Ethical ???

Specialties Neuro

Published

Okay I am a new grad on a Neuro ICU unit. I am not sure if I have endangered my liscense by taking this job.

Yesterday I had a patient who was TBI and his ICPs( >60) were out of control. The family wanted everything done for the patient and the doctor disagreed and told the family he would no longer treat the ICPs. So he wrote for us to d/c the drugs that were treating the ICPs and also told me not to treat the pt. BP which was 220/120. Now I am still on training but I asked my nurse at what point in time is this a ethic board issue and she didn't seem to have a problem with it. I understand the doctors point not wanting to treat the kid any longer but at what point and time is my license endangered. And the family really did want everything done.

Specializes in Med/Surg, Geri, Ortho, Telemetry, Psych.
Probably do stay longer because of the low stress and satisfaction. Most of their patients are happy and so are the families. :idea: Idea: if we went back to the OLD WAY of the patient just takes what we give them & the family has no say all would be well, right? JUST KIDDING!

Oh Neurogeek, you so silly. :biere:

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Specializes in Neuro, Critical Care.
As a long timer (and I mean L-O-N-G timer) in the neuro ICU, I also am a professional witness and case reviewer. First of all, ICP's in the 60's with treatment? This kid is going down. No matter what....however, did anyone sit down with the family & say to them, "he's going to die, no way we can cure him, this is it"? Sometimes docs aren't really good about that. Second, is there an ethics committee in your facility? Next time call them. They must be involved. Legally, the family can continue treatment until the patient is declared brain dead. Were they aware that the doc dc'd everything? They could sue if it was done without their consent. Now, was this kid alive or brain dead? If brain dead they can't sue because the time of legal death is the time declared brain dead. No matter what they say the vent goes off (unless you are harvesting) and the kids body goes bye-bye. I assume he was still (barely) alive. Always call ethics in these cases. CYA.

By the way wiht an ICP in the 60's what the heck was this kids CPP running?

I agree, ICPs in the 60's not much chance of survival there. In situations like this we always get an ethics consult. I had a similar case. 26 y/o aneurysm (sorry its been awhile so i cant remember where it was etc) his ICPs were in the 60's opening pressure. Then came down a bit but not much. He ended up in a barbs coma...the family wasnt ready to let go yet so we treated him, even with ICPs that high. He lived, but is a vegetable now. Sad, our docs treat as long as the family want it. Usually though whhen we sit down with the family, the nurse and the doc...and we tell them there is nothing else we can do they usually make the decision to w/d care. Sad stuff and its very hard.

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Specializes in Neuro, Critical Care.
If there is critical care internship in your neuro ICU then by all means go for it. If you're not fortunate to have an internship at your hospital then ICU is still ok as long as you have an extensive preceptorship. For a new grad with no internship this type of patient might be too challenging for the first few months. Again, it's all dependent on the training. I don't support that old theory that a nurse should work med-surg or tele for a year or so before transferring to ICU. See, those dept's are great but won't teach you a thing about being a critical care nurse. I've heard people argue about how it will teach you assessment skills, etc. Floor nurses don't assess pt's the same way ICU nurses do. I can take a green nurse to the bedside and teach her all the skills she could learn on med-surg in a couple of weeks (IV's, foleys, assessment, etc). It's the other stuff....the gut instinct, the critical thinking skills, that take time. And all the time in the world spent on tele or med-surg isn't going to grow that in a nurse. However, if there is no training program and not a good preceptorship (just the old sink-or-swim method) then I wouldn't consider it as a new grad.

Nicley put and i totally agree. that is the exact reason I went neuro ICU after graduation. Ive been pretty succ. thus far in the NICU. Yes, I was pretty green as you put it but it doesnt take long to learn how to put a foley in or start an IV and on an ICU unit you wi ll have more opp. to learn. Critical assessment skills, I agree, those can really only be cultivated in a critcal care area. I didnt think it was too hard starting in an ICU, but its all I know.

Sorry for the side note. :)

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OB? Gads, why would there be a fight to do that? ;) I guess it's a relatively nice environment, not the dog-eat-dog world we live in....:smiley_ab :smiley_ab

I totally agree about the OB thing---YUK!!!!!!!!

We have had our share of new grads in our ICU, and we never let them take care of the neuro patients. Our neurosurgeons would crap a twinkie if we ever did. Besides that I don't think any of them ever lasted more that 6 months IF they got off orientation before being asked to go elsewhere first.

We have a nice new grad program that keeps them in the tele areas to get used to the intermediate care type patients and the ones that excel in that program are oriented to ICU. If they do well with that, then they are allowed to interview for an ICU position.

We have a core group that usually takes the really acute neuros. I used to hate neuro and was the coordinator of a CV ICU, but I now enjoy them and love to teach newbies.:nurse:

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Hey, what are ICP and CPP?

Thanks.

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There's about 6 new grads in our Neuro ICU. I'm one of them. We get a 6 month preceptorship program. No one has left the program and every one of us is an excellent neuro nurse.

Now, to the opening poster's question. Did the physician team sit down with the family and explain that he was going to die shortly no matter what/or MAYBE live to be a vegetable? Usually, once this is explained, families agree to withdraw care in favor of organ donation or a more peaceful death in palliative care. If this was not explained, and family has the impression that you are stopping care despite their requests, then I think that there may be some definite legal concerns.

At our ICU we treat patients, even if they have horrible prognosis, if they family wants it. I'm not saying this is ethically right either, but legally speaking it's safer.

If I were in a situation where the family was feeling that we were stopping care that they were wanting, and there was no living will/advanced directives, I would bail out of the situation and refuse to participate. FOR LEGAL REASONS. Ethically speaking, I think it's wrong to torture a soon to be dead person. But I would focus all my ethical concerns towards making sure the family understands the situation, knows that it's not "us against them" and is able to make an informed decision.

Could you have organized a family meeting with the physicians and family to clarify the situation or was that already done?

I know this whole area is really tough, so you have nothing but my sympathy. You're right to be worried though, I think.

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Specializes in Leadership, Psych, HomeCare, Amb. Care.

Now, to the opening poster's question. Did the physician team sit down with the family and explain that he was going to die shortly no matter what/or MAYBE live to be a vegetable? Usually, once this is explained, families agree to withdraw care in favor of organ donation or a more peaceful death in palliative care. If this was not explained, and family has the impression that you are stopping care despite their requests, then I think that there may be some definite legal concerns.

At our ICU we treat patients, even if they have horrible prognosis, if they family wants it. I'm not saying this is ethically right either, but legally speaking it's safer.

Your job is to be the patient's advocate, whether that means providing more care, or less care.

Continuing a course of action only to protect the legal concerns of the hospital & staff is not ethical IMHO.

Being sure that the prognosis & course of action was discussed with the family AND DOCUMENTED by the physician is critical. Also document your conversations confirming treatment with the doctor, plus converations with your manager. Plus, you should have access to an ethics consultant to discuss this with.

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Specializes in ICU's,TELE,MED- SURG.

Ok, this is what I'd do and remember I have been in ICU 26 out of 28 years of Nursing so here goes...

#1 Nurse Manager and House Supervisor MUST know about an order such as this

#2 Risk Manager needs an Occurrence Report since this can bring litigation into the Unit with a copy of the Occurrence stapled to the report

#3 You only discuss this case with your Charge Nurse and do NOT fight with the Dr. or take sides with the family. You need the hospital to back you all the way. To side with the family pits you as a Professional up against the Dr. You have the Nurse Manager along with Administration to bang heads with the Doc and you back off from this with referring this above your head. Do NOT give any kind of advice, sympathy or education at this point. Why? You will be pushing a suit that can happen based on your opinions.

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Continuing a course of action only to protect the legal concerns of the hospital & staff is not ethical IMHO.

Yeah, I agree. Have you ever worked in an ICU? I said I do everything I can, within the role of a nurse, to lead the family towards informed decision making so that they end up making the best decision for the patient. I'm sorry but I seriously doubt that you have a solution that is both entirely ethical and entirely safe from litigation. And I also seriously doubt you'd want some renegade nurse deciding what your comatose family member would have wanted!!

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Hey, what are ICP and CPP?

Thanks.

ICP is intracranial pressure. CPP is cerebral perfusion pressure, or the pressure of blood flow to the brain. You derive CPP by subtracting your ICP from your Map, or MAP - ICP = CPP. Anything

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Specializes in Neuro ICU, Neuro/Trauma stepdown.

good explanation, neurogeek!

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Hey, what are ICP and CPP?

Thanks.

ICP is intracranial pressure. CPP is cerebral perfusion pressure, or the pressure of blood flow to the brain. You derive CPP by subtracting your ICP from your Map, or MAP - ICP = CPP. Anything

Thank you, thank you! MAP = mean arterial pressure? How'd'you get that? The systolic/diastolic difference?

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