Hello, I am a first year student and I have an Ethical dilemma. Can anybody help?!
You are working afternoon shift as a third year student on a medical ward, caring for a patient who is in the terminal stage of cancer (metastasised). You have known him since his admission over 3 weeks ago, and aware that it has been difficult to effectively control his pain for some time. His wife and children have been very supportive, but are distressed about him suffering. During your shift it becomes apparent that the patient will die shortly (not expected to survive the night). The doctors belive that they can not safely give him any more pain medication. The nurse in charge tell you to give him a "sponge" in bed and make him comfortable. However, when you start to wash him, he cries out in pain and begs you to stop. The more you continue, the more he screams. The nurse in charge still insist that you continue and that the patient be "sponged"!!!!
What actions would you consider taking and why?!
From an ethical perspective, how you would ensure that the "right action" is implemented?
Sep 4, '01
If the patient is telling me he doesn't want to be bathed I wouldn't bathe him. It is his right to accept or refuse any measures we want to take. I'd discuss with him peri care, oral care and "freshening up". This might make him feel a little better. But, again, it is his right to refuse treatment. So, I'd do as much as he allows and come back later to see if he's up to doing a little more.
Sep 4, '01
I'm sure you could make a case for increasing the pain meds, regardless of the end result, by asking the question... What (who) will it hurt to make a person who will die within hours comfortable?! As well, continuing on with the sponge could be considered an assault and if the family is aware of this, they could press charges and you could be arrested. We cannot force any treatment on a patient, no matter how much better it would make us feel. Sometimes we have to advocate for our patients against all odds.
Sep 4, '01
When I was in school, it was my experience that the charge nurse or my instructor would suspect that you were just avoiding the task if you did not do a bath.
That charge nurse probably suspected that you were just avoiding it or didn't offer some alternative like just mouth and peri-care. Maybe you DID offer that alternative...but you're probably just a lowly student in her eyes.
In that situation you could have asked the charge nurse to go in and verify with the pt that he did indeed decline a sponge bath. Trust me, that charge nurse knows darn well that you can't and shouldn't force things on a pt. I suppose if the pt's mentation was altered you could be justified in going against what he wants. BUT-- this man is going to die soon and he last hours shouldn't be a blur of pain. Yes, maybe a warm washcloth to the face may have made him more comfortable, but rubbing and blotting and drying and moving him wouldn't. It's called nursing judgment and you used it.
I think you made the right decision. Just remember that you don't answer to her and you don't have to feel bad because you didn't make her happy.
Sep 4, '01
...and you know, how dirty does he really get just lying in bed in pain???? I didn't touch that issue...there SHOULD be something they can do to relieve his suffering. And you know what? If he was that miserable I wouldn't even change his linens unless they were soiled. Face, mouth, armpits, privates, fresh gown...tops.
Sep 4, '01
The only ethical delimma I see here is with this charge nurse insisting that you assault a dying man. He has the right to refuse any treatments and as nurses we have to respect that when a patient says stop, we stop. This charge nurse should not have put you in this predicament. Even as a student you can be a patient advocate and explain to this Nurse Ratchet that the patient is refusing the bath and you therefore you feel it is inappropriate to continue. Involve you instructor or the nursing supervisor if needed.
Was the family there? If someone treated my loved one this was there would be hell to pay.
As far as the pain meds. go, there is only so much you can do as a student. Unfortunately it is a fact of life that terminal patients often have their pain undertreated. With all of the medications we have at our disposal no one should die in pain. We have dealt with this issue in our hospital and if the nurses feel a patient 's pain is not being properly managed we can involve the ethics commitee, but this still continues to be a problem.. Doctors need to be educated on end of life issue. They also need to be more involved in the care of their patients. Many, many of them waltz into the room for 2 minutes and then depart, leaving us to deal with someone in agony for the next 12 hours.
You obviously are very caring . Good luck in your nursing career.
Sep 9, '01
Unfortunately pain management is difficult to approach with many MD's. The reason is because of the fear of lawsuits. You might be amazed at how many families have filed lawsuits saying that the pain meds hastened death. For this reason, MD's are reluctant to "overmedicate". MD's who are experienced in pain management generally like to use morphine drips. It is a shame this patient did not get this option.
Sep 9, '01
Thank you ALL for your support and good advice. And yes, i did stop washing the patient but the nurse incharge, still hates my guts
So what?!... at least i feel good for what i did! In my opinion, a good nurse is that one who can put herself in her patients position... I was once a patient myself!
Sep 9, '01
You can hose him off AFTER he dies!! Bathing is a comfort measure for most pts, but to this one, it wasn't. As the charge nurse, I should think she'd be interested enough in his condition to go and assess him if you told her you thought he wouldn't tolerate a bath. You could also ask if she knows any way to bathe him without hurting him, because he's clearly not enjoying it!
Try just washing his face and hands, comb his hair (looks like you really did something), spray his armpits, use some baby wipes on his bottom next time he's on his side, and maybe rub some lotion on his sacral/coccyx. Do these things slowly and gently, probably one at a time, over the course of your shift, and that should keep her happy. Don't you wonder sometimes?
Sep 9, '01
Lord, spare me from the knee-jerk "must have a bath and be pulled up in bed" Ratchits! First, I would call the doctor and describe the pain behavior in detail. All he can do is say no. What is this guys BP and pulse? Even while actively dying, these can be elevated because of pain. When I call a doc about pain, I have an arsenal of arguments. It helps that we have a state law mandating patients be kept comfortable. Also, I would document every hour what his pain behaviors are. Narcotics don't kill you when you're in pain. Pain relief will allow death to occur in a timely manner. I feel for you!
Sep 15, '01
Congrats on standing your ground! It is so hard, especially as a student, to stand up to "authority". I once worked nights in an institution where the first words out of the day shift's mouths was "who got a bath?" - not "what kind of night did you have?" or "where your patients well cared for and comfortable?". It didn't help that the nurse manager believed all patients needed to be bathed on nights - said if they weren't appropriate to bathe at 0400, then we should bathe them at 2100 - like I had nothing better to do at 2100! Why is it that so many nurses are hung up on baths and linen changes? Most elderly patients are actually put at a "intact-skin" disadvantage with daily "baths". Their skin is naturally lower in oils, more fragile, and more likely to breakdown. SO - we give them baths with soap and remove the rest of the oil, scrubbing their fragile skin. If you'd ask, most of the patients over 65-70 only take "sponge baths" daily (what we called 'pits & peri') and only a full bath about once a week. And who do you know that changes their linens at home DAILY? Yeah, if it's soiled, or if the patient never gets out of bed, that's one thing . . . but if they're "activity ad lib" -WHY????? Anyway, let me get down from my longstanding soap box . . . by the way, the most recent floor job I held - I NEVER heard "who's had a bath?"
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