Ethics!!!

Pediatric Critical Care Columnist · Nov 8, 2008

When a client has brain damage, and the husband/wife/parent decides they would like to take the client off feeding tubes/life support; how do you decide what right and wrong? When taking the plug out isn't that a type of murder? Isn't murder murder and wrong?

If a person with severe brain damage is unable to sustain life without the assistance of mechanical or artificial means (ventilator and artificial airway, infusions of medications that support blood pressure and heart rate, tube feedings and so on) they are essentially already dead and removing life support is not murder, it's allowing nature to take its course. This also applies to people who have lethal illnesses or genetic disorders. If the technology has not already been put into use and the patient dies because of their illness, that is not murder. If the technology has been put into use and the patient is not recovering and has no potential to recover, removing that technology is not murder. The person who removed the breathing tube or turned off the drugs, for example, did not kill the patient, the disease did. These sorts of issues arise in hospitals all over the world everyday.

Dealing with patients who are deeply suffering from some type of sickness, If there wish/will is to die who decides whether or not to help them die or not? (Has to do with Dr. K...hmmm can't remember spelling.)

Dr Kevorkian is the most visible proponent of assisted suicide in the world, but he isn't the only one. Assisted suicide means different things in different situations. In a person with Lou Gehrig's disease or amyotrophic lateral sclerosis, the act might include giving the person a huge overdose of sedative drugs that will effectively stop them from breathing by turning off the regulatory center in the brain that tells the body to breathe. For others it could mean setting up an intravenous infusion system with first a sedative and then potassium similar to that used in lethal injection executions, then passing the control device to the person wishing to die. The majority of health care professionals however are not willing to assist someone else to take their own life. The Hippocratic Oath includes the admonition, "First do no harm." Some countries such as the Netherlands, and states such as Oregon and Washington, have laws that allow for euthanasia, or the active ending of someone's life by a physician with or without their knowledge. The methods may include injecting the patient with enough potassium to stop their heart, or heavily sedating them and then giving them a paralytic drug to stop them from breathing. (That is completely different from withdrawing life support.) They rationalize the act by speaking of saving the person and the family from suffering, and for saving the health care system money. I and many people I know stuggle ethically with these two issues, especially when confronted by a teenager whose severe health problems have left them with no desire to continue living, but who lacks both the physical and the legal capacity to do anything about it.

If two patients one who is seventy five and one who is twenty needs a heart transplant ASAP who decides whether or not which person gets it?[

The organ procurement and sharing organizations are bound by law that outlines the ethical selection of recipients. The criteria used are based on need first and foremost, and there is a very clearly delineated scale and process for decision making. The primary criteria in choosing the potential pool of recipients include blood type, tissue type, body size (for lung and liver transplants) or heart size (for heart transplants) and status. Status is determined by how desperately the patient needs the organ. Obviously if choosing between a person who is at home and on a lot of drugs to support their health and wellbeing (Status 2 on some scales) and another person who is in intensive care on maximal life support (Status 4 on the same scale), the person in the ICU will be chosen. Other considerations relate to the type of organ being transplanted and how long it will remain viable once removed from the donor. If the 20 year old is in the same city and the 75 year old is in another city 3000 miles away, the risks of transporting the organ over that long distance will weigh on the choice, with the organ likely going to the 20 year old. The decision is never as simple as the age of the recipient.

When it comes to poor or less fortunate people who can you deny healthcare to?

Nobody should ever be denied health care on the basis of ability to pay. It should be a basic human right. In Canada, that's how it works. If you need a $1-million bone marrow transplant and you live in a one bedroom apartment on the poor side of town with 7 other people and are on welfare, you get the bone marrow transplant and are assisted in obtaining the necessary drugs and other treatments to follow in order to get the best result. How the insurance companies and managed care organizations in the US determine who is worthy of health care comes down to money. I personally feel that is wrong.

Does this help clarify things for you?

tripletrouble03 · Nov 8, 2008

Wow, thank you for all of that. Yes it clarified alot for me. I was just dealing with some problems of what was right and wrong based on certain ethics. So what do you do (job wise)?

I'm still in high school but i've committed to becoming a RN. I am even thinking of doing an internship this summer!!

thanks again.

Pediatric Critical Care Columnist · Nov 8, 2008

I work in a high acuity pediatric ICU. We care for children from birth to 17 years old who have critical illnesses of every description. Our hospital performs more than 500 cardiac surgeries every year, and our surgeons accept patients that other hospitals have turned away. These kids sometimes come to our unit pre-op unless they're newborns. Those babies go to NICU until they've had their surgeries then they come to us. Our hospital is the North American training and referral centre for the Berlin Heart, a device that takes over the work of the heart until a transplant can be done. We also care for kids who have had organ transplants (heart, liver, kidney, lung and multi-organ), children who have had brain surgeries, traumatic injuries, severe respiratory illnesses, congenital metabolic disorders and defects, overdoses, child abuse and a multitude of other things. We have a pediatric transport team that covers a huge portion of western Canada and one of the busiest pediatric extra-corporeal life support (ECLS or heart-lung bypass) teams in the country. Our annual admission rate is something like 1000+ separate patients (and climbing) and our lengths of stay vary from a single day to more than a year.

We've had 11 heart transplants this year so far, and 8 livers. We've implanted five Berlin Hearts. We've had about 30 ECLS runs. We have at least one child on dialysis all the time. It's a really busy unit.

We bump up against ethical dilemmas all the time. Should we continue to provide expensive high-tech care for several more days for a child who has met brain death criteria because the family isn't ready to say goodbye? Will they ever be ready to say goodbye? Should we perform a heart transplant on a child who had no kideny function? Should we ignore the wishes of a teenager who does not want a transplant and would prefer to die, but Mother wants the surgery? Should we continue to admit a child whose genetic disorder is lethal and will progress until the child dies, everytime the disease progresses and the child has a crisis? Should we send an air ambulance out to pick up and then admit a child for whom PICU can offer nothing more because Father is talking about calling his lawyer? These ae just some of the things that have cropped up in the last few weeks. The nurses feel powerless to influence any decision-making because the doctors ignore us. Moral distress... there's something for you to look up and add to your paper.

tripletrouble03 · Nov 9, 2008

Wow, you deff. know your stuff. Yes, that sounds very difficult to come upon. It seems an endless wheel or moral distress to me. Thanks for all the info you've given me. I've had alot of advice and I think i'm gonna stick in with school, and just allow myself to try and enjoy the years I have. I just don't want to grow up to fast, and its inedivitable...that everyone says its best to just take the course. Maybe my senior year I might focus on taking half college- half highscool.