one dies sooner than later. I have no trouble empathizing with them, and some have even verbalized the conflict they experience over hating to see their loved one continue to suffer, but hating to see them go, too. I never know what to tell them, but I suppose my best role is to listen.

    If I felt, even intuitively, that the patient was uncomfortable, I'd give the med. I'd evaluate signs and symptoms, like I was taught, but nursing is also an art, and art is more visceral than intellectual. My heart and my gut can see things my brain can't.
  11. Visit  donsterRN profile page
    0
    Quote from nursemike
    I'm against euthanasia. I have no problem with interventions to keep a dying patient comfortable, even if they may hasten death. My position almost seems hypocritical, even though it is also the law in my state (and most others, I believe.)

    It is a hard situation to deal with. Assessing pain in a non-responsive patient is very difficult, and we all know even with patients who are expected to recover fully that families tend to over-estimate their loved-ones pain. I have also seen families in the position of having to hope their loved one dies sooner than later. I have no trouble empathizing with them, and some have even verbalized the conflict they experience over hating to see their loved one continue to suffer, but hating to see them go, too. I never know what to tell them, but I suppose my best role is to listen.

    If I felt, even intuitively, that the patient was uncomfortable, I'd give the med. I'd evaluate signs and symptoms, like I was taught, but nursing is also an art, and art is more visceral than intellectual. My heart and my gut can see things my brain can't.
    Excellent post. I learned something.
  12. Visit  Cattitude profile page
    0
    Quote from tweety
    people should die in comfort.

    giving pain medicine to someone with depressed repspirations isn't a very comfortable situation. i had a situation happen once when a patient actually had rapid respirations but died within minutes after i gave morphine. did i kill her? i don't think so. i'm perfectly comfortable with it. i've also given pain medicine to a dying paitent with depressed respirations as well.

    .
    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]
    [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.
    [color=#483d8b]
  13. Visit  wildmountainchild profile page
    0
    Not only is it humane, it's absolutely legal.

    At least in terminally ill patients with intractable pain. The court, at least in California, has ruled that providing adequate pain relief to dying patients is of such importance that practitioners should not have to worry about it hastening death (from a legal standpoint anyway) because dying in peace is more important than a few more painful moments.

    The patient's family probably hate seeing thier loved one in pain. I know that if my father, or husband was at the end of thier life and in incredible pain that I would rather them die than have to suffer needlessly. I think most people would. Particularly when the end is already near and life has lost all joy.
  14. Visit  RN BSN 2009 profile page
    0
    You Did the right thing!
  15. Visit  jill48 profile page
    0
    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.


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