MORAL DILEMA

[TonyaM73]

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.

[sissiesmama, ASN, RN]

#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...

:yeah:

Anne, RNC

[classicaldreams]

55 mg MSO4 in an hour? I've had families ask me to do this kind of thing and I refused. I don't let the patient suffer, but this is malpractice and unethical. Can you imagine if the media and SBON hears about this? What was this nurse thinking?

Classicaldreams

[Esme12, ASN, BSN, RN]

You can be a DNR and not be on hospice.....but you can't be on hospice and NOT be a DNR. Anyone has the right to refuse treatment if clinically competent. If I thought I might tube this patient with end stage COPD I would definately have "The Talk" with the pateint and make sure they realized what the options were or were not available. I would NOT intubate now and ask questions later to discuss peg tube and traches......people are entitled to dignity when the die and they deserve to die on their own terms whenever possible.

I think you were right on target and we very tuned in to your patients needs...well done.

[sharkdiver]

You did the right thing OP.

I agree completely.

An important part of a nurse's job is to advocate for their patient and respect their wishes - you did exactly that, while continuing to provide care and support. You did good - nothing to beat yourself up over....

As other posters have stated, any patient with capacity has the absolute right and the final say in what course of treatment they will accept. This includes the right to refuse any or all treatment, even if the result of refusal may be life threatening to the patient. This is well supported by legal precedent. Further, the patient's refusal to accept potentially life saving treatment may not be used to question their capacity to make that decision - also supported by legal precedent.

Other posters have been fairly gentle regarding your coworker's comments - I'm going to be a little more blunt. Your coworker clearly has no understanding of medical ethics or a patient's rights when it comes to decisions about what care they will accept. They also clearly have no understanding of the difference between suicide and a natural death process. Health care personnel have absolutely no right to interject their own personal beliefs into the equation. If they can't respect the patient's right to make their own decisions, regardless of whether or not they personally agree with them, then, IMHO, they have no business caring for patients in these situations. I personally would not want someone with that attitude caring for me or my loved ones.

[leslie :-D]

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!

in case i'm misreading you, i'd like to emphasize that the nurse gave the mso4, to ease his suffering...

and not to purposely hasten his death.

that said, i'm very relieved your dad died peacefully...

as it should be.

leslie

[leslie :-D]

55 mg MSO4 in an hour? I've had families ask me to do this kind of thing and I refused. I don't let the patient suffer, but this is malpractice and unethical. Can you imagine if the media and SBON hears about this? What was this nurse thinking?

Classicaldreams

actually, 55mg/hr is not unreasonable.

but administering said amt, with intention of 'getting it over with', is highly unreasonable, and is cause to lose her license.

leslie

[leslie :-D]

You can be a DNR and not be on hospice.....but you can't be on hospice and NOT be a DNR.

while there are some hospices that require their pts to be dnr, there are also many others that do not require this.

just an fyi.:)

leslie

[TonyaM73, ASN, RN]

Thank you guys. I wasn't beating myself up, but I was having some introspective thoughts that needed to be clarified by more experienced nurses. I really like and normally respect this co-worker and was a little thrown by her attitude, which is why I posted. Just wanted to make sure I was not in lala land with my thought process. Thank you again to everyone who read the post and provided thought provoking insite.

[TonyaM73, ASN, RN]

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

Thank you for this prospective. This particular patient was offered hospice the day before and told that untimatley he would need to go to a vent and fairly quickly (he was end stage lung disease). Pt refused intibation, but had not either been offered DNR or not made the decision by the time I recieved him. ABGs looked terrible, but pt still AO 4 at the time of deciding on DNR. There was no question about the pt's ability to make decisions since MD, Pulmonary MD, rapid response MD, charge nurse, respritory, and floor RN examined the pt and concluded that pt was AO4. Pt had suboptimal family support, but when the family was made aware of the situation they did come down and support pt's decision to choose not to prolong life even if that meant the comfort of some oxygen. Like I said this was a tough case and with having 5 other patients + a stroke admit at the same time, needless to say it was a rough day.

I felt comfortable with all that was done until my co-worker said something yesterday and so I wanted to hash it out, because you know this may (most likely) come about again sometime in my career. Most of the patients that I get are already hospice or DNR, I have never had to place someone as DNR myself or rush the process because the patient has refused such a lifesaving drug as oxygen and I knew that the decisions needed to be made now with the appropriate paperwork while the pt was still concious and able to make these decisions. I could have left it all in the air and then when he coded left it up to the MDs, but I wanted to do what the patient wanted for his life, not what I would have chosen or what was easier.

[hiddencatRN, BSN, RN]

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.

It actually sounds like it's the coworker who is confusing the two, and the OP is just looking for reassurance that she did the right thing.

[classicaldreams]

Leslie,

I agree, 55 mg in an hour is not unreasonable for a hospice patient or perhaps those who are opiate naive, but on what this poster wrote, this sounds like malpractice. Was this nurse repeatedly bolusing him over the course of an hour?" So if the nurse came in every 20 minutes (not unreasonable), that's almost 20 mg every 20 minutes. Like I wrote, I've had families request that I just give more morphine and get it over with. Unethical. Patient should be comfortable, but watching the dying process can be uncomfortable. The family has to use us and others to lean on for comfort.

Sorry, this post really bothered me. Talk about a way to undermine our clinical judgment. That's all I need for families, mgt., doctors, and JACHO breathing down my neck on stuff like this.

Classicaldreams

"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."

[hiddencatRN, BSN, RN]

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.

In the OP she says she offered the patient O2 and pain/anxiety meds several times.

"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."

I think you're making some logical leaps here in interpreting the OP's words. Feeling doubt based on the coworker's words isn't the same as agreeing with them.