Ethical Decisions

snowfreeze, BSN, RN · Dec 7, 2007

Ethical issues are tough, first is facility standard, second is family and patient perspective and then the nurse and physician perspective while following what is legal. Educating the patient and family helps if they are receptive but usually ethics committee consults are due to non-receptive patients and/or the person having medical decision powers.

Social services can be helpful in offering alternatives to care such as hospice in a facility and home hospice. Hospice also offers a year of post death counseling for family.

I would ask the social worker to talk to the family about these issues and find out why they don't want this patient to know about their diagnosis and prognosis.

One difficult decision I made for a terminal ICU patient turned out well. This patient had been in the hospital for over a month, started out with GI problems then developed post op cardiac issues, after multiple debridements after GI surgery and an MI, transferred back and forth from ICU, OR, med-surg, rehab and now late evening septic back in ICU and not strong enough to survive the OR again. As his nurse I made the decision to tell him that he was probably going to die tonight, he could do that in the OR or peacefully here in the ICU. His body had used all its reserves and an infection had ruined his kidneys and heart and he would never be able to digest food due to a dead bowel. He was on multiple pressors to maintain a blood pressure, intubated with pneumonia, no bowel sounds, infection in gut and weeping abdominal wound. HemoDialysis had been initiated due to renal failure. I asked him if he wanted to try the OR one more time and I would call his wife to come in and help with this decision if he would like that. He chose to not go to OR, and to have his wife at his side. I gave him some pain medication and called his wife and asked her to come to the hospital, telling her he had made another turn for the worse. I told her the whole prognosis when she arrived and had this coordinated with the docs. This couple had about a half hour of time privately then the wife asked for care to be withdrawn and pain to be controlled. She stayed with him for the whole time, stepped out for a few minutes for extubation and making him comfortable. She spoke to me later and thanked me, he was of native american heritage and was quite relieved that his soul was finally allowed to go to the next step. We had extended his life here for a little longer than he would have without all the encouragement from surgery etc. When the wife arrived at the hospital she seemed to know it was the end before I started to tell her the medical technical stuff making him so near death. She took hold of my hand and said, "honey, you don't have to justify his dying, it is part of life and he is ready to go"

Valerie Salva, BSN, RN · Dec 7, 2007

Given the following situation how would you respond?
An elderly woman, who's health is clearly quickly diminishing, is in a nursing home. Her dx is breast ca. She repeatedly asks what is wrong with her and keeps reminding you that she wants to go home. She yells for someone to help her, and you go to see what you can help her with. All that she says she needs help with is to know what is going on with her and what's wrong with her. But!!!, (BIG BUTT!! here) the resident's family, has made it VERY clear to everyone interacting with this woman, that she is NOT to know her dx of breast ca. How would you respond to this situation? Would you tell the woman what her dx is? Would you tell the woman that she needs to talk to her MD? Can they legally keep this woman in the dark about her own health an healthcare, since she is clearly askign about it?

I have been in this very situation a number of times. It's very uncomfortable and disconcerting. In all of these situations, soc serv was aware. I have just told these patients "I encourage you to discuss your concerns with your family and your doctor."

jaystrupp · Dec 7, 2007

I remember working on a cardiac floor and preoping a patient for a CABG. The kicker was that the patient was 92 years old. Why would we put a patient through this? The family felt that she had some good time left. I asked the surgeon who responded that she is a "young 92 year old." I stated that she may act young, but her ogans are still old. They did the surgery and she died of cource, and I always wonder what that family felt like. Did they make the right decision? I would have rather had grandma around for a few years on medication and keeping her comfortable, but in todays medicine we are always trying to push every procedure and such no matter what the outcome may be. Sad.