Ethical Dilemma

  1. 27

    Motor cycle accident with neuro status changes and a difficult decision for the family to make

    Ethical Dilemma

    Last week, I took care of a 25 year old male, Mr. L, who had a motorcycle accident. He had bilateral femur fractures, a pelvis fracture, and a right tib-fib fracture. He was drinking during the accident and had a small subdural hematoma from not wearing a helmet. Upon receiving him from the Operating Room, he was intubated, sedated, and on pain medications. The orthopedic team had done an ex-fixation on his right lower extremity, plated his pelvis, and proceeded with a right ORIF of his femur fracture but not his left at this time.

    I was weaning off the sedation to get a full neurological assessment when he became tachycardic and tachypnic. When asked to follow commands, he would squeeze my hands but not wiggle his toes. He would open his eyes but not track when spoken to. He was becoming frantic and looked to be air hungry. At that point his oxygenation started to decline. I went from a Spo2 saturation of 98% down to 78%. I called the respiratory therapist to come assist and help bag the patient. We turned up his Fi02 to 100% and started bagging. I called the trauma service managing my patient and updated them on his condition.

    I sent off an ABG to assess his oxygenation and a full set of labs. I re-sedated him and received an order for a bolus of pain medicine. I got him back to a resting rate and a lower tachycardia but his oxygenation was not improving. My first thought was a pulmonary embolism or fat embolism secondary to his long bone fractures. I mentioned this to the physician and they immediately ordered a stat CT Angio of the chest. An hour later, I was back in my room post scan with the radiologist calling with the result. There was a cluster of fat emboli throughout the left lung causing him to not oxygenate. I also mentioned to the physician that when I pulled the sample of blood I sent to the lab, there was large fat molecules that I wasted and sent in the tubes. The patient does not have a history of high cholesterol that would normally cause this to happen. I wasted some blood again to show them and brought to their attention that the last time I saw this happen, the patient also had the fat emboli travel to their brain causing severe brain damage that ultimately led to that patient's death.

    Upon hearing this, the physician felt it was in due cause to order a stat head CT to check on the brain. My suspicions were right. I received a call from the radiologist stating he could see several new areas of infarct from what probably is caused from fat emboli showering into his brain. I called the physician immediately and informed them of this change in status. There really isn't much you can do for fat emboli like you can for blood clots. There is no medicine to give to help dissolve them or remove them. At this time the only thing we can do his just help support him and maintain ample oxygenation. WhenI tried to reassess his neurological status again in the shift, my patient was not following any commands and his pupils were equal but sluggish.

    The physician had made several vent changes to help increase his saturation with no success. They called the attending on call and received an order for Nimbex to paralyze the patient so their respiratory drive was subdued. Not letting him work to breathe might allow his lungs to do a better job with the occlusions they had. I started the Train of Four (TOF) with a baseline of 4/4 twitches on 4 amps. I started the Nimbex per policy and titrated it up to a TOF of2/4 twitches. With the patient paralyzed, I was able to increase his saturation from 78% to 92%. I received an order for Flolan and the respiratory therapist connected and started this medication to help make the blood carry the oxygen easier throughout the body. I placed the "No pregnant caregiver" sign on the door and informed the staff of the new medication added.

    I then talked to the doctor about this young patient's prognosis. I asked them what else we could possibly do for him and all they said was "just wait". I had the physician call the patient's mother and update her on her son's condition. I felt that she should be here in case he doesn't pull through this. An hour later, his mother and father were at the bedside crying over their son. Then the arguing started. The patient's parents were not on the same page about their son's quality of life. The dad made it clear that if the physicians felt he was not going to improve, that he wanted his son to be made a DNR and all this "nonsense" betaken off and for him to pass peacefully. The patient's mother on the other hand, wanted everything done for her son no matter the result or consequence.

    I immediately called the chaplain to come to the bedside to help talk to the parents. I felt with their experience they could help them both make intelligent decisions and maybe come to a middle ground. I asked my charge nurse to come over and see if they could talk with them while I took care of their son. I still had so much to do. The ethical dilemma surrounding my patient is one I see a lot when it comes to families not agreeing on hard life choices. By the time my shift was over, the parents had agreed to give their son a certain amount of time before making any rash decisions. They would wait and see if the clots would migrate or move on and his condition improve or possibly decline. At shift change, I had his saturation at barely 90% adequately paralyzed and sedated per policy. He was on pain medications as well, and did not look like he was struggling like he was before. I feel like I made some really good decisions concerning my patient's care and acted appropriately to get the best results that I could.

    It has been a week since I took care of Mr. L, and when I came to see how he was doing I was informed that he didn't make it. He was so young to be taken so soon. The family came together in the end and agreed on letting him go when he stopped making any neurological progress,and his condition was declining despite the medical team's hard work.
    Last edit by Joe V on Jun 16, '18
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    14 Comments

  3. by   Buyer beware
    And the lesson of this story may be: don't go zipping through traffic at 100mph, drunk, without a helmet. This scenario I often see on the interstate (Florida) where there are no helmet laws. "Born to be Wild" OK song, bad lifestyle.
  4. by   canoehead
    This is a great case study! Thanks for sharing.
  5. by   BSN16
    thank you for sharing! As a nurse, (ESPECIALLY IN THE ICU) it was very good to both be a patient advocate, do all that you can for such a young patient but also to be realistic. Sometimes the kindest thing you can do for your patient is to not prolong their suffering.
  6. by   FolksBtrippin
    I hope one day I am as good as the OP.
  7. by   TeamNutella
    Quote from lnvitale
    I hope one day I am as good as the OP.
    I agree, me too.
  8. by   armyicurn
    Patience grasshopper! Patience.... you will get there. Don't be in a hurry.
  9. by   shellyscorner
    Wow! I am so sorry you had to deal with that. But, YES, I recognize that's what we're signing up for. It still sucks, especially with someone so young! But like two of the previous posters, I hope, if ever in the same situation, I can do as well as it sounds like you did! I hope you have the peace of knowing that you did everything you could have possibly done for him!

    It's such a shame. Yes the young man made some bad choices, but many young people do. So, I don't think the take away from this is. as one poster put it: "[FONT=Open Sans, verdana, sans-serif][COLOR=#000000]don't go zipping through traffic at 100mph, drunk, without a helmet." I agree, that would certainly be a smart thing to NOT do, but that said, I think the real take away is that EVERY ADULT, no matter how young (obviously above 18/21 depending on the laws) should have an Advanced Directive/Living Will.[/COLOR][/FONT]

    [FONT=Open Sans, verdana, sans-serif][COLOR=#000000]NONE OF US has any guarantees! Even if we're NOT doing something we SHOULDN'T be doing! We can be minding our own business and STILL find ourselves in similar situations. And because WE DON'T have any such guarantees, to NOT have an Advanced Directive/Living Will leaves our friends and families in a HORRIBLE position! We FORCE them to make decisions that NO ONE should have to make for us! MOST of us have NEVER EVEN THOUGHT about what we want in such situations, let alone talked to someone else about it, which means we may have NEVER EVEN CONSIDERED filling out the proper paperwork! Seems like for ALL the campaigns we do in this country, blood drives, drunk driving awareness, cell phone use while driving, etc. (the list could go on indefinitely) we could do a better job a teaching people the value of such documentation! There HAS to be a way to raise awareness of the critical value of such documentation! Imagine the money that could be saved in the healthcare system for those that get the end of life care that they don't need. And NO, it's not about the money, but it IS undeniably part of the picture. And it ONLY adds to the stress for the family members, when they get the inevitable bill, that they probably can't pay, and ultimately . . . the stress to the healthcare system. It's all part of the picture/problem. As nurses and student nurses, I hope we ALL have the appropriate paper work filled out. I do. Do you?

    It's all just so sad . . .
    Last edit by shellyscorner on Jul 30, '16 : Reason: Deleted something.
  10. by   tmerritt224
    Excellent advocacy for your patient... thanks for sharing.
  11. by   Scroll89
    Is it bad that all I could think reading this is "Man what a rough day"..? We specifically have a team of nurses, physicians, ect.. that are trained to handle this. Anybody in the hospital can put in an ethics committee consult and the chaplain heads the team. They assist the patients family in making difficult decisions such as this, and have even gone so far as to get court orders to remove patients from care when the patients family refused to do so (it was causing the patient to be in agony, they didn't want pain meds but wanted vent/CPR ect..). Hate to say it but a lot of the time I simply don't have the time of day to continue to humor the patients families that refuse to take action, so I'm glad there is a team that is specifically for this purpose.
  12. by   djh123
    Wow. I applaud you for your knowledge, suggestions to the doctor(s), and more. And the case, though drastically different, reminds me of one in my facility, where family is not in agreement as to the patient's actual condition and what should be done.
  13. by   subee
    [QUOTE=shellyscorner;9136572]Wow! I am so sorry you had to deal with that. But, YES, I recognize that's what we're signing up for. It still sucks, especially with someone so young! But like two of the previous posters, I hope, if ever in the same situation, I can do as well as it sounds like you did! I hope you have the peace of knowing that you did everything you could have possibly done for him!

    It's such a shame. Yes the young man made some bad choices, but many young people do. So, I don't think the take away from this is. as one poster put it: "[FONT=Open Sans, verdana, sans-serif][COLOR=#000000]don't go zipping through traffic at 100mph, drunk, without a helmet." I agree, that would certainly be a smart thing to NOT do, but that said, I think the real take away is that EVERY ADULT, no matter how young (obviously above 18/21 depending on the laws) should have an Advanced Directive/Living Will.[/COLOR][/FONT]

    [FONT=Open Sans, verdana, sans-serif][COLOR=#000000]NONE OF US has any guarantees! Even if we're NOT doing something we SHOULDN'T be doing! We can be minding our own business and STILL find ourselves in similar situations. And because WE DON'T have any such guarantees, to NOT have an Advanced Directive/Living Will leaves our friends and families in a HORRIBLE position! We FORCE them to make decisions that NO ONE should have to make for us! MOST of us have NEVER EVEN THOUGHT about what we want in such situations, let alone talked to someone else about it, which means we may have NEVER EVEN CONSIDERED filling out the proper paperwork! Seems like for ALL the campaigns we do in this country, blood drives, drunk driving awareness, cell phone use while driving, etc. (the list could go on indefinitely) we could do a better job a teaching people the value of such documentation! There HAS to be a way to raise awareness of the critical value of such documentation! Imagine the money that could be saved in the healthcare system for those that get the end of life care that they don't need. And NO, it's not about the money, but it IS undeniably part of the picture. And it ONLY adds to the stress for the family members, when they get the inevitable bill, that they probably can't pay, and ultimately . . . the stress to the healthcare system. It's all part of the picture/problem. As nurses and student nurses, I hope we ALL have the appropriate paper work filled out. I do. Do you?

    It's all just so sad . . .[/QUOTE

    Perhaps...no directives, no driver's license?
  14. by   BeenThere2012
    [QUOTE=subee;9137757]
    Quote from shellyscorner
    Wow! I am so sorry you had to deal with that. But, YES, I recognize that's what we're signing up for. It still sucks, especially with someone so young! But like two of the previous posters, I hope, if ever in the same situation, I can do as well as it sounds like you did! I hope you have the peace of knowing that you did everything you could have possibly done for him!

    It's such a shame. Yes the young man made some bad choices, but many young people do. So, I don't think the take away from this is. as one poster put it: "[FONT=Open Sans, verdana, sans-serif][COLOR=#000000]don't go zipping through traffic at 100mph, drunk, without a helmet." I agree, that would certainly be a smart thing to NOT do, but that said, I think the real take away is that EVERY ADULT, no matter how young (obviously above 18/21 depending on the laws) should have an Advanced Directive/Living Will.[/COLOR][/FONT]

    [FONT=Open Sans, verdana, sans-serif][COLOR=#000000]NONE OF US has any guarantees! Even if we're NOT doing something we SHOULDN'T be doing! We can be minding our own business and STILL find ourselves in similar situations. And because WE DON'T have any such guarantees, to NOT have an Advanced Directive/Living Will leaves our friends and families in a HORRIBLE position! We FORCE them to make decisions that NO ONE should have to make for us! MOST of us have NEVER EVEN THOUGHT about what we want in such situations, let alone talked to someone else about it, which means we may have NEVER EVEN CONSIDERED filling out the proper paperwork! Seems like for ALL the campaigns we do in this country, blood drives, drunk driving awareness, cell phone use while driving, etc. (the list could go on indefinitely) we could do a better job a teaching people the value of such documentation! There HAS to be a way to raise awareness of the critical value of such documentation! Imagine the money that could be saved in the healthcare system for those that get the end of life care that they don't need. And NO, it's not about the money, but it IS undeniably part of the picture. And it ONLY adds to the stress for the family members, when they get the inevitable bill, that they probably can't pay, and ultimately . . . the stress to the healthcare system. It's all part of the picture/problem. As nurses and student nurses, I hope we ALL have the appropriate paper work filled out. I do. Do you?

    It's all just so sad . . .[/QUOTE

    Perhaps...no directives, no driver's license?
    Or no motorcycle license....

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