Ethical Issues

offlabel · Sep 28, 2017

You're still pretty new and have to defer to your preceptor's judgment. If you can ease a patient's discomfort in the process of dying, you are obliged to do that. If in that attempt, the patient dies from your efforts, you can rest in good conscience that you've done no harm and have acted in the best interests of the patient.

That said, if a CNS depressant was given gratuitously and without warrant to a patient in whom it could be reasonably expected by a medical or nursing professional would not tolerate it and die, were that to be investigated local or state authorities, it could be a career ender at best.

Most hospitals should have an ethics board through the chaplaincy office or chaplain. Be careful here.

ShanHK · Sep 28, 2017

I understand what you mean. I trust my preceptor's judgment but I just can't fight the feeling of thinking it's my fault. The patient did try to pull his ETT out. As a new grad everything is so heightened- my senses, anxiety. I second-guess everything.

Another thing I need to get used to is the way these nurses handle death. I guess working in a unit where death occurs almost every day, you have to develop a healthy way to cope and deal for the long-term. So, I've just told myself that the things I hear some nurses say during a code or after a patient passing is their way of dealing.

Just want to know if this is the norm. As a new grad, I have nothing else to compare it to.

Cowboyardee · Sep 28, 2017

There have been many threads on this topic. The replies on these threads may give you an idea of how more experienced nurses feel about the issue. Here is a recent one:

https://allnurses.com/general-nursing-discussion/syringe-driver-terror-1115233.html

In your case, I don't know enough about the situation or the patient to tell you what was appropriate or inappropriate. I can tell you that 4 mg of morphine q15min is not a ridiculous or unnecessary amount for all patients - I've had people on PCA pumps with 10 mg or morphine q10min who were not on hospice. It depends on the patient and the situation.

Also, I feel that deaths in terminal or hospice patients are often mis-attributed to pain or sedative medications by less experienced health care personnel. In other words, just because opiates can kill and the patient received opiates doesn't mean that the patient died because of opiates. Did the patient still have an ET tube and mechanical ventilation at the time of his death? (your second post sounds that way). If so, it is unlikely the morphine played a substantial role in the patient passing, appropriately ordered or not.

MunoRN, RN · Sep 28, 2017

I am fresh out of nursing school and working in an ICU residency program.
The only experience I have in critical care is the 1 month that I had during my senior practicum. I fell in love with the unit and the things these nurses were doing. I felt like truly, this is what being a nurse is all about. I loved how autonomous the nurses were and how much the nurses made a difference in the treatment/outcome of the patients on the unit.
Anyways, one thing that has been concerning to me and something that has bothered/caught my attention since starting is how they treat DNR patients and patients who are on their death bed.
A 70+ year old male was prescribed morphine 4 mg. He had received a dose 1 hour prior and this was prescribed every 15 minutes PRN (which to me is a ridiculous and unnecessary amount). The patient did not look like he was in any discomfort but my preceptor said he looked uncomfortable and needed a dose. I administered the medicine and the patient passed within 40 minutes.
Basically, I feel like I killed the patient and I feel like my preceptor knew this would happen. The way she and other providers talked sounded like it was "about time he went". Has this happened to anyone?
I really don't know how to feel about this.

(Bolding mine), I'm not sure what you're basing the idea on that 4mg morphine at really any interval is by definition excessive, it well could be excessive for some patients, but there are definitely those for whom this is appropriate or even insufficient, particularly when transitioning from aggressive treatment to comfort measures only. Even in patients who are still full treatment require morphine or an equivalent amount of fentanyl in doses that are similar to that.

I'm confused about whether the patient was on comfort care or just DNR, you mentioned that he still had his ETT in, was he comfort care?

getoverit, BSN, RN, EMT-P · Sep 29, 2017

MunoRN asks a good questions, just DNR or comfort care? Huge difference. 4 mg MSO4 q15m isn't that much and with an order like that I'm assuming they were comfort care. Also still intubated at time of death? Was he trying to extubate himself as he died? Some details aren't real clear.

As far as dealing with death, it may sound callous but it comes with repeated exposure. The few times when I've felt like I was somehow responsible for a patient's death I've spoken with the physician to get their impression and opinion. I've always been glad for those conversations and they stay with you for the next time something similar happens. Believe me, I've had plenty of shifts where I thought I was going to go insane if I had to work another code. Some of the things we do or say during those events are ways of dealing with it, things we say to each other we'd never say in front of a family member (or certain MDs for that matter!!)

File these experiences away, lock them in the vault or however you call it because eventually you will be the preceptor and a new grad will be looking toward you the same way. The wisdom and experience you gain between now and then will be what shapes your response.

allnurses Guide · Oct 21, 2017

DNR and "comfort measures only" are 2 different things. CMO requires actively treating any agitation or discomfort, tachypnea etc and the order set calls for frequent (q15 min) assessment for those things. This is not "causing" the patient to die. They are dying, and you are treating their symptoms within that process. The only thing to feel is thankful that you were able to make the patient comfortable.

NewHam CRNA · Oct 21, 2017

All the above posters offered insightful comments. I'd just add that if a patient is actively dying, it is nice to have morphine you can give that frequently to keep the patient comfortable and prevent "air hunger" or cheyne-stokes breathing. Idk if we can stay that cheyne-stokes breathing is uncomfortable for the dying patient, as they are almost certainly unaware at this point, but it can be seriously upsetting to the family. There is an interesting ANA, AACN consensus statement that states that, in an actively dying patient on comfort measures, hastening a patient's demise by treating their symptoms is ethically justified.

If your patient was actively dying and on comfort measures only (CMO), but totally comfortable in appearance the morphine dosing is probably questionable. In this situation, grimacing, gasping or tachypnea, tachycardia, increase BP may be signs of discomfort in an actively dyingt, non-aware patient that would be reasonable to treat.

If your patient was DNR but not actively dying/on comfort measures, then that is a whole different can-o-worms.