Allowed to die

[nettie01]

hello, i'm writing from new zealand. it's really interesting reading your posts - usually i write in the hospice section but i thought i'd 'come over' to talk to you geriatric experts.

last week i looked after an elderly lady who'd been admitted during the night with urinary sepsis. she was from a rest home and quite dependant for her adls; she had some dementia. the decision (by the husband, son and doctors - i wasn't there so i don't know who had the most 'sway' in the discussion) was for no antibiotics, no fluids, no feeding. she was 'cast' in bed, being turned two hourly - it seemed the relatives expected her to die.

do you have this scenario often in your work?

i'm not 100% sure that what we were doing was morally acceptable: it seems 'murky' ethically to me.

jeanette:stone

[dawnbee]

Syncronicity! I nurse in a small Canadian hospital. Just two weeks ago I struggled with the same ethical dilemma as the original poster. My patient on Med/Surg was a 94 year old gentleman who had lived in a small apartment in his daughter's home, independent except for the supper meal his daughter prepared and brought to him, until a fall brought him to us. No major injuries apparent at first, a couple lacs and contusions, a bump on the head. He was awake and alert. During the days before he died, I watched his loving and attentive family, who never left his side, gradually request withdrawal of treatment. They seemed convinced that this was to be his last illness, although he didn't seem to think so. Instead of mobilizing him, he was kept in bed, because it was "unsafe" for him to get up. We started using pshycotropic meds to calm him as he struggled to regain independence. And morphine for the pain from the fall. Then, eventually, he gave in to the "inevitable." This whole scenario troubled me at a deep level, yet I felt powerless to intervene, and then guilty because I hadn't, and what was the best outcome I could hope for anyway? It would be so easy if everything was white or black, wrong or right. But it's the grey areas that keep us up at night.

[CapeCodMermaid, RN]

This thread has me thinking about a situation which occurred yesterday in the ICU unit where I am on orientation.

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 what is being discussed here.

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...I think it was 2-4 mg, can't remember the frequency, probably q 1-4 hours. It was not the morphine drip starting at 10 mg/hr 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 there is probably a euthanasia/ethics thread that this might fit under more appropriately, but you all really have me thinking here. Should I post this also under any other thread? (I am relatively new to posting.)

And believe me, 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.

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

What a lovely, well thought out post. Not being there to assess the patient myself, I can only say that given what you've said, I would NOT have given any morphine. If the orders read "for pain or resp. discomfort or SOB" and the patient is peaceful in bed, I would not give it. I have told my nurses and families the same thing. Morphine is a wonderful drug to be able to use at the end of life, but it seems that from what you said, people there were trying to actively end his life instead of making him comfortable.

I had a patient die today. He was a DNR/comfort measures only. He had an order for Roxinal for resp distress. He had no distress. He passed quietly in his room with his wife of 62 years holding his hand.

[doodlemom]

I think I'd rather be in hospital with an IV for my comfort pain meds, rather than rectal. Not all LTC can do IV care, here they send folks to us for anything IV.

There are plenty of meds that can be given SL and pt's stay very comfortable. Most Hospice patients never require IV comfort meds.

[nettie01]

syncronicity! i nurse in a small canadian hospital. just two weeks ago i struggled with the same ethical dilemma as the original poster. my patient on med/surg was a 94 year old gentleman who had lived in a small apartment in his daughter's home, independent except for the supper meal his daughter prepared and brought to him, until a fall brought him to us. no major injuries apparent at first, a couple lacs and contusions, a bump on the head. he was awake and alert. during the days before he died, i watched his loving and attentive family, who never left his side, gradually request withdrawal of treatment. they seemed convinced that this was to be his last illness, although he didn't seem to think so. instead of mobilizing him, he was kept in bed, because it was "unsafe" for him to get up. we started using pshycotropic meds to calm him as he struggled to regain independence. and morphine for the pain from the fall. then, eventually, he gave in to the "inevitable." this whole scenario troubled me at a deep level, yet i felt powerless to intervene, and then guilty because i hadn't, and what was the best outcome i could hope for anyway? it would be so easy if everything was white or black, wrong or right. but it's the grey areas that keep us up at night.

oh boy! thanks for your post. i'm shocked to read about this scenario. am i cynical to wonder what the family stood to gain by the man's death? to me it's quite clear - it's not a 'grey' case as so many are. he was alert and wanted to continue living. he had motivation and the ability to get up. he struggled to regain independance - this man had the will to live! i don't understand how other people were allowed to decide for him when you describe him as a person who could decide for himself. i'm accustomed to the principle that other people decide only when the patient has lost their ability to decide.

i think your gut feeling was connected to reality.

what you describe was clearly unethical - perhaps there are more facts in the case that you didn't mention?

how could this happen??!

ageism!

thanks for your post!

jeanette

new zealand