Please read and tell me if this is wrong

[chenoaspirit]

I have a patient who is dying....not due to illness but due to the family's choice to withdraw IVF's and TF's. She has been hanging on for almost 2 weeks like this and Im really having a hard time with it. From the beginning.... this patient was at home, getting ready for church when she fell and broke her ribs while getting dressed. The ribs pierced her right lung and it caused a pneumothorax (actually a hemo-pneumothorax). She was admitted to ICU, had a chest tube, was intubated, and a PEG was placed for tube feeds. Later was extubated and a trach was placed. She is now able to breath on her own, with O2 sats in low 90's with O2 via trach.

After months in ICU, fighting for her life, now her family is allowing her to die. She was admitted to the floor and was placed on hospice. They want her to remain sedated with Ativan or Dilaudid. Last night everytime she moved, the son wanted her medicated. I did. I wasnt happy about it. At one point later in the night she opened her eyes and was looking around the room, instantly the son again her medicated. He said she was hurting. But he couldnt decide which med he wanted administered...Ativan or Dilaudid (both are IV). Now this patient has a PICC, with NO IVF's going thru it. I told him that Ativan and Dilaudid are two totally different medications, and asked him why he wanted her medicated. He said that she is dehydrated and is sure she is hurting because of it. He then said "IM NOT DOING ASSISTED SUICIDE!" Of course I assured him that I was not infering that he was. This son seems so loving though, loving on her, kissing her, talking to her, etc. I really do think he loves her, but I just dont understand.

Her husband couldnt sign her to hospice, he sat and held the pen while staring at those papers and just couldnt do it. So the son did it. The husband sat by her side day and night prior to hospice consult. Now his heart is broken and the guilt is keeping him from her. I guess my question is...is this legal or ethical? I mean is it ok to keep nutrition and hydration from a patient. Her illnes isnt killing her, the neglect is. I dont like this situation and feel guilty for starving her like this. Her urine output last night was only 100 ml's and her bp is now dropping. She is only 65 years old. What would you do? :cry:

Oh, also, the son says that she has Alzheimers and her quality of life wouldnt be good if she were to live through this.

[aeauooo]

Without upsetting the apple cart too much, there are different ways of thinking about providing nutrition and hydration to a dying person and a lot of research into the topic.

That being said, I'm Catholic and not willing to argue with the Vatican on this one. This is also close to home for me because my brother-in-law has been in a minimally conscious state for five years.

Ultimately, we must respect our patients' autonomy and/or the autonomy of the person making decisions for our patients - that's the law. If I'm not mistaken, nurses also have the legal right not to be placed in situations that we can effectively argue violate our personal ethics or sense of morality.

I suggest you look at some of the resources on death and dying that are out there. One place to start is the American Nurses Association. If you have access to a medical library data base, you can search the literature on the subject.

http://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/EthicsStandards/EndofLife.aspx

[loriangel14, RN]

I'm a new nurse, so forgive me ... but isn't 65 a little young for Alzheimers? At least Alzheimers that is severe enough that her "quality of life wouldn't be good if she were to live through this." ?

I have seen a couple of pts with end stage Alzheimers in their 60's. I know personally one lady who was diagnosed at 53 and passed away when she was 62. Very sad.

[santhony44, MSN, RN, NP]

I'm a new nurse, so forgive me ... but isn't 65 a little young for Alzheimers? At least Alzheimers that is severe enough that her "quality of life wouldn't be good if she were to live through this." ?

The first Alzheimer's patient I ever saw was in her 50's.

[morte, LPN, LVN]

the original definition of Alziheimer's dementia included that it was presenile dementia...meaning onset before the age of 60 (senility being over the age of sixty) often in the forties; with a statistically higher rate of familiarity...now they include those with dementia with no other known cause......of course, if she has this variety of dementia....here son may be showing signs as well.....good luck

[chenoaspirit, ASN, RN]

Last night I again had this patient. I had the time to review her chart. Her son told me that the patient had a living will which was NOT in the chart. He told me last night, in exact words..."I wish we could put her on the white juice"...meaning diprovan. I told him that I could not do that. He said "ICU did it!" I explained to him that in ICU she was a full code and was intubated at that time and the diprovan was to prevent her from fighting the vent, etc. The sister said "I wish she would die tonight, Im sure not having food or water is hurting her. Do you think she will die tonight?" She asks this every night. At one point, the patient was lying in bed, motionless due to the meds. The son asked for Ativan and Dilaudid. I told him that I would adminster one at a time. If he felt she was in pain, I would administer pain medications, to give it time. If that didnt ease her comfort, I would then administer the Ativan, but that I would NOT administer both at the same time. He said "she is going to die anyway and I want her to be sedated." I told him that may be true, but I would not be the cause of it when if did happen. Sooo, I administered Ativan (my coordinator is now involved in this situation and advised me to administer the Ativan, NOT to administer both at the same time). So thats what I did. The physician was on the floor and he also advised me the same. 15 minutes later, the sister came to the nurses station and said "MRS *** NEEDS HER PAIN MEDICATION NOW!!!!" I go to the room with the Dilaudid in hand and assessed the patient. She was lying in bed, motionless, in no distress, eyes closed. I didnt see the need, but I did as the family asked and administered it. They then later told everyone that I allowed this patient to lie in bed for 1 1/2 hours with-holding pain management, which was NOT true. Today an ICU nurse was pulled to our floor due to short staffing (ICU had minimal patients and she was not needed in her unit) and she was assigned this patient and totally agreed with me. She also had cared for her in ICU. Apparently this family caused turmoil in the ICU and security was paged. It has been a nightmare. I read the charts, the patient had WALKED into the hospital on admission, was orient x 3. The docs had plans to admit her to TCU for rehab and eventual discharge home. The husband planned to care for her in his home. This all changed when the sons decided that her quality of life wouldnt be good enough to continue care. This patient has NOT been given the chance to WAKE UP and even TRY to voice her desires. When her eyes open, meds are given. When her hands move, meds are given. When a tear falls down her cheek, meds are given. I did oral care and she grabbed the swab with her mouth for moisture. They say that she has minimized brain activity, so in essence, the sons believe that if she isnt completely "normal" then she will have no quality of life. Now I do understand hospice, I know its to allow patients dignity to die at home or in the hospital with comfort measures to allow an easy passing. But I dont believe in admin meds to CAUSE the passing. I cant do it. Not in this case. There is no terminal illness process to warrant it. There is a picture in her room of her and her husband sitting at a restaurant. She is smiling and sitting at the table with her husband, looking happy. This pic was just taken this past December! I have been upset all night long. I can not sleep, Im sick. The entire floor of staff agree with me. The charge nurse and I reviewed her chart together.

I once had a friend who was hospice, he was BEGGING for water to drink, the family wouldnt give it to him. Response from family....he is going to die anyway. It ended up being a fight over his property and belongings. I believe hospice is a wonderful thing for terminal patients and their family, but sometimes its abused and patients end up suffereing because "they are going to die anyway". I am hoping to have better experience with future hospice patients. Im very upset.

[SDS_RN, RN]

I am so sorry for you. That is an awful situation. This situation just seems wrong and I really feel for you. I hope it all works out for the best.

[Tweety, BSN, RN]

There's no easy answer.

What stood out for me was the months in ICU fighting for her life, probably a vent at some point, and now a tube feeding. I tend to understand the son about quality of life issues. Maybe this isn't what she wanted and how she wanted to end her life.

My brother in law went through this last year when the kids declined to treat their mother and other relatives screamed "why are you killing her?".

It's perfectly understandable you're having some feelings about it.