Ethical issue?

[nursesmatter]

Hello. I have a question to ask because I have been reading about ethical issues and moral distress. I recently experienced an event on my unit which caused multiple staff including myself to feel frustrated and somewhat angry. I cared for one member of an elderly couple that were involved in an accident. Unfortunately, the woman's husband passed during the accident. She survived and I cared for her for 2 days immediately after the event. Her adult children were present at her bedside throughout her hospitalization for her emotional well-being. Upon arrival to my unit, one of her family members pulled me aside and told me (not asked) not to disclose her husband's death because they wanted her to get well first, then eventually tell her. Family members also told each staff that provided her care the same thing. During the 2 days I cared for her, multiple times she asked me about the condition of her husband. Whenever she asked me this, I looked at her family members and they would glare at me. So I ended-up distracting her or would tell her to focus on her healing first. Not telling her what happened to her husband ate me inside. If that were my significant other, I would want to know right away. Finally, the family told her about her husband's death on her 5th day of hospitalization.

I'm not sure but I feel as though this type of situation may be more common than I think. But my question is: Do you think this is an ethical issue that could have initiated an ethics consult??? Thanks for your input!

[retiredmednurse]

As a past member of my hospital's ethics council with MD's, I say "yes". It is definitely an ethics question. We had an elderly Chinese man who spoke no English. His family members were the translators. I'm not sure how it was found out, but the family only translated what they wanted him to know. They never told him how serious his medical condition was. It was his case that prompted my hospital to use the AT&T translation service using speaker phones. This now allows any patient to be told in his own language the things a health professional needs to say from a translator who has been taught and understands medical terminology, without relying on the family to pass on incorrect information.

[MunoRN, RN]

missmollie said:

I work in neurosurgery. For my patients it is a matter of what the family believes is best, the extent of their injuries, and their ability to comprehend the information. For the majority of my patients, it absolutely IS up to the family and it is ultimately their decision.

Family understand their loved one better than you or I will after a mere 12, 24, or 36 hours with the patient. Why would you believe you know more about the patient than the family, if everyone in the family is saying not to tell him/her. Granted, every nurse must make the decision based on the situation on hand, but if every family member believes it is best, then I will do what I can to ensure they are making an educated decision. You do what is right for the patient based on all information, not just based on your own personal beliefs.

In situations where the patient cannot make their own decisions, it's not actually up to the family to substitute their wishes for the patient's wishes. The decision makers responsibility is to relay what the patient would want in certain circumstances even if that contradicts what the decision maker would want for the patient. In this case, it's the family that doesn't want the patient to know, the patient clearly wants to know since she keeps asking, in this case you know what the patient's wishes are and there is no basis to defer to family on this decision.

[nursesmatter]

Thank you everyone for providing your input thus far. I am overwhelmed by the interest and the variety of responses to this issue. Everyone's insights are greatly appreciated.

[elkpark]

retiredmednurse said:

We had an elderly Chinese man who spoke no English. His family members were the translators. I'm not sure how it was found out, but the family only translated what they wanted him to know. They never told him how serious his medical condition was.

This is just one of the many reasons why it is considered unacceptable and inappropriate to use family members as interpreters in healthcare settings. Hospitals are required to have interpreter services, whether live interpreters or interpreter services like the telephonic service you mention, available for clients who need them. How long ago did this happen at your hospital?

[jodispamodi]

Personally yes I think this definitely met the criteria for an ethics council meeting. I guess the questions I would have would be was the patient alert/oriented enough to understand, was her condition relatively stable, was her health care proxy invoked? Personally I don't think its the nurses job to relay this type of news but MD's with either a social worker or grief counselor present. We had a similar case on my unit, and that patient knew right away hubby had passed but was provided much support and handled it well. I dont know what can be gained by witholding info, when the patient realizes people are redirecting her everytime she asks she's going to have a good idea her spouse didnt make it and then that might make her question what is being withheld about her own condition and negatively impact healing. Honesty is the best policy, and if her HCP has not been invoked the family really has no right to say dont tell her, but again that is the MD's job not the nurses. jmho

[jodispamodi]

No, never and could you in a lot of hot water with a BON if found out.

[Nalon1 RN/EMT-P, BSN, RN]

If it were me, when asked by the patient the status of her husband, I would simply say I don't know, but you can ask you family (and turn and glare back at them).

Family wishes are kept, patient has been told who can inform her of it.

I would call the hospital chaplain and case management/social services as well.

[nursesmatter]

Thanks for your feedback. Upon admit to my unit that night, she was dehydrated and slightly hypothermic, but otherwise stable. Aside from some minor cuts and scratches, she didn't complain of any pain. Completely alert and oriented x4. She was fortunate to have gone through the accident with no major physical injury. According to her family, prior to the accident she was an alert, fully independent woman in her late 80's, that used no assistive devices with just a history of hypertension. And by the end of my 2-night stretch caring for her, she was downgraded and was just receiving minimal PT/OT rehab.

[JKL33]

nursesmatter said:

Thanks for your feedback. Upon admit to my unit that night, she was dehydrated and slightly hypothermic, but otherwise stable. Aside from some minor cuts and scratches, she didn't complain of any pain. Completely alert and oriented x4. She was fortunate to have gone through the accident with no major physical injury. According to her family, prior to the accident she was an alert, fully independent woman in her late 80's, that used no assistive devices with just a history of hypertension. And by the end of my 2-night stretch caring for her, she was downgraded and was just receiving minimal PT/OT rehab.

Just so bothersome to think about.

I realize the family is under acute stress and grieving as well...but, geez, they at least have the opportunity to go through the initial most acute stages together. And they are doing it without her. Have they told other family/friends? Talked about possible plans for "final arrangements?" I'm just musing...but this is so wrong.

In a way it makes me wonder how close-knit the family is. Not that it matters, just a curiosity on my part.

[canoehead, BSN, RN]

I would sidestep for the first 12 hours, "I haven't seen him come through here" and encourage her to ask her family for more information. After that I would tell her that her family really wants to be the ones to talk to her about it, and let her ask them if they are present, or hand her the phone.

[Glycerine82, LPN]

Did she have a dementia dx? Depending on her cognitive status it could have been the right or the wrong call. If she is confused and asks for her husband all the time regardless of recent events, no, i would not have told her. If she clearly remembered the accident and was inquiring about him in that regard, she should have been told.

[missmollie, ADN, BSN, RN]

OP, you are questioning your decision. Talk it out with co-workers or your manager to fully understand if you had other options you didn't explore. It's not an easy issue, it is an ethical question, and if you are questioning it you have the chance to learn from it. Don't be afraid to say you made a mistake and to really contemplate what you could have done instead. The answers you are looking for will not come from this forum but from your facility.

I have no issues about the decision I made because I know it was the right one, based on what was happening with the patient at the time. My patient didn't know her name, but knew something was missing. I gave education to the family, called in the physician, and had a chaplain. You can't solve all issues. You are part of a larger group, and you can utilize that group to help or even to learn. That is okay. Ask these specific questions to your manager and see what they think would be better. I wish you the best of luck. Nursing is difficult, but as you encounter similar situations, your reaction and response will get better, and you will feel better about the care you give.