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Ethics

Posted
Florian Florian (New) New

A patient you meet on the ward has had A.I.D.S. for some time and is now seriously ill with pneumocystis carinii and other opportunistic infections. He frequently suffers respiratory failure, and has been resuscitated many times during each episode. During your contact with him, he begs you not to let anyone resuscitate him again, he "has had enough". A few days latter, while you are in his room, he suffers another episode of

respiratory failure. Do you call the resuscitation team?

Using utilitarian & deontological theories.....

Have you talked to this patient about signing off so that there is a DNR order? As long as there is not DNR order, yes I would call the team (no matter how I felt). At the next opportunity though, I would speak to the patient and have them sign for a DNR, after going through all of the aspects of what that entails and letting them know that all comfort measures would be taken.

hoolahan, ASN, RN

Specializes in Home Health.

Yes I call the team, unless there is a DNR/Advanced directives etc... If a pt ever starts a conversation like that, I start that ball rolling asap. You have to remind me what utilitarian and deontological theories would be though. :confused: I just finshed a 7p shift in the CT ICU.

Speaking of which, we all prayed that we would not end up with the emergency case. 86 yo highly functioning Prior to Admit, with same day massive inf wall MI and RV infarct, had retavase in ER, and arrested last night, went to the OR for CABG!!! For crying out loud, aren't we supposed to die at 86?? I pray my family never does that to me. Anyway, we know how that is, emotions were just so high, they can't see the big picture, but the surgeon certainly should have. If I had been the surgeon, I would have advised we monitor her overnight. Then she would have arrested again and died w/o her chest split open. As it is, she died on the table. A few weeks ago they had another train wreck who they brought out and said she'll probably only live 20 minutes. Two weeks later, the nurses demanded an ethics meeting to d/c life support on this poor corpse. I said, that woman probaly met this lady in the light and grabbed her hand and pulled her into the light and said, "You don't want to go back there, trust me." The other nurses on said, that would not surprise them in the least!

Now, I will admit, there have been times, the team has decided that "baywatch Barbie" compressions are best. You know, total bend at the elbows, all done for the sake of a show, or a 10 minute code, or push drugs real s-l-o-w. Bring the crash cart real s-l-o-w. etc... We used to call that a gray code, fell into the gray area.

I have also had docs who refused to make a pt a no code, and a family member watch their dad be repeatedly defib'd. I told the son, don't worry, I'll call you first if BP drops, then the doc, you and your family get up here asap. The BP fell, the son came up with several sisters and brothers, they formed a circle around the bed, holding hands and refused to let the docs touch their dad. That was the best "teamwork" I have ever participated in!

Anyone see that weird movie with Nick Cage as a paramedic who put the pt's ecg leads on his own chest while he disconnected the vent, until it was way to late for any code to bring the guy back? What was the name of that movie??

when i did my clinical in icu we had a 89 year old woman who kept coding. we were advised that the family wanted her to be alive for her 90th birthday in a few weeks. she was a full code. we were also told that her son was a lawyer so we had to give it our best shot and document everything.

the poor woman seized with every code. it was awful. she made it to her birthday tho. most likely in a vegatative state. they prob propped her up and put a party hat on her.

i think whats worse are the terminally ill cancer patients that the surgeons offer false hope to. i had a patient that had mets to the bones. it was all through him.

he had come to grips with the fact his life was over when the docs decided to try to remove one of the tumors on his spine. they never mentioned that this wasnt going to be a cure.

post op the man couldnt walk.

i watched him deteriorate and then just give up.

his last days were horrible. these docs ruined what time he had left.

did they really think they were doing good?

P_RN, ADN, RN

Specializes in ORTHOPAEDICS-CERTIFIED SINCE 89. Has 30 years experience.

This sounds very much like a Junior Project in Ethics 101.

Is this a true situation or is it hypothetical?

As long as the patient is alert and oriented, without aids psychosis, he/she will be the one to determine code status. Once the physician is made awary and changes the status then the ethics of the situation fall on him.

Deontological theories: ("deontology" literally means "the study of duty") Broadly: theories that are not consequentialist. Specifically: Theories that give a set of (non-consequentialist) moral rules that must be followed; a right action is then one that is in accordance with the rules. (Nozick, Kant, Ross) 2 forms of deontological theories:

Absolute deontological theories: Hold that the rules are inviolable and exceptionless.

Moderate deontological theories: Hold that the rules may sometimes be overridden.

Utilitarianism is hedonistic, consequentialist, altruism. Thus, utilitarians hold that one ought always to do whatever will produce the greatest total amount of pleasure in the world, weighing everyone's pleasure equally.

http://home.sprynet.com/~owl1/note100b.htm

P_RN, ADN, RN

Specializes in ORTHOPAEDICS-CERTIFIED SINCE 89. Has 30 years experience.

No more comments?

I'm surprised.

debbyed

Specializes in ER, Hospice, CCU, PCU.

One of my top priorities in cases like this is to get that DNR/DNI order from a doc ASAP. It is necessary to have that order to "cover your butt". Without it you are responsible to do what a "good and prudent" nurse would do. In this case without a DNR order a "good and prudent" nurse would call a code and begin resusitation.

There is however something you must also remember about a DNR/DNI order. It can be cancelled at any time by the patient. I have also found that once a patient becomes unresponsive and family members are present there can also be a problem. If family members want everything possible done, most times physicians will "code" the patient and than leave any further questions concerning the patients final wishes to the hospital ethics board.

Personally, I believe that people should be allowed to die in peace and dignity and (although very difficult) I was able to hold on to those beliefs as my grandparents and parents died. I have found through years of experience that my beliefs are in the minority. Daughters and Sons do not easily let go of their parents. Of course I also have my views on why this is so but that would be a whole different thread.

I just finished a 12 hour shift and I fear I ramble so I'll stop now.

hoolahan, ASN, RN

Specializes in Home Health.

P_RN, I have no more comments cause I am still trying to figure out that definition!! :eek: LOL!! Thanks for providing it, but I still have no idea how to apply that mumbo jumbo to the original question :rolleyes: :confused: :rolleyes: :confused: :D It hurts my brain to try!

P_RN, ADN, RN

Specializes in ORTHOPAEDICS-CERTIFIED SINCE 89. Has 30 years experience.

Hey Hoolahan don't blame me, I just cut and pasted.

(1) absolutely follow the rules no matter what.

(2) Whatever floats your boat.

I would explain to him that he needs a legal D.N.R. order, written by his Dr., to not have heroic measures done again. I would encourage him to talk with the Dr, leave a note for the Dr. and pass this along in report ,I work nights), so the next nurse can be sure to follow through. If, the next time I have the patient, this order isn't written, and the patient codes, I would call a code.

Legally, thats all that can be done.

The Nicholas Cage movie was "Bringing Out the Dead"

I have read so many stories about families who want "everything done" and don't understand what suffering that involves. I think it is because they are almost never around to see their loved one suffer. Their frame of reference are those ER shows where the patient lives or dies peacefully. If the family would share in the suffering they would think different. If they would see suffering they would think different. We in the medical profession all want to go peacefully and the same for our loved ones (except maybe for my ex. LOL sorry a little sick humor) because we see first hand that too many times technology only extends the inevitable. :cool:

A patient you meet on the ward has had A.I.D.S. for some time and is now seriously ill with pneumocystis carinii and other opportunistic infections. He frequently suffers respiratory failure, and has been resuscitated many times during each episode. During your contact with him, he begs you not to let anyone resuscitate him again, he "has had enough". A few days latter, while you are in his room, he suffers another episode of

respiratory failure. Do you call the resuscitation team?

Using utilitarian & deontological theories.....

so what's the answer by using utilitarian and deontoligical theories?

renerian, BSN, RN

Specializes in MS Home Health.

I would call it. Without the documentation to that effect it would be considered here say.

renerian

Tweety, BSN, RN

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac. Has 28 years experience.

I wouldn't have waited a few days. As soon as he told me not to resusitate him, I'd be on the phone with the MD. Any MD worth anything would immediately grant the patients wishes at that time. Be a patient advocate, don't let it go in one ear and out the other when he says he doesn't want to be resuciated, get him to fill out the papers and get the DNR order STAT.

This sounds very much like a Junior Project in Ethics 101.

Is this a true situation or is it hypothetical?

As long as the patient is alert and oriented, without aids psychosis, he/she will be the one to determine code status. Once the physician is made awary and changes the status then the ethics of the situation fall on him.

http://home.sprynet.com/~owl1/note100b.htm

P RN - this link is no longer valid, but once i further study the 'linguistics' of deontological theory, i'll respond accordingly. but if it is indeed guided by a moral duty, then it is up to the nurse/advocate to honor the patients' wishes through a legal channel.

I wouldn't have waited a few days. As soon as he told me not to resusitate him, I'd be on the phone with the MD. Any MD worth anything would immediately grant the patients wishes at that time. Be a patient advocate, don't let it go in one ear and out the other when he says he doesn't want to be resuciated, get him to fill out the papers and get the DNR order STAT.

I agree with the above.

Understanding this an old thread...however, the greatest evil would be the nurse who knew this and failed to institute the necessary measures to honor the wishes. If in fact the patient disclosed this wish to you and you failed to honor it i think that would fall along the lines of assault. If you mentioned it and it was ignored and you didn't pursue that either I think that is unethical. I would be interested in hearing how one would apply the utilitatairian theory to this.

Isn't it interesting that you can change your mind at any point about DNR and all it takes is your word. Your heart starts doing dangerous things and you get scared and say, "Wait a minute, I don't want to die yet, go for it". And we rescucitate you. But in the same scenario, if you want to die it takes an act of Congress to let you go . . . .

I'm definitely with Tweety here . . that first conversation needed to be acted upon. If not, you must act and rescucitate and if there is not a DNR order.

steph

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