Ethic Question For Nurses

Some years ago when I worked on a stepdown unit we had a perfectly alert and oriented woman with severe endstage COPD who was transferred from ICU who was intubated. She needed the ET tube and oxygen to keep a patent airway. She had extubated herself several times in the ICU and had been re-intubated again each time and her wrists restrained. We had orders to keep her restrained on our unit as well, but had orders that if she extubated herself that we were to do nothing and she was made a DNR. Without the ET tube and the oxygen she would not be able to breathe and would literally suffocate and die. I worried so that she would extubate herself on my watch that I practically wore myself out checking on her and parked my carcass at her doorway when I was sitting down charting. She would ask each of us to untie her and told us all she wanted to die. I was very concerned because it seemed to me that the doctors were, in effect, not addressing her emotional issues yet leaving her hanging in limbo. And, it did happen. On someone else's shift, she managed to get her hands loose and she had her ET tube out very quickly. From my understanding, she died within 10 minutes because of inadequate oxygenation. What I couldn't get out of my mind was a picture of her going from being vibrant and active to dead in a matter of minutes that I feel could have been easily averted.

Had another situation somewhat similar to this in a nursing home with a patient who was on dialysis who had become more and more depressed and had been talking about wanting to end it all and die for several weeks. So, it was not a last minute decision she made when she started refusing to go to dialysis. At first it went on for a week before she changed her mind and decided to continue treatments for another two weeks before totally stopping them again. Again, she had been alert and oriented and knew fully what she was doing. The second time she stopped dialysis she was dead within the week from complete organ failure. Again, this was a patient who I talked with every day, told jokes to and got updates about soap operas from. Dead by her own hand to my way of thinking while we watched.

I fully understand that patient's have a right to make their own treatment decisions. And I suppose I can't really say that if I were in a similar situation as these two people I might not want someone interfering in my healthcare decisions. But, to allow them to carry through with their decisions without at least attempting to address the depression or at least exhaust all possibilities of attempting to improving their situations before finally letting them end their lives is what bothers me most about them. In both cases there was no psychiatric intervention.