MORAL DILEMA

CrunchRN, ADN, RN · Aug 3, 2011

It is really depressing that in this day and age health care professionals continue to deny patients the right to make informed decisions for themselves and that some would even deny adequate pain control based on their own belief systems.

They do NOT have the right.

TonyaM73, ASN, RN · Aug 3, 2011

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.

EXACTLY RIGHT!! Like I said it was a very emotionally draining day, but I felt that I did the right thing by the pt. It's just when this co-worker mentioned the suicide thing, it made me question my decision. It was extremely hard to watch this patient and know that I could do nothing for them because he didn't want anything done. Very impotent feeling! :idea:

CBsMommy · Aug 3, 2011

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.

I 100% agree with this. This patient was not committing suicide. It was a natural, end-of-life process.

You advocated for your patient by following their wishes.

Put yourself in the patient's shoes for a moment. You have a chronic disease process. You are sick and suffering. You ask the RN and MD in charge of your care to consider your request to stop treatment. The MD has you sign all of the necessary forms. You call your family in and let them know of your decision. You are in the process of grieving with them and completing "unfinished business". A couple of hours later, your RN walks into the room and AGAINST YOUR WILL, puts your oxygen back on because she thinks she knows better than you or the MD. How would you feel if you were the patient? How would you feel if you were the family?

BabyLady, BSN, RN · Aug 3, 2011

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!)

Well, that isn't the series of events you mentioned in your original post (please go back and read).

Also, considering you agreed with a co-worker regarding confusing assisted suicide with a patient's legal right to refuse treatment...it was a logical conclusion in my mind that you might be equally confused on how a DNR can be revoked.

So yup, I wrote that because it was warranted.

elthia · Aug 3, 2011

The patient had been informed about his diagnosis and prognosis, he knew what his treatment plan was, and made an informed decision to choose otherwise. That is not committing suicide, that is deciding to basically to not take any medical interventions at all and to let his disease processes take their course. To place oxygen on him against his wishes if and when he should become unconscious would be violating his right for considerate and respectful care. It would also be violating his advance directive.

However, should he at any point decide to rescind his DNR, then by all means do everything you can to provide medical and nursing interventions, such as oxygen, BIPAP, medicines, etc.

It may be that the pt is not ready to consider hospice because he does not fully understand the concept of hospice, but he feels that oxygen therapy and BIPAP/CPAP is futile with his endstage lung disease. Explore the idea of hospice as a lifestyle, way of living with endstage illness, not just a way to die, and he may be more receptive.

wee_oneRN · Aug 3, 2011

EXACTLY RIGHT!! Like I said it was a very emotionally draining day, but I felt that I did the right thing by the pt. It's just when this co-worker mentioned the suicide thing, it made me question my decision. It was extremely hard to watch this patient and know that I could do nothing for them because he didn't want anything done. Very impotent feeling!

You did not do "nothing" for your pt. You were there for them and supported their right to choose quality of life over quantity. Your coworkers is seriously confused. Refusing medication (o2 is a med) is not suicide, its a legal and ethical right. Who are we to decide what is best for someone else's life? We are there to make sure they understand the consequences of their actions. It is always difficult to see someone die, or to start their journey. It is emotionally draining, but know that you have made the right decision to advocate for them in life and in death.

massrn116 · Aug 3, 2011

i am an "old" nurse. it use to be that dnr/dni did mean do not treat. in this day and age, even when a patient is alert and oriented, able to make their own decisions, have made their decisions known in the past, several practioners and family members will try to insert their opinion and their beliefs when the end of life is coming. they totally bypass the expressed wishes of the patient and in my opinion, "when the co2 rises" will then assault the patient with an oxygen mask/bipap/ventilator. a physcian can always find one weak family member that cannot let go because they are put in the position to decide life and death of a much loved family member. instead of encouraging the family that the patient has already decided and the right thing to do would be to provide comfort, the family member is talked into treatment, "just for 24-48" because we can treat the pneumonia, we can treat the uti, we can treat whatever one organ is in trouble at the time but we are not looking at the patient as a whole. so you know what, we do treat, we are good at what we do. the patient gets discharged to the nursing home and we will see them in a couple of weeks, again starting the assault until someone steps up and says no, we need to honor the patients wishes.

TonyaM73, ASN, RN · Aug 3, 2011

Well, that isn't the series of events you mentioned in your original post (please go back and read).
Also, considering you agreed with a co-worker regarding confusing assisted suicide with a patient's legal right to refuse treatment...it was a logical conclusion in my mind that you might be equally confused on how a DNR can be revoked.
So yup, I wrote that because it was warranted.

),.....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.

BabyLady: Actually, I did re-read my post after you posted your 1st one and it is stated just as I intended. Pt refused O2, pt educated about the ramifications and consequences of such a decision, then pt signed DNR order. I did not agree with my co-worker, as I stated that I still felt that I did the right thing. My co-workers statements made me reevaluate my position to make sure that I did the right thing. I was just looking for some input as to what other nurses have done and confirmation that I was following the pt bill of rights.

CloudySky · Aug 3, 2011

You did the right thing OP.

NeoPediRN · Aug 3, 2011

In regards to pain medication and end of life - we withdrew life support on my dad two years ago. He did not die of hypoxia, he died because his nurse gave him 55mg of morphine in an hour. I am sooo grateful she did because he was air hungry and it would have taken hours for him to pass had she not kept coming in the room and saying "he looks a bit uncomfortable, how about a little more morphine?" I knew what she was doing and she knew what she was doing. I wouldn't have wanted him to go any other way!

TonyaM73, ASN, RN · Aug 3, 2011

In regards to pain medication and end of life - we withdrew life support on my dad two years ago. He did not die of hypoxia, he died because his nurse gave him 55mg of morphine in an hour. I am sooo grateful she did because he was air hungry and it would have taken hours for him to pass had she not kept coming in the room and saying "he looks a bit uncomfortable, how about a little more morphine?" I knew what she was doing and she knew what she was doing. I wouldn't have wanted him to go any other way!

If I was in that position, I would want that for me and my loved ones as well. Pt refused all morphine, ativan and haldol when he was concious. I don't know what he was punishing himself for, but it was hard to watch. I kept asking, of course, but he wanted nothing. I asked him if he wanted anything in particular, food, comfort, anything and he kept saying no. He was funny though, when I came in one time when his family finally got there and he was still concious. He looked at me and said "here is the dragon lady" and then laughed. Apparently he said that because I kept hovering over him until the family got there and asked him one too many times if he needed anything and if he changed his mind about the oxygen. I guess I would rather that than if he had signed the DNR and I just left him alone. I just didn't want him to die alone or die if he had changed his mind and noone asked him if he wanted anything.

classicaldreams · Aug 3, 2011

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.

Dear TonyaM73,

Just coming from a RRT perspective, do you know the results of the blood gas and his/her history well? Was it the patient's attending that signed the DNR and how thorough were they in their assessment of the situation? I always ask questions of the attending to rule out any patient confusion or if there is a sudden change in mental status. (Attendings should know their patients!) Quality care by attendings varies tremendously, and if not already done, I'll talk with the family, as they often know the conversations around DNR/prognosis. (Always scary if the patient doesn't know their attending in the hospital or if the family is clueless.) Cover your bases if yesterday the patient didn't want hospice/DNR and today they are refusing care. There is a reason. Patient's can have cerebral events, poor ABGs, pneumonia, etc. Doesn't take much to send a COPDer over the edge.

If there is any question as to the patient's decision-making capacity to sign a DNR, I would repeatedly ask to tube them, and then deal with the prognosis in the ICU. That is part of our job, and don't let any burnt-out critical care nurse tell you otherwise. The patient is sedated and made comfortable and then it is up to the ICU team/attending and the CCRN to help the family on deciding future care (extubation without re-intubation) or trach and peg with long-term sub-acute care. Many families, after seeing their loved one tubed without successful weaning, accept a poor prognosis and will go forward on more humane care.

I understand you are on a Meg/Surg floor, and you may not have the opportunity to know your patients as well as we do in the ICU (my RRT experience). I'm just suggesting, and hopefully it is helpful, to use your critical care nurse's experience--as we see this all the time! CCRNs can be a valuable resource as they know how to thoroughly cut through this kind of situation and see the outcomes. Perhaps having the confidence that you used a team approach (you, your charge nurse, the RRT, the patient and the patient's family) will help in the future.

Classicaldreams