(Naive?) Student with a moral/ethical nursing dilemma...

Tweety, BSN, RN · May 13, 2007

Welcome to Allnurses. You're critically thinking like a nurse. Kudos to you for that.

If he has an anoxic brain from a cardiac arrest with permanent brain damage all the sleeping pills in the world are not going to regenerate those cells and wake him up.

That is very interesting research and I'm sure it's not necessarily a hoax as your instructor presumes.

oneLoneNurse · May 13, 2007

I am so grateful to have found you all!!...
So....I was doing my prep paperwork, and I dunno about when you all were in nursing school, but its ALOT and much of it is research. I came across these headlines and was intrigued- something along the lines of- "Sleeping Pill Proven to Reverse Vegetative State!" I am thinking, yeah, likely story. So I check it out. Credible source (BBC) that I came across but found that the original research was posted in "NeuroRehabilitation" (after further digging). It is VERY recent - in the world of research anyway- less than a yr old. So I am blown away. I take it in to my instructor the next day all like hey we could really make a difference here and waddya think, I am so excited....and I was crushed bc she basically blew it off as a hoax. I didnt press it at the time bc I hadnt done thorough research at that point, but now have done much more. I did a Google search - try it- "ambien and vegetative state"....over 17,000 hits! All over the world it seems, this is being talked about and tried - many times with success (at least they claim). The most RECENT research (about 2 weeks ago) FINALLY, recruiting is happening in the United States for clinical research trials to either prove or disprove it on a clinical basis rather than anecdotal reports.
My dilemma: My instructor has blown me off like I am a three year old who doesnt know any better. And please, dont let my website-chatty writing style mislead you...I am at the top of my class in a VERY competitive program, so (at least I feel) I have proven that I...I dunno....can be trusted I guess, or at least am worth not dismissing. What do I do? I feel like I have done a disservice to this family by "withholding" information from them. That it isnt up to me to decide whether they pursue it or not, but at least provide them with the information!!! I dont have any moral/spiritual feelings one way or the other about them disconnecting everything...I cant imagine being in that situation, but I feel like they should have a heads up on this before they come to a decision. What can it hurt right, duh, its an Ambien!!I feel like my hands are tied and I am REALLY not okay with it...but I am not about to get kicked out of my program I worked so hard forever to get into either. Anybody have some insight?
Again, anything is helpful...sorry to ramble, I am so fortunate to have found this site. Due to what this situation has sparked within me, I think I may be interested in research when I graduate.
~Dykely

I looked this up on PubMed to find these articles. Looks to me like your argument has validity and your instructor needs to lend an ear. And sorry I don't know how to get that to happen.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15553102&query_hl=2&itool=pubmed_docsum

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=14985499&query_hl=2&itool=pubmed_docsum

Please note there was no abstract or content for the second link.

Its also on Wikipedia under uses for the drug, BUT who knows who put it there.

http://en.wikipedia.org/wiki/Zolpidem

Looks to me as if your discovery is part of Evidence Based Medicine (EBM) which is defined as, "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research." (Sackett D, 1996).

http://www.hsl.unc.edu/services/tutorials/EBM/whatis.htm

Something, I am getting more proficient at as I struggle and learn in an MLIS program.

Altra, BSN, RN · May 13, 2007

Kudos to you for wanting to make a difference for your patient.

I found some references (mostly non-scientific mass media) in a Google search for the case of Dr. Ralf Klauss who reports improvement in 1 patient's condition after administration of Ambien. Just remember, Google "hits" do not indicate anything about the quality of the information contained therein. How many "hits" does "Britney Spears" generate?

Some things to think about:

Look up the pharmacology of Ambien, and apply it to what you know about your particular patient's neuro status. Persistent vegetative state is a description of neuro status that could be caused by any number of underlying conditions.

As you progress through clinicals you'll learn more about the team approach to patient care - consults of different medical specialties, etc. - and see how decisions are made regarding patient treatment. See what you can find out about ethics consults and your facility's process for approving experimental treatments.

Respectfully - remember that real patient care is not "House, MD" :rolleyes: but a methodical process of symptom management and differential diagnosis.

jmgrn65, RN · May 13, 2007

I have to agree with Tweety, the patient probably has anoxic brain and you don't bring that back. He is already dead. Just because his heart is beating, doesn't mean alive. sorry. however your research is great and your instructor should have aleast explained it to you. of course she may not know.

Daytonite, BSN, RN · May 14, 2007

hi, dykely!

something that you may not know about hospitals and research is that most facilities have rules in place about using investigative procedures and medications. no procedure or medication is given at any facility unless it has been approved and a policy developed for it. that includes it's intended use. so, although ambien is approved as a hypnotic, it's use for reversing vegetative states here in the u.s. may not have been approved by the fda. now, as nurses, we are familiar with nursing policies. however, the physicians also have very strict guidelines and protocols that they follow in therapeutics as well. so, even if the family knew about this intervention and sought it out, the chance that one of the doctors at the facility where he is currently in residence would be able to, or willing to, administer it is iffy. when patient's with diseases go looking for experimental treatments they have to do a lot of searching for the doctor(s) and facilities where these things are being done. the fda must approve the treatment first as well. if the fda hasn't given a thumbs up to a doctor or facility here in the u.s. for the use of ambien that you were reading about, then it isn't going to happen here is the u.s. yet. so, you see, there are laws that have to be considered as well.

i recall the first patient we gave azt to back in the 80s where i was working. the story of azt is an interesting one. it was still undergoing clinical trials, but the results were so astounding that they couldn't be ignored. the fda allowed patients with special circumstances (such as our patient) to be able to get the drug even though it was still technically in clinical trials and hadn't been granted final approval for use. azt was the first hiv drug that got the fda kiss of approval and it made headlines at the time. we had a very ill patient and his very astute physician who knew the fda was going to allow exceptions to their own rule on allowing the use of this drug for certain cases had to jump through hoops to get the hospital to approve the use of this drug for this one patient. i laugh now because when we finally got the drug for this patient, it was so precious that we kept it locked in our narcotic drawer and signed out every dose! the hospital pharmacy had to make special arrangements and get special approval from the fda to get the drug.

don't give up the prospect of going into research nursing. check out the website of the cdc. many of the various va hospitals have large research facilities connected with them. many of the larger world famous medical centers are also involved in a lot of research projects. the large cancer centers also are engaged in a lot of research. you can find information on research on the cdc website. find the nurses and doctors who are doing research and publishing and you will find the research jobs.

good luck!

since you are a student, you might want to check out the nursing student forums on allnurses. here is a listing of them:

https://allnurses.com/forums/f196/

welcome to allnurses! :welcome:

CHATSDALE · May 14, 2007

what type of a 'coma' were the patients in that were helped with the ambien

don't be surprised by your instructors attitude...many people in and out of nursing don't believe anything that hasn't been in use forever

anc33 · May 16, 2007

Following up with what Daytonite said...

Hospitals do participate in many clinical trials. For example, someone who is has been hospitalized due to a DVT or some other kind of clotting problem may receive an experimental blood thinner/clot buster, etc. However, these trials are closely controlled followed according to a specific protocol. Depending on the trial, these may be written by a pharma company, device maker, etc. The protocols are usually overseen by one or multiple principle investigators with a research coordinator (usually an RN) in charge of patient follow up. Clinical trials of this nature are very documented very thoroughly with information flowing to the sponsor and eventually the FDA for approval of the treatment. Of course it is much more involved that that.

As other people have mentioned, Ambien will probably not have any effect on his condition. And technically, while a Dr. can write and off-label prescription, all off-label uses are audited by the FDA and both the drug company and/or prescribed can get "dinged" by the FDA, especially in this case.

But as others have said, you did a great job with your research. Hopefully, this will spurn you on to learn more about the ins and outs of clinical trials. Maybe even become a research nurse.

Chaya, ASN, RN · May 16, 2007

Did you mention (or show) your websearch to your patient's nurse? Or even mention it to one of his md's? Even if this is bogus I would feel perfectly appropriate asking the md if (s)he has ever heard of this. Or I would leave the md a note just to put a bug in his/her ear.

Good luck!

**canoehead, BSN, RN** · May 16, 2007

Say to the MD during a quiet period " I was reading about using Ambien on coma patients, do you think there's anything to it?"

Alternatively, when family mentions the remotest possibility of a miracle you could reply, "yes, we hear lots of the miracle stories- look at the patients that were revived with Ambien- one in a billion chance..." They may choose to leave it alone, or they may research it on their own.

DDRN4me · May 16, 2007

Kudos for thinking "outside the box" however, i would caution against saying anything to the family in this instance.... families under that amount of stress tend to say things to the doc and other nurses like " the student said that you should be giving him ambien, and that would wake him up..why arent you?" even when that is the last thing that you would have said! :idea:

leaving a copy of the research for the primary nurse at the nurses station or for the doc is a better way of getting your message across.

castens · May 31, 2007

Alternatively, when family mentions the remotest possibility of a miracle you could reply, "yes, we hear lots of the miracle stories- look at the patients that were revived with Ambien- one in a billion chance..." They may choose to leave it alone, or they may research it on their own.

Whoa! Just be careful how you do this... and I would NOT advise a nursing student to do this. There is a very realistic possibility - I've seen it happen too many times myself - that the family might behave like Jim Carry in "Dumb and Dumber"

"Do you think there's a one in a thousand chance you could love me?

"I'd say more like one in a million."

"So you're telling me there's a chance!"

One in a billion is still a chance - and it's that chance that a lot of families pick up on... especially when they're trying to decide on continuing support. Also keep in mind that the one in a billion chance, if it exists, probably wouldn't materialize for YEARS.

A more realistic course of action is to understand for yourself (by inquiry, or reading the chart) what the physician's take on this is. Have there been blood flow studies, EEGs, MRIs? What is the medical prognosis - which is not the same as "a chance"? If in fact this is determined to be a permenant vegitative state, I would discuss the patient's wishes with the family. Would "Steve" want to live this way permanently? At this point, the patient's wishes are the only thing that the family, physicans, and nurses as patient advocates should consider.

Having said all that...

1. Good job in doing your research! Evidence-based practice is what I wish 90% of my staff looked at!

2. Miracles do happen, I've seen numerous myself. But even as a devout Christian, when I'm dealing with tragic patient cases, I make my rule: Believe in miracles, hope for miracles, but don't count on miracles.

3. There ARE fates worse than death.

4. Everybody dies sometime, the only differences are how soon and how well. It may be that at this point, the best death is all that can be done.

By the way... if Steve's family (or other document) indicates that Steve would want to be kept alive by all heroic measures possible, the staff will have to accept that as well - and sometimes that can be harder for nurses than withdrawing support.