Ethical dilemma

2027 · Mar 8, 2007

On friday, I was taking care of a very elderly person, who was knocking on death's door. Pts respirations were 5 per minute. Pt has had these breathing episodes a few times over the last few days. Family stated pt was in pain, and that I should give pt a pain shot, since it was time. (Dilaudid, 1mg IM)
Patient was not able to communicate if they were in pain. Pt was not showing any outward signs of being in pain, but I also had the feeling that pt was either in pain, or very anxious. It was hard to tell. It was my gut feeling that pt was not comfortable. The patient has been receiving the same dosage for several weeks. There was not an increase in the dosage or frequency of the med.
I explained to family, that if I were to give the Dilaudid, pt may stop breathing. It was not absolute, but there was a chance.
I can not give more details about the situation, but the family was TOO okay with this. They actually made a comment about me euthanizing the pt. I can not say the actual comment they made, since I do not want to give too much info.
The primary doc was aware of the situation, and wanted me to give the Dilaudid. He even came to the floor, since I called him several times about it.
What would you have done?

I would give the Dilaudid, on my opinion, a dying patient needs dignity, give them the most comfortable way as possible, difficult for the patients relatives as well to see their love ones in agony, i've witnessed so many scenerio as such, and relatives are more pleased that relatives passed peacefully.

kindaquazie · Mar 8, 2007

It is ethically fine for nurses to give medication for pain and/or discomfort at the end of life, even if doing so will hasten death. Nurses DO NOT kill people. We have to balance everything. Is it better to NT suction someone who is nearly dead and has a "death rattle" or to just give them some morphine so they don't suffer? I think NT suctioning is probably noxious and would opt for the second if the patient were that close to death. The point is, you have to know in your heart that it is ok to treat suffering and pain at the end of life. It is our ethical duty to do so. We do not euthanize people.

pepperann35 · Mar 8, 2007

I deal with this situation often. The main goal in end-of-life situations is to keep the patient comfortable. I have had patients with very rapid respirations that, when pain med was given, began to relax and "let go". The pain med really helped. If your patients respirations were diminished, I can see your hesitation, but you did the right thing. The family was probably just anxious to see the patient out of his/her assumed misery. You informed the family of the possibile outcome and they understood. You did the right thing.

cardsRN · Mar 8, 2007

in my opinion, where end of life care is concerned my role is to comfort the pt and the family and make sure all care is rendered according to the wishes of the pt or if they are unable to speak, their proxy. this is regardless of my personal religious/spiritual business. i have often been troubled by participating in heroic measures with no hope of return of function but in this case too; we do what the pt/family wants. as tweety said, it is an honor to ease dying pain and give the final comfort. rest your head OP, you did right by that patient.

SE_BSN_RN, BSN · Mar 9, 2007

On friday, I was taking care of a very elderly person, who was knocking on death's door. Pts respirations were 5 per minute. Pt has had these breathing episodes a few times over the last few days. Family stated pt was in pain, and that I should give pt a pain shot, since it was time. (Dilaudid, 1mg IM)
Patient was not able to communicate if they were in pain. Pt was not showing any outward signs of being in pain, but I also had the feeling that pt was either in pain, or very anxious. It was hard to tell. It was my gut feeling that pt was not comfortable. The patient has been receiving the same dosage for several weeks. There was not an increase in the dosage or frequency of the med.
I explained to family, that if I were to give the Dilaudid, pt may stop breathing. It was not absolute, but there was a chance.
I can not give more details about the situation, but the family was TOO okay with this. They actually made a comment about me euthanizing the pt. I can not say the actual comment they made, since I do not want to give too much info.
The primary doc was aware of the situation, and wanted me to give the Dilaudid. He even came to the floor, since I called him several times about it.
What would you have done?

I recently had a situation like this, too. Pt had cancer and the family said "He's in pain, give him more morphine (SL liquid.) I did not give it because he didn't say he was in pain, showed no s/sx of pain, and was in and out of consciousness even with me there asking him if he hurt. I was afraid that if I gave it to him he would go, and I didn't want to do that. The family got upset. One of the family members owns a hospice in LA and supposedly wrote a book saying morphine does not decrease respirations. But it is also used for "air hunger," which he may have had, but I didn't see that at the time, either. I had my review a few weeks after he passed away and was told "The famly was upset that you didnt give the morphine when they told you pt was in pain." I didn't get in trouble for not giving it, but afterwards the hospice came and did an inservice on pain an morphine, etc. I am a new nurse (almost 2 years,) so I am still learning, and had a hard time with that, the family asking me to give it when he showed no signs of pain...so does that mean if the family requests it, do I give it? I hope as I grow in my career that I can be comfortable with doing so. Some of you have had good posts. I didn't look at it as tweety said, but it does make sense. Thanks Tweety!

BarbraJean · Mar 11, 2007

I read the postings with a great deal of interest. As a Canadian Certified Hospice Palliative Nurse, it took a long time for me to get from way back there to here. As students we're taught what meds can do and what we should do with that knowledge, we are after all our patients advocates. I too, do not believe in euthanasia, however the standard of double intention is very prevalent when it comes to palliative care. Does the good go the medication or action that we are carrying out outweigh the negative factors? We do not hasten death, we do what we do only after careful consideration for what our client would want. It is no different than someone who is in obvious pain,cannot verbalize same, we go to give the pain med & the family says no. We advocate for the adm. of the pain med as we do not cause needless suffering. I hope this makes sense. You have put alot of thought into your note.

TrudyRN · Mar 11, 2007

OP - you did the right thing, I think. Especially involving the priest and the doc. That was very wise.

Keeping a patient comfortable is merciful, not doing so is unmerciful.

Feel easy, I'd say.:icon_hug:

ertravelrn · Mar 11, 2007

What you did was right, and you put a lot of thought into it. My own experience was a Dr that wouldn't let my MIL come home on hospice......his stance was life at all costs, so he finally had to d/c her home, but only gave enough meds for two days, making sure we brought her back to the hospital.....we contacted hospice and they helped us locate a Dr that would take her on as a patient and assist us in caring for her, with dignity, and with the amount of pain meds she needed. She also was breathing 5 times a min, and for a while only 4 times a min, and we felt for sure we were going to kill her with the pain meds, but she actually slept all night, breathing easier and woke up and ate breakfast.......granted it was the last good spell she had, but it was nice to have it.

fr.dad · Mar 12, 2007

Gooey,

I, too, agree it was right to give the med. Your intention was to ease the pain you thought the pt. was in. Such palliative care is absolutely ethical in end of life situations, in spite of risk for depressed respiration.

You said it was your "gut feeling that the patient was not comfortable." Many others have written encouragingly about following your gut. I suspect a careful and thorough examination of all you observed, combined with all you knew at the time about your patient's history would show that you actually had enough clues for your 'gut' to pick up on, causing you to believe your patient was not comfortable, even though your conscious mind was not picking up on those same clues.

Wouldn't this sort of situation be so much easier for caregivers to deal with if all patients had written out advance care directives/living wills addressing this issue directly? Mine says I request pain control even if it should hasten my dying. Although no one can force people to write out their final instructions, both health care professionals and chaplains can encourage and assist them to do so before the time of crisis. We all ought to be educating and encouraging people whenever we get an appropriate opportunity.

Gooey -- do not misunderstand. This call for education and encouragement is not directed at your deathbed scenario. It needs to happen much earlier, while the pt. can still express an informed decision. You did the right thing for your pt.

twotrees2 · May 10, 2007

I did give it. But not before discussing it with the priest. (I did call him in, since the pt belongs to our parish, and the priest has been there to visit him daily) I still felt pretty sick afterwards. The pt did not die that evening, I don't know if he will still be there tonight. At the weekend mass, the priest did stop me after mass and we discussed it in quite detail. (not breaking hipaa, the priest probably knew more about the pts condition than I did) Basically, the priest picked up the same feeling about the family. But since MY intent was to make him comfortable, it was ok to give. It would have not been ok if my intent was to end his life. Unfortunatly, its a very small hospital, with no ethics group or hospice or anything like that.
Thank you all for making me feel better about my decision to give the med.

in my opinion it was still a hippa violation - if the priests name was not on the contact list we use for those that need to be told stuff- no matter what the priest knew from the family - it was not your place - especially out in public to tell the priest anything - if he is on the list then you have the right to talk to him at the placce the resident is at not out in public.

most people will say the same thing - i know i might - in distress not really meaning to "kill" someome but that they just really want to see the patient comfortable and if that means they die in the process many people are more aware that that is OK - they know it "may help it along" but to not do it and let them be in pain to live a few more days would be cruel.

i would anbd have many times done the same thing you did - i used toi get teased at my last job as i had quite a few hospice pts and i had like 4 people in 2 yrs die at shift change shortly after i had given em morphine supp - the night nurse would say its ok " you killed them with kindness and comfort" - noone truly meant anyone "killed" anyone- it is hard to let pts go though - so i undestand your feelings.

(ps) i am sayig i agree that you did right giving the med - and i understand your feelings cause after many yrs it is still hard to "let go" for me - though i do - i just feel that discussing the pt with the priest after mass without family permission or family being there was not the proper thing to do, no matter how much the priest knew from the family. it could in some instance cause a nurse trouble if it had been done with the wrong people - i guess im just saying be careful what you say and to who.