MORAL DILEMA

Published

Specializes in MED/SURG STROKE UNIT, LTC SUPER., IMU.

So what if one day you go into work on your med/surg floor and have a pt that has sats of 87% on NC 4L. You check everything, place a mask, call the MD with no results, call respiratory, respiratory changes to a non rebreather (still with minimal results), call a rapid response, MD places bipap (with good results),.....then after everyone leaves, pt decides they don't want oxygen anymore because they are end stage emphazema? This pt refuses all O2 at this point and you explain that they will die today with out oxygen. The pt states they are aware. (pt is AO4) Pt then signs a DNR (yes, during all of this they were a full code:uhoh3:), but refuses hospice. MD, charge nurse, nurse and respiratory explain to pt that without any oxygen pt will die today. Pt states understanding to everyone. WHAT WOULD YOU DO?

I am having second thoughts about how I handled this after talking with a coworker, but still feel that what I did was right since I followed the patient's wishes. I documented everything and offered several times oxygen, morphine and ativan for this patient, but pt refused everything. Pt refered to hospice the day before, but the pt refused. What would you do? One of my coworkers stated that she would placed the oxygen on the pt when they went lethargic from low O2 because otherwise was helping the pt comit suicide.

This sounded like a good one to hash out on AN.

Up Vote Up Vote ×
Specializes in NeuroICU/SICU/MICU.

I actually wouldn't be that concerned about a COPDer satting in the high 80's..they need a lower O2/higher CO2 to keep their respiratory drive alive. That said, I'm sure they drew ABGs and did other assessments during the rapid response, so obviously something was going on.

If the patient is alert and oriented, and understands the consequences, he has the right to express his end-of-life wishes and refuse any medical treatment he wants. I would have allowed him to pass peacefully as per the wishes he expressed.

Up Vote Up Vote ×

Anyone over 18 and of sound mind can refuse any treatment that they want to, and if a patient signs documentation stating that he refuses oxygen after the consequences have been thoroughly explained to him by several different people, then that's the end of it. I'm having a hard time understanding what you could or should have done differently.

Up Vote Up Vote ×

#1 the Patient has rights and one of those rights is to refuse treatment at anytime. You educate the patient, and you make sure that all the care-givers involved are aware and they educate the patient. I have been in situations like this. You are a nurse, according to your information you have done your job as a nurse...

Up Vote Up Vote ×
Specializes in MED/SURG STROKE UNIT, LTC SUPER., IMU.

Thank you!! That was the way I felt as well. I was talking it over with another nurse yesterday when she happend to mention that she would not have helped a pt to commit suicide. It was a hard case and emotionally draining, but I felt that I educated him, had everyone else educate him and documented. After all of that was done, I followed his stated wishes till the end and made him as comfortable as possible. I just wanted to make sure that I was not in my own little world here. Thanks again for the responses.

Up Vote Up Vote ×
Specializes in NICU, Post-partum.

What is the moral issue?

The patient WAS NOT on a DNR at the time you got an order to help get their O2 sats back up.

THEN they signed a DNR.

THEN they refused additional treatment.

To me, that is a patient's right and respecting their right to choose.

I personally, would have zero issue with it.

You cannot force treatment on them.

Up Vote Up Vote ×
Specializes in NICU, Post-partum.
Thank you!! That was the way I felt as well. I was talking it over with another nurse yesterday when she happend to mention that she would not have helped a pt to commit suicide. It was a hard case and emotionally draining, but I felt that I educated him, had everyone else educate him and documented. After all of that was done, I followed his stated wishes till the end and made him as comfortable as possible. I just wanted to make sure that I was not in my own little world here. Thanks again for the responses.

I think you are confusing the right to refuse treatment with assisted suicide and I cannot believe that educated healthcare professionals are confusing the two.

You cannot LEGALLY not provide treatment without a physician's order or the patient verbally refusing. From your post, the patient didn't even verbally refuse oxygen for comfort and hospice until after they signed a DNR.

I also hope your staff is educated in the fact that a DNR can be REVERSED AT ANY TIME by the patient and they DO NOT have to sign anything in order to do so if a signature at the time is not reasonable...ie. the patient being unable to breathe and begging for help...you cannot stand there and say, "Well, you signed a DNR, sorry!".

Up Vote Up Vote ×
Specializes in Clinical Research, Outpt Women's Health.

To place oxygen on a patient with a legal DNR made while of sound mind who has specifically stated no oxygen would be assault. Legally, not phyiscally of course. Follow doctors orders and make sure all is documented. The patient has the right to deny treatment!

Up Vote Up Vote ×
Specializes in MED/SURG STROKE UNIT, LTC SUPER., IMU.
I think you are confusing the right to refuse treatment with assisted suicide and I cannot believe that educated healthcare professionals are confusing the two.

You cannot LEGALLY not provide treatment without a physician's order or the patient verbally refusing. From your post, the patient didn't even verbally refuse oxygen for comfort and hospice until after they signed a DNR.

I also hope your staff is educated in the fact that a DNR can be REVERSED AT ANY TIME by the patient and they DO NOT have to sign anything in order to do so if a signature at the time is not reasonable...ie. the patient being unable to breathe and begging for help...you cannot stand there and say, "Well, you signed a DNR, sorry!".

No, the pt refused the oxygen, then was educated that he will die, then was asked if he wanted CPR if/when his breathing were to stop. Pt stated he wanted no oxygen, no cpr, no ventilator, no treatment what so ever. Pt then signed a DNR form and then the MD signed since pt refused all treatment. Pt was repeatedly asked if he wanted oxygen or treatment the entire day. (pretty much anytime I went into the room, i asked if he needed anything or would like the oxygen put back on.) I kept the bipap machine in the room the entire time in case he changed his mind. Pt did not want any treatment and family was at bedside at that time and agreed with pt. Everyone involved continued to ask the patient if he would like anything, which included changing his mind. I would never stand there by my choice and watch a patient SUFFOCATE TO DEATH! (I can't believe you even wrote that!)

Up Vote Up Vote ×
Specializes in PICU, Sedation/Radiology, PACU.

You did the right thing. When the patient was a full code and was accepting treatment, you got him the medical attention that he needed. When he was a DNR and didn't want treatment, you respected that, educated him and tried to make him as comfortable as possible.

Your co-worker is wrong. In fact, if you had initiated medical interventions against the patient's wishes, you could be held liable and your license would potentially be in jeopardy.

Please refer your co-worker to the patient's Bill of Rights.

Up Vote Up Vote ×
Specializes in Acute Care Cardiac, Education, Prof Practice.

I don't see it as "committing suicide" personally. I see it as selecting end of life care and exercising patient rights. The patient had a natural death process occurring and decided, just like all DNR patients who refuse intubation/cardioversion etc to let that process run its course.

I wouldn't assume I was helping someone commit suicide if I didn't cardiovert them or intubate them against their wishes. I couldn't use the excuse "they were passed out and lethargic so I did it then".

You respected the patients wishes and, IMO, did the right thing.

Up Vote Up Vote ×

I think I may see part of the problem. It isn't the problem with the pt's refusal of tx...It's the doubt the OP had with the whole situation...and then the mentioned co-worker likening of respecting pt's wishes as "assisted" suicide just added a ton of guilt to that doubt.

Had the same thing happen to me recently. Cancer pt in extreme pain..was hospice, DNR, but the prescribed pain meds weren't even making a dent in this man's pain. I got an order from the MD and Hospice for MSO4 Q 2Hrs. One of my co-workers started refering to me as Dr Kervorkian, saying I was just speeding up this man's dying.

I was po'd and yes doubt crept into my mind but I decided the doubt wasn't in my own judgement...it was in my co-workers statements. I decided my co-workers statements (probly meant in jest) didnt equel my own judgement and any doubts I had disapeared as regardless of outcome or means..I advocated for my pt first and foremost.

Up Vote Up Vote ×
+ Join the Discussion