MORAL DILEMA

sn2bnp · Aug 4, 2011

Once the DNR is signed you , as the PATIENT, advocate are required to enforce the Patient's wishes....not yours.

It is a doctor who gives you the order and you must follow that order. Using oxygen when the patient becomes unresponsive is a violation of the order, and the patient's wishes. If morally you cannot comply you must ask your supervisor to remove you from that assignment.

leslie :-D · Aug 4, 2011

Using oxygen when the patient becomes unresponsive is a violation of the order, and the patient's wishes. If morally you cannot comply you must ask your supervisor to remove you from that assignment.

unless the pt outright states, "no o2", then oxgen is a comfort measure, and NOT life extending.

with or without o2, the pt's disease process has come to its end, and will die one way or the other.

i agree with you about removing yourself from assignment, if unable to do job.

leslie

~Mi Vida Loca~RN, ASN, RN · Aug 4, 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.

I don't see what you could have done. Most our COPD and end stage emphazemers (not sure if that is a word. LOL) are normally around 86-87 here with 02 so we aren't concerned with that. Where I am at too though 02 as long as above 90 is good since we are at such a high altitude.

You can't force a patient to comply with your beliefs. You are doing something morally wrong if you go against the patients wishes and you are also opening yourself to a huge lawsuit and job termination. That's why we have things like DNR's and living wills and so on.

Did the actual hospice people come and talk to the patients? I think there is a big misconception regarding hospice with not only lay people but even medical people. We see better results with people accepting hospice care when the hospice workers talk to the patients and or family.

~Mi Vida Loca~RN, ASN, RN · Aug 4, 2011

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.

This nurse needs further education. The patient isn't committed suicide. His body is failing him and he is allowing nature to take it's course. He isn't asking anyone to give him a lethal dose of morphine or smoother him with a pillow which could be considered "helping him commit suicide" I would be worry about this nurse and the care she is giving her patients that are not wanting these treatments if she is saying she would do it anyway. She needs to understand the situation and her role.

~Mi Vida Loca~RN, ASN, RN · Aug 4, 2011

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.

Really? Interesting.....we all recognize that the patient is dying and that death is inevitable so services are set in motion to ease the suffering of the dying process because they are dying to allow death with dignity....with a code at the end. I have not run into this at all......ever. Interesting.........really......Thanks!!!!!!!!!:):heartbeat

Yep, this is a misconception. We have had a few Hospice guest speakers and they all told us the same thing. Being admitted into hospice does not always equal DNR although that is usually the way it is.

TonyaM73, ASN, RN · Aug 5, 2011

unless the pt outright states, "no o2", then oxgen is a comfort measure, and NOT life extending.
with or without o2, the pt's disease process has come to its end, and will die one way or the other.
i agree with you about removing yourself from assignment, if unable to do job.
leslie

Absolutely correct! The problem with this case is he stated NO O2 at all. I asked from bipap all the way down to nasal canula (and everything in between) and finally asked him "can I put any oxygen on you at all?" and he stated NO. (well crap) :uhoh3: I told him a little O2 would help but not keep him alive, and he stated NO. (double crap) :eek: He was just over it. If I have comfort care only pts or hospice pts, if their oxygen is down a little, I will pop some on them just to keep them comfortable, but I am not about to go against someones express stated wishes.

This did turn out to be an interesting thread. Thanks to all that replied with encouragement and helpful advice. :nurse:

CrunchRN, ADN, RN · Aug 5, 2011

He was lucky to have you as his nurse and the other........

And it was a very interesting thread.

Penelope_Pitstop, BSN, RN · Aug 5, 2011

unless the pt outright states, "no o2", then oxgen is a comfort measure, and NOT life extending.
with or without o2, the pt's disease process has come to its end, and will die one way or the other.
i agree with you about removing yourself from assignment, if unable to do job.
leslie

THANK YOU, Leslie.

I was wondering if I was practicing nursing on some other planet.

For a simple DNR, we do nothing IN THE EVENT of respiratory or cardiac arrest. (We also have a 2nd tiered DNR that usually states no intubation, or not pressors, no dysrhythmia meds, etc, and a 3rd tier that is comfort care only but makes no mention of 02 because we usually utilized humidified O2 via mask during end of life care as a comfort measure.)

I have argued this point with other health care and medical professionals (prime example, "why would we sent a DNR to the ICU?" Ummm...cause we want to prevent a critically ill patient's death as best we can even if that patient doesn't want to be resusitated IN THE EVENT his or her heart stops or he or she stops breathing).

Sorry, off soapbox.

Anyway, Tonya, you did very well. I hope someone like you cares for my loved ones if they need a strong advocate!

Donna2011 · Aug 5, 2011

I am going to give you a different perspective. I think you did the RIGHT thing, by a family member's POV. I watched my mom slowly die from Small Cell Lung Cancer. Basically the same thing happend to her, that you described with your pt. Her lips, nose, ears, and nailbed were all blue, and after telling the nurses(who wouldn't listen), I finally told her RT, and she was on 2L o2, he ended up increasing it to 6L's on the nasal canula, and she ended up with a BPAP and a CPAP before the night was over, she was in soft restraints b/c she kept fighting. Long story short, I was with her in ICU for 5 weeks, with her on a vent the whole time, and then a treach(sp) until she died. I didn't have POA. If I had POA, I would have let her go instead of letting her suffer for 5 weeks, in a state I KNOW she never wanted to be in to begin with. Don't beat yourself up. You did the RIGHT thing.

TonyaM73, ASN, RN · Aug 5, 2011

Delana,

I whole heartedly agree. I had another patient come up recently that was slated for ICU, but since he was comatose and the family signed a DNR, he came to med/surg. HUH??? This pt came in with respiratory distress, ARF, and sepsis, just because a DNR was signed does not mean this pt belongs on med/surg. He came up with a bp of 76/40 and with orders for morphine and dilaudid for pain. I saw the doc almost right after I admitted him and asked him, what was with the morphine and dilaudid? No one is going to give this pt those drugs with a bp that low. He said that he wrote the order, it should be followed. I told him to put an order in to give the morphine no matter what the bp is, since he thinks the patient is going to die anyway. He ALMOST wrote that order, but then gave me a look and said "Well if he is in pain his bp is going to go up anyway." :0

Now don't get me wrong, this pt is end of life, but was not on a pallative bed assignment or on hospice since the family refused. What are they thinking sometimes????

TonyaM73, ASN, RN · Aug 5, 2011

Crunch,

Thanks so much. That really means a lot!! :)

Penelope_Pitstop, BSN, RN · Aug 7, 2011

Delana,
I whole heartedly agree. I had another patient come up recently that was slated for ICU, but since he was comatose and the family signed a DNR, he came to med/surg. HUH??? This pt came in with respiratory distress, ARF, and sepsis, just because a DNR was signed does not mean this pt belongs on med/surg. He came up with a bp of 76/40 and with orders for morphine and dilaudid for pain. I saw the doc almost right after I admitted him and asked him, what was with the morphine and dilaudid? No one is going to give this pt those drugs with a bp that low. He said that he wrote the order, it should be followed. I told him to put an order in to give the morphine no matter what the bp is, since he thinks the patient is going to die anyway. He ALMOST wrote that order, but then gave me a look and said "Well if he is in pain his bp is going to go up anyway." :0
Now don't get me wrong, this pt is end of life, but was not on a pallative bed assignment or on hospice since the family refused. What are they thinking sometimes????

That is awful for the poor patient!

I know we've had patients in dire straits who were REFUSED by the ICU even though the ER and/or internal med docs thought it would be warranted, just because of DNR status (or other stupidness).

I had a man MIing on me (positive troponins, symptomatic, EKG changes in ER) refused by the Cardiac ICU attending because "the last time that man was in the hospital he didn't want to be cathed...I'm not wasting a unit bed on him." Srsly? And suddenly a general med bed is the appropriate one? But I po'd enough doctors and nurses that he was sent immediately to vascular stepdown and cathed first thing in the AM.