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.
Given the patients respiratory status, it's unlikely he will maintain normal o2 sats. Was he symptomatic? If he is alert and oriented and understands completely (and it's documented) what can happen without adequate o2 and he signed a DNR there is nothing you can do. He is within his legal rights to self determination - meaning he can refuse any treatment, including hospice, 02. Just make sure you document everything obviously. As difficult as it may be, a competent adult has the right to make the decisions this man did even if the caregiver thinks differently. Part of nursing is or should be respecting a patients healthcare decisions even if they are not the decision we would make for ourselves. This is also more of an ethical dilemma than a moral one in my humble opinion..you did nothing wrong.
Your posted is not correct..I work hospice on a PRN basis and have had 2 family members who were on hospice..though both my family members were DNR's a patient does NOT have to be a DNR to be on hospice - it's the patient's choice to place a DNR or remove a DNR at anytime - if the patient is unable to make the decision then their Power of Attorney or Healthcare Surrogate makes the decision. If any hospice ever told me someone HAD to be a DNR or they would refuse service I wouldn't want to use them period.
Your "co-worker" sounds like she needs a little education. What a mean thing to say to you!! A sat of 87% for this particular patient is okay. (End-stage lung disease.) But to say "suicide?!?" That was horribly naive!
I just hate nurses who feel they can over-ride a patient's wishes for thier own agenda. They are walking timebombs for total insanity. We all know who they are, because we've all heard their comments and mutterings at work. Wish they'd all just leave nursing. You feel like you need to notify the world that they have an agenda - look out for that one over there... maybe we can tatoo something on thier foreheads so people can spot them.
Once a DNR was in place putting oxygen on while patient was lethargic or otherwise is battery.
It probably can be classified as malpractice, too. Once the patient has been educated, is over 18, and cognitively intact his or her wishes are it and the only thing a nurse should do. Nothing means nothing; period. The patient may revoke the DNR at any time. Whoever said they did not want to assist with suicide is not aware of the laws regarding DNRs, and assault and battery; this person needs a review. If someone knows of a link to a CEU course they should post it so it can be shared with this person and anyone else who wants a review.
OP, you did what was best for your patient, and what he wished . I have a hard time not asking a laboring mom if she wants any pain relief - even if her birth plan states "NO DRUGS!" in bold. I've also had moms with five/six page birth plans detailing no pit/no epi/etc decide that they would like some rest, and respite, from their pain (and dealt with an irate doula over the matter more than once as well).
You can set your mind at ease. From what you've posted, you followed his wishes :)
Specializes in Emergency, Case Management, Informatics.
I would never stand there by my choice and watch a patient SUFFOCATE TO DEATH! (I can't believe you even wrote that!)
The hard reality here is that if the patient does not want further treatment, has signed a DNR while mentally competent to do so, and does not express a desire to have the DNR voided while they are circling the drain... you have no choice but to watch your patient suffocate to death.
It is the patient's choice. It is not assisted suicide. It is the patient's desire to not suffer further. You're not pushing drugs into their system to kill them. You're allowing nature to take its course, and you're allowing a reasonably informed person to make a decision about their own life, not yours.
It may weigh heavy in your heart, but you cannot override your patient's DNR. If you do so, you'll find yourself in front of the Board of Nursing (and probably a judge in civil court, if not criminal court) very quickly.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Your posted is not correct..I work hospice on a PRN basis and have had 2 family members who were on hospice..though both my family members were DNR's a patient does NOT have to be a DNR to be on hospice - it's the patient's choice to place a DNR or remove a DNR at anytime - if the patient is unable to make the decision then their Power of Attorney or Healthcare Surrogate makes the decision. If any hospice ever told me someone HAD to be a DNR or they would refuse service I wouldn't want to use them period.
Leslie already corrected me.....it had not been my experience. I thanked leslie for for correction and education and it makes perfect sense. We are a very large country with many different hospitals and many different methods of treatment that vary from one place to another. The intolerance in the variances in practices and personal beliefs here is sometimes really ANNOYING!!! I have seen that much morphine give for comfort on a dying patient and especially on terminal weans for comfort ONLY, IS titrated, and NOT with the intention to use the med to end their life........euthanasia...jeeze... Where I live we have "Comfort Care" legal and binding so that EMT's EMTP's can also respect the DNR. DNR's hospice, and comfort care are all intertiwned in my state.
A DNR is NOT a do not treat. Some DNR's are specific to NO intubation, but everything else. Some DNR's are NO CPR and everything else. Some are NO defib and everything else. Some are "full" DNR's and while they don't want to be coded they still want treatment for pneumonia and their underlying diseases as long as they feel OK. I have known some really bad CHF patients that while they didn't want to be coded or intubated were not against IV drugs when in crisis. Attempts to make the patient comfortable are not unlawful nor are they assault and battery. Restraining a patient that doesn't want bi-pap that are perfectly alert IS however....assaultive and unlawful restraint.
The OP knew her patient, heard her patient, advocated for her patient, followed her patients wishes and gave hinm the necessary information so he could make the best decision for HIMSELF and die with dignity. She advocated for her patient, listened to her patient and I applaud her for being nurse enough to confront the difficult subject of death and dying and advocate for her patients right to make his own health care choices and right to die with dignity.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Once a DNR was in place putting oxygen on while patient was lethargic or otherwise is battery.
It probably can be classified as malpractice, too. Once the patient has been educated, is over 18, and cognitively intact his or her wishes are it and the only thing a nurse should do. Nothing means nothing; period. The patient may revoke the DNR at any time. Whoever said they did not want to assist with suicide is not aware of the laws regarding DNRs, and assault and battery; this person needs a review. If someone knows of a link to a CEU course they should post it so it can be shared with this person and anyone else who wants a review.
I think you may need some instruction also........here are some good resources. :)
Very interesting thread. As a fairly new nurse I'm always looking for learning opportunities and I learnt a whole lot from this one. I could be in OP situation one of these days...
Specializes in Leadership, Psych, HomeCare, Amb. Care.
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...
Actually, it may not be either. In ethics, intent counts for a lot.
Even though the Catholic Church is against assisted suicide or euthanasia, they do respect the need to alleviate suffering.
If the intent of giving the medication is to cause a person's death, that's unethical. However, if the goal of the medication is to decrease pain & suffering, even if the secondary effect may be death of the already dying DNR patient, it may be considered an ethical & permissable act. Of course, there needs to be a converation & education ahead of time, "I can give more more pain medication (up to prescribed limits), but it may decrease your respirations, even up to the point of respiratory arrest and death."
"Continuous IV: 0.8 to 10 mg/hour. Maintenance dose: 0.8 to 80 mg/hour. Rates up to 440 mg/hour have been used"
The patient may revoke the DNR at any time. Whoever said they did not want to assist with suicide 
is not aware of the laws regarding DNRs, and assault and battery; this person needs a review. If someone knows of a link to a CEU course they should post it so it can be shared with this person and anyone else who wants a review.
. I have a hard time not asking a laboring mom if she wants any pain relief - even if her birth plan states "NO DRUGS!" in bold. I've also had moms with five/six page birth plans detailing no pit/no epi/etc decide that they would like some rest, and respite, from their pain (and dealt with an irate doula over the matter more than once as well).
I have seen that much morphine give for comfort on a dying patient and especially on terminal weans for comfort ONLY, IS titrated, and NOT with the intention to use the med to end their life........euthanasia...jeeze...
Marshall1
1,037 Posts
Given the patients respiratory status, it's unlikely he will maintain normal o2 sats. Was he symptomatic? If he is alert and oriented and understands completely (and it's documented) what can happen without adequate o2 and he signed a DNR there is nothing you can do. He is within his legal rights to self determination - meaning he can refuse any treatment, including hospice, 02. Just make sure you document everything obviously. As difficult as it may be, a competent adult has the right to make the decisions this man did even if the caregiver thinks differently. Part of nursing is or should be respecting a patients healthcare decisions even if they are not the decision we would make for ourselves. This is also more of an ethical dilemma than a moral one in my humble opinion..you did nothing wrong.