MORAL DILEMA

[TonyaM73]

So what if one day you go into work on your med/surg floor and have a pt that has sats of 87% on NC 4L. You check everything, place a mask, call the MD with no results, call respiratory, respiratory changes to a non rebreather (still with minimal results), call a rapid response, MD places bipap (with good results),.....then after everyone leaves, pt decides they don't want oxygen anymore because they are end stage emphazema? This pt refuses all O2 at this point and you explain that they will die today with out oxygen. The pt states they are aware. (pt is AO4) Pt then signs a DNR (yes, during all of this they were a full code:uhoh3:), but refuses hospice. MD, charge nurse, nurse and respiratory explain to pt that without any oxygen pt will die today. Pt states understanding to everyone. WHAT WOULD YOU DO?

I am having second thoughts about how I handled this after talking with a coworker, but still feel that what I did was right since I followed the patient's wishes. I documented everything and offered several times oxygen, morphine and ativan for this patient, but pt refused everything. Pt refered to hospice the day before, but the pt refused. What would you do? One of my coworkers stated that she would placed the oxygen on the pt when they went lethargic from low O2 because otherwise was helping the pt comit suicide.

This sounded like a good one to hash out on AN.

[TonyaM73, ASN, RN]

DeLana,

That is good! I was throwing a fit, but no one was listening. I was trying to get the family to choose hospice for them and for the pt, but they didn't seem to understand. If he had been on hospice and became uncomfortable, we could have given him narcotics. As it stood, we would have had to watch him suffer if the bp did not come up. I really think some people think that DNR means Do Not Treat! It is very frustrating. Depending on what I go into the hospital for, I want to be a DNR. If I am that bad that they would have to do compressions, I am pretty sure I don't want to come back, but that does not mean that I don't want pain meds if I am hurting.

[Penelope_Pitstop, BSN, RN]

I was throwing a fit, but no one was listening.

*Sigh* I truly believe the hardest, most exhausting part of our job is that of patient advocate. We have to go to such great lengths to just have our thoughts CONSIDERED by others.

Keep fighting the good fight. Advocating is tremendously difficult but oh-so-rewarding when it works!

[xtxrn, ASN, RN]

Thank you!! That was the way I felt as well. I was talking it over with another nurse yesterday when she happend to mention that she would not have helped a pt to commit suicide. It was a hard case and emotionally draining, but I felt that I educated him, had everyone else educate him and documented. After all of that was done, I followed his stated wishes till the end and made him as comfortable as possible. I just wanted to make sure that I was not in my own little world here. Thanks again for the responses.

This nurse has no right to through her beliefs into the care of the patient who is able to act on his own rights. I'd probably get something to help end stage breathing (MS, scopolamine).... but if this guy has decided today is the day, then God bless him :)

I'd be SO mad at the nurse who said you helped him commit suicide- that's not even a little bit OK.... it's fine if she believes that- but not to cram it down anybody's throat- especially towards someone who had actually been providing care ..... I don't like her !!

[nursemarianne]

Unfortunately there are many responses discussing the use of morphine for en-of-life pain control by nurses who are not aware of the guidelines. Many times the use of morphine at the end-of-life actually extends life for a short time. The morphine decreases physical and mental stress that would normally hasten death. Morphine can relieve some of this stress if not all of it in some clients. Those undergoing pain control in large doses prior to the end-of-life will require much larger doses of morphine at the end-of-life. Cancer patients taking 200mg. of oxycontin twice daily are not going to get any relief from MSO4 10-20mg. every two hours. I have had clients in hospice care take over 60mg. of Morphine every 30 minutes with no relief and no respiratory depression. Respiratory depression is one of the goals when using morphine at the end-of-life for someone with a respiratory rate in the high 20s and in the 30s. Some doctors will use a guideline as low as 8 breaths per minute to slow the morphine and others prefer to slow the morphine at 12 breaths per minute. Some end-of-life reading should be done by a few of you who have responded here. With careful monitoring morphine can be utilized at high doses to provide pain relief without hastening death.

[nursemarianne]

Leslie,

I agree, 55 mg in an hour is not unreasonable for a hospice patient or perhaps those who are opiate naive, but on what this poster wrote, this sounds like malpractice. Was this nurse repeatedly bolusing him over the course of an hour?" So if the nurse came in every 20 minutes (not unreasonable), that's almost 20 mg every 20 minutes. Like I wrote, I've had families request that I just give more morphine and get it over with. Unethical. Patient should be comfortable, but watching the dying process can be uncomfortable. The family has to use us and others to lean on for comfort.

Sorry, this post really bothered me. Talk about a way to undermine our clinical judgment. That's all I need for families, mgt., doctors, and JACHO breathing down my neck on stuff like this.

Classicaldreams

"He did not die of hypoxia, he died because his nurse gave him 55mg of morphine in an hour. I am sooo grateful she did because he was air hungry and it would have taken hours for him to pass had she not kept coming in the room and saying "he looks a bit uncomfortable, how about a little more morphine?" I knew what she was doing and she knew what she was doing."

The 55mg of morphine did not necessarily hasten the death of the patient. MSO4 20mg. every 20 minutes is fairly common in hospice. This dose is only given if needed for comfort AND if the respiratory rate would support giving such a dose.

[nursemarianne]

sometimes these patients get fluid overload in the hospital or a worsening pneumonia. very treatable.

yes pneumonia is treatable, but people have the right to refuse treatment. also, what kind of quality of life would this patient have? you treat the pneumonia, sure, but this is a dying man. i would not want to be hooked up to iv's, machines, etc, while i am dying. leave me be, dose me up with my morphine, keep me comfy, and allow a dignified death.

restraining someone so you feel better about their care is terrible, imho. they are dying, it is so undignified to die like that.

you cannot restrain a person to force them to accept treatment -- malpractice. md found the patient competent to make his own decisions which he did after hearing about the course his life would take without further treatment. as nurses we have no right to question his decisions or to attempt any care going against his wishes. there should be no other discussion, period. if some of you want to irrationally call it suicide, go ahead but this does not change your job. you explain what the chosen path will do to the client's life. you do not assist the process; you try and ease the journey. morphine used correctly slows death and does not hasten it.

[heron, ASN, RN]

Deleted post - issue already addressed. Should have read the rest of the thread! :icon_roll

[nursemarianne]

I think you may need some instruction also........here are some good resources. :)

http://tinyurl.com/3crbjev

Nothing I wrote goes against the sources in your link. Did you even read them? A person declared competent by an MD, NP or PA can make their own decisions which includes a DNR. They can aslo specify wha the DNR includes or does not include. They may also revoke or change the DNR at any time. Any healthcare practitioner who does not follow these wishes are potentially liable for charges of negligence, malparactice, assault and/or battery. In Massachusetts many EMTs and paramedics will not follow DNR orders unless they have a copy of the order or at least see the order. They err on the side of treatment unless they see or have the documentation. If the patient is conscious and they state a refusal of treatment, as is their right, with or without a DNR they cannot be treated. In Massachusetts a patient has a right to refuse treatment of any kind as long as they are cognitively intact. Disallowing a patient's wishes is against the law. Depending on how their wishes are disregarded would depend on the types of charges that could be brought legally. The healthcare worker could also be "punished" by their employer and/or the Board of Nursing. License suspension or revocation is always a possibility.

[suanna]

Putting O2 on a patient who has refused it could be paramount to assault. What right do we have to decide how and when a patient in the end stages of a terminal illness faces thier demise. COPD is exhausting- end stage every breath is a battle. If the patient chooses not to accept hospice all you can do is support his decision and advocate for his rights. Some patients see hospice as fancy suicide. The fact that they will give you meds that may hasten your death as they make you more comfortable sounds like euthanasia to some people. If he becomes distressed by his hypoxia- offer to call in hospice again- or use your nursing skills to provide what relief you can- hospice care dosen't require a hospice department. Nurses know how to relieve pain, calm anxiety, and provide emotional support.

[leslie :-D]

Some end-of-life reading should be done by a few of you who have responded here. With careful monitoring morphine can be utilized at high doses to provide pain relief without hastening death.

and the fact, that mso4 has no ceiling for dosage amts.

no ceiling whatsoever...

you can give 1000mg w/o overdosing.

Nurses know how to relieve pain, calm anxiety, and provide emotional support.

yes, we are qualified to do so.

no, MANY do not utilize these interventions, r/t variable etiologies.

leslie

[Esme12, ASN, BSN, RN]

Nothing I wrote goes against the sources in your link. Did you even read them? A person declared competent by an MD, NP or PA can make their own decisions which includes a DNR. They can aslo specify wha the DNR includes or does not include. They may also revoke or change the DNR at any time. Any healthcare practitioner who does not follow these wishes are potentially liable for charges of negligence, malparactice, assault and/or battery. In Massachusetts many EMTs and paramedics will not follow DNR orders unless they have a copy of the order or at least see the order. They err on the side of treatment unless they see or have the documentation. If the patient is conscious and they state a refusal of treatment, as is their right, with or without a DNR they cannot be treated. In Massachusetts a patient has a right to refuse treatment of any kind as long as they are cognitively intact. Disallowing a patient's wishes is against the law. Depending on how their wishes are disregarded would depend on the types of charges that could be brought legally. The healthcare worker could also be "punished" by their employer and/or the Board of Nursing. License suspension or revocation is always a possibility.

In Massachusetts the EMT's follow DNR orders when they Have a Comfort Care in hand.....hence the comfort care laws. I have been a nurse and an ED nurse for 32 years and I have never forced a patient to take or not take a treatment......I ma confused to what you are refering to........of curse a patient may envoke or revoke a DNR whenever they wish and I was mistaken when I said that you had to be a DNR on hospice. It was the hospices I ahd been exposed to and not the common belief.

http://www.mass.gov/?pageID=eohhs2subtopic&L=5&L0=Home&L1=Provider&L2=Guidelines+and+Resources&L3=Guidelines+for+Clinical+Treatment&L4=Comfort+Care+-+Do+Not+Resuscitate+(DNR)+Order+Verification+Program&sid=Eeohhs2

Who said I said a patient has no right to refuse????? Either I misunderstood you or you misunderstood me but of course a patient that has been deemed competent can refuse what ever they want. I am going to have to go back to the post.....and NO I didnt read them all.....that's why I used "Let me Google that for you":smokin::)

update: Oh........The oxygen........oxygen can also be viewed as a comfort measure, like a warm blanket, by many standards and by no means is assaultive in nature. A lot of what is viewed as assaultive or not assaultive is the intent of the action itselfIf it aggitated the patient just remove it but if a feww extra O's makes them less restless when they are stuporous it's no harm and is not condsidered life sustaining in nature. Now if you disagree with the patient and decide to restrain their hands and make them wear the O2 all the while screaming no...that is a different story...that's assaultive and is punishable by law.

If you took offense....none was meant.......Peace:hug: