Ethical Question and Concern

[oncnursern]

We have a patient on our oncology floor that was declared brain dead after being found in a pool for over 10 minutes. She had ETOH in her system well above the normal. She was in ICU for several weeks intub and family called in from out of state. Her family decided basically to let her die and with held all feedings. She was transferred to us several days ago on room air with no feeding tube with orders to start a drip if uncomfortable. Since that time she responds to you by shaking her head if we ask her certain questions. She can mover her left arm, opens her eyes tries to speak but no words come out and she gets frustrated. We made a comment to her about we wished she would not have went into the pool that night and she shaked her head yes. She is becoming septic with positive blood cultures now, hot and running at high temp. My question is it ethical to just let her die knowing that she is responding and not brain dead as we were told originally. We are all having a difficult time dealing with just letting her die. Any thoughts would be appreciated. Others on the floor indicated that they would not want to live if not total functioning. Thanks.

[TheCommuter, BSN, RN]

This is an immensely difficult situation to approach. This situation highlights the reasons why we should all have living wills as a way to express our wishes when we verbally are unable to do so.

[canoehead, BSN, RN]

If she was brain dead she would not breathe on her own so she is well past that. A living will would be helpful, but right now what about a competency exam.? If she is able to answer yes or no questions she may be able to help family with their decisions.

[JoeyDog]

Has her family been informed of her progression? I think that if she is obviously not brain dead and can respond to questions she should be treated for her sepsis and so forth. If she had originally had a stroke and had this level of response she would not just be left to die, living will or not. This is all b/c at one point she was said to be brain dead...hmmm. Things change, as we all know the human body can be amazingly resilient (sp?), and docs have been known to be wrong now and again. Moreover it is not up to others on the floor to determine if her quality of life would be their desired quality of life.

Sorry if I seem nieve (sp??) but this seems pretty silly and really gets under my skin. You must advocate for your patient and inform the family of their options. Good luck.

sorry for the poor spelling! :)

[MiaLyse, APRN]

It seems that the family made their decision based on the fact that she was brain dead. If the situation changes the family needs to be notified so they can make decisions based on the actual situation. I'm assuming the physician knows the progress this patient has made? If so, why isn't he/she calling the family?

[pkapple]

oncnurse

you don't say what state you are in, but most states do not ask a family what to do with a "brain dead" pt. Brain death occurs when the brain stem ceases to function(simple explanation).This pt was not brain dead.

sounds more like an anoxic injury occured with your lady, either from a stroke, etoh or most likely the "near" drowning.

The current situation certainly needs to be brought the attention of the family. They made a decision for her and her status has changed! Remember a DNR never means no care so she needs to be re-evaluated. If you have a risk manager please involve her/him. There may be more to this situation.

ps-why is she on the oncology floor? You guys are my favorite nurses for compassion and comfort!

[BabyRN2Be]

ps-why is she on the oncology floor? You guys are my favorite nurses for compassion and comfort!

I was going to ask this same question, and I definitely agree with the above statement. Oncology nurses are so wonderful. Can't say enough good things about them.

Question: have you all received the paperwork for yourselves to see if this person has been in fact declared brain dead? It sounds as if this family has just dumped her there. Maybe I'm wrong, but it seems as if they may have other motives (wanting her dead). The situation seems odd; as others have said, if she was transferred to your floor on room air, how is she brain dead? Are you able to contact other people other than the family who knows about this case?

I agree with everyone else in that she needs to be re-evaluated, and a living will would have helped in this situation. Who knows, maybe she will recover to a point in which she'd have some semblance of a life. Stranger things have happened.

Best of luck to you all in helping this lady.

[gr8rnpjt, RN]

Is the family aware of her current level of fuction? Do they converse with her like the nurses do? and does your facility have an ethics committee? If so you should contact them asap!

[LoriAlabamaRN]

Definitely contact the ethics committee, and also the physician for a reevaluation.

[oncnursern]

This was not my patient to begin with but I could not stand by and watch this person die, I knew what was happening with this patient due to covering for each other during breaks, lunch, etc so I contacted our pallative care coordinator today that is on the ethics committee along with the nurse that took care of the patient. She would be looking into the matter today and bringing it to the ethics committe ASAP and contacting the family about the patients condition. We are a med/surg oncology floor that takes patients on overflow from other floors based on availability of beds. This pt was a transfer from ICU after being taken off the vent. She was placed on a supportive care pathway and DNR status. In the notes the family was here for several days then went back home. A note was left in the chart to contact the brother after the pt expired with a card from a funeral home attached to the chart. She has no family locally or real friends that has seen here while on our floor. One doctor note was that pt was smiling, and comfortable but the doctor was following the wishes of the family. Basically to become septic and die which is what is happing at this very moment. One social workers note in ICU said that the family reported that the patient would not want to be a burden on people and this is what she would have wanted. What gets me is that nurses in ICU keeps telling us that she is brain dead, I don't know if they understand the meaning of the word. She may have some brain damage but she is not brain dead. I don't know if the family trully understood the patients condition when they expressed their wishes for the patients demise or that they just didn't want to be bothered with a family member that would require care to be possibly given on their part. I will keep you informed of the situation after tommorrow when I go back to work. Hopefully we will have a better outcome.

[KellieNurse06]

Wow very sad story!!! Just a question though..how can this person be "brain dead" if she is on room air and shows some response?????? If someone is brain dead they wouldn't show any sign of responding to anything, and they are on a vent & as soon as they are taken off they stop breathing...... wouldn't be any response to anything pretty much.... I cannot believe ICU nurses actually are saying she is brain dead.....,maybe they're brain dead!!! I bet you must feel awful, this would be eating away at me for sure.....the doctor who declared her brain dead might want to review brain death., and what's up with that ..him not letting the family know she is changed in her status???????? .......this is scary!!! I would just ask her ...and see if she can maybe even try to write or communicate with another person present to witness this...because they may try to say it just what you want to see..........but if you don't do anything to advocate for this woman then I don't know what to say......you may wantr to get going right away on trying to save this lady............imagine if it were you in her position ..aware of everything going on & being declared brain dead........imagine how scared she must be..............the minute I saw any type of response from her..I would of been right on top of trying to help her..............I hope you & the other staff that are frustrated will do something....................just think of yourself in her spot......good luck..I would be very interested to know what happens.............and sad for the family IF they really do care because they are already going through the greiving process IF they do care and then to have thr rug pulled out from under them so to speak...geez talk about a roller coaster of emotions.............I'd be having a chat with the CEO of the hospital if it were my family member & no one was communicating any changes in their condition to me if they have obviously changed to better conditions................yes get going on this one...sepsis can kill quickly as you are probably more than well aware of already.................gosh this is going to be bugging me & I don't even know this patient

[Antikigirl, ASN, RN]

I think the pts MD should be talking with the family about the progression! I also feel the MD should ask the pt how they feel if they are able to respond, even if it is a hand grasp or what not!

I had a pt who was dying and wished to go, but there was a sudden and treatable complication that arose and a quick decision had to be made! She was non verbal and in and out of consciousness...however I was able to show, in front of the MD and two other nurses (I wanted witnesses big time!) that she wished to be let go.

What I did was ask a series of questions, and tested her on her ablity to squeeze my hands. Left meant no, right yes. We tested this out several times till we all felt comfortable that she was responding correctly. Then we asked the question about treatment or nothing...she squeezed my left HARD...then we asked a few other questions...came back to that one..same responce. She was allowed to die in comfort.

Maybe that can help you...finding a way to communicate, prove that you can to others, and ask the pt if that is possible.

Good luck!