Moral Distress

:typing

I can't say that the moral distress I have experienced has ever been over what myself or any other nurses have done since we are always following Doctors' orders. We cannot increase a morphine drip without a Dr's order. (Personally, I would very willing do that when someone is dying, to ease pain and suffering.) Where my moral distress occurs is where I see Doctors not be aggressive with a certain patients for reasons I don't understand. I wonder if it comes down to their ability to pay, and I highly suspect that it often does.

i am writing a paper on the topic of moral distress and would like some feedback from r.n.'s. please base your response on this question: have you ever been put in a position morally in your career where you questioned the actions of yourself or other nurses? one example would be increasing a morphine drip on a dying patient to satisfy a family. what did you do about it? any info will do! thanks!!

long, long ago and far, far away, i was working next to a nurse who was withdrawing care on her patient. that particular institution had a very definite withdrawal of care policy, requiring three physician signatures before care could be withdrawn and a note from the attending documenting that further care was futile, that withdrawal of care had been discussed with the family and that everyone was in agreement. all of those "i"s had been dotted and "t's" had been crossed.

the patient was started on a morphine drip per protocol, the pressors were d/c'd and the ventilator removed. but the patient didn't die. the family, who was all about being at the bedside for the moment of death began to complain that "this is taking too long," and "we've been here all day. can't you get this over with so we can go home?" the nurse in the room, whom i'll call cokie came to me and asked what should she do.

you can't euthanize your patient, but when i went to talk to the family, that's what they wanted. i told cokie "i'm very sorry about the family, but you've done all you can do."

later, i found out that cokie had been turning up the morphine drip to try to hurry things along. she wanted me to agree with her that it was the right thing to do, but i told her "i wouldn't do that."

"why not?" she wanted to know. "the family has been here all day, and they're tired."

there are so many reasons not to try to "hurry things along." i'm comfortable withdrawing care if the protocol is followed and everyone is in agreement. but there's a big difference between withdrawing care and actively euthanizing a patient. i know a lot of folks are kevorkian fans -- i'm not. maybe it's because i'm catholic, but it just seems wrong. if the patient wishes to choose to die at a time and place that seems appropriate to them, that's between them and their god. i don't want to be involved. i don't want that sin on my soul, and i think it's wrong to ask someone else to take that on for you. and even if there were a protocol/procedure for euthanizing a patient, i'd have a real problem with that.

cokie's patient died at 0300, and the family was long gone. but i think sometimes patients choose whether or not they want their family with them when they die, and they expire when they're ready!

ruby, that was active euthanasia.

and it's very cut and dry, on where to draw the line.

that line was crossed.

i just can't imagine actively killing someone, to accomodate a family's request.

and i've been working w/the dying for 12 yrs.

i've heard it all.

when our palliative care pts become hospice, we dc all txs too...

but to intentionally cause death?

what the heck was she thinking?

leslie

I don't know if this can be considered moral distress or not...but I had this gentleman who was dying of what started as lung cancer and had metastisized to his brain bones etc. The man was in so much pain. He would just look at me and say please just give me enough morphine to put me to sleep forever. This would break my heart. I would explain to him I could only give him so much morphine. His wife however would not let me medicate him. She "wasnt ready to let him go yet". I would spend a lot of time explaining to her his obvious pain and how we needed to keep him comfortable. She still refused. I would medicate him when she left the room to smoke or whatever. What I didnt realize was she was waiting for his youngest son to get to the hospital from another state. Once the son got there and saw his dad in such distress he wanted to know why I was "letting him suffer" I looked at his wife and she held my hand and said "its time"....I kept him as comfortable as possible for the rest of my shift. Encouraged her to lay in bed with him. He died one hour after my shift ended. But peacefully and as comfortable as possible.

I was torn. My heart told me I needed to take care of my pts needs, my charge nurse and supervisor reminded me the family was important too. Im glad the wife finally came around and let us keep him comfortable for his last few hours.

ruby, that was active euthanasia.

and it's very cut and dry, on where to draw the line.

that line was crossed.

leslie

she thought she was accomodating the family. believe me, as soon as i found out what she was doing, i put a stop to it! i got into trouble the next day, though, when the nurse manager told me that i was "sticking my nose in where it doesn't belong."

i said, "she asked me. i answered."

she thought she was accomodating the family. believe me, as soon as i found out what she was doing, i put a stop to it! i got into trouble the next day, though, when the nurse manager told me that i was "sticking my nose in where it doesn't belong."

i said, "she asked me. i answered."

hmmmph.

i hear ya.

awful lot of covering up and looking the other way.

this is where 'moral distress' comes in.

it eats through your stomach.

leslie

I would feel horribly guilty if I were one of the family members that wanted someone to die when it was convienent for me. I know that was hard on you to hear that this nurse was willing to accomodate them!

I don't think that was active euthenasia...there is such a fine line with death and dying. I had a patient who had a remarkable family. One of the daughters was an ICU nurse, once the decision to make him comfort measures only, I began the MSO4 gtt, per protocol. I titrated up a couple of times, and the man seemed comfortable. Now the daughter nurse, began coming out every hour and requested Ativan, and an increase in the morphine. This gentleman only moaned when moved etc. so that is what I did, I adjusted him, turned etc. Documented Flacc, and accomodated the family. He died by 4pm during my shift. Now if that was euthenasia...sue me. I accomodated, a loving family, and eased the suffering of a TERMINAL patient. That is part of my job. I tend to believe that once we are at the end of life, my job as a nurse now needs to really encompass the family. Now they never were so cold as to ask"how long will this take". That would p*** me off. The daughters just didn't want their father to suffer, and they didn't want their elderly mother to have to witness a long drawn out death. I do not feel that I did anything wrong. The family thanked me profusely, and I felt that I did the right thing for the patient and the family as a whole. I hope that when I am faced with a situation like this with my family that someone will be there to accomodate me and my loved one.

I don't think that was active euthenasia...there is such a fine line with death and dying. I had a patient who had a remarkable family. One of the daughters was an ICU nurse, once the decision to make him comfort measures only, I began the MSO4 gtt, per protocol. I titrated up a couple of times, and the man seemed comfortable. Now the daughter nurse, began coming out every hour and requested Ativan, and an increase in the morphine. This gentleman only moaned when moved etc. so that is what I did, I adjusted him, turned etc. Documented Flacc, and accomodated the family. He died by 4pm during my shift. Now if that was euthenasia...sue me. I accomodated, a loving family, and eased the suffering of a TERMINAL patient. That is part of my job. I tend to believe that once we are at the end of life, my job as a nurse now needs to really encompass the family. Now they never were so cold as to ask"how long will this take". That would p*** me off. The daughters just didn't want their father to suffer, and they didn't want their elderly mother to have to witness a long drawn out death. I do not feel that I did anything wrong. The family thanked me profusely, and I felt that I did the right thing for the patient and the family as a whole. I hope that when I am faced with a situation like this with my family that someone will be there to accomodate me and my loved one.

i don't think anyone is disputing the titration of ms04, to ablate suffering/ease pain.

ativan is a given, w/morphine.

groaning w/repositioning, indicates a need for more analgesia.

but when level of comfort has been achieved, totally achieved, where does the rationale for more morphine come in?

truly, i'm curious.

leslie

Most responders have answered with the scenarios when patients(and families) are ready to end the suffering. I also see this as the medical field dragging its feet against pt(family) wishes. My facility does not have 24 hour emergent facilities. So at night, we are pretty much on our own. We do ship/transport pts after hours if ordered and/or needed. However, there is one doc in our facility that makes everyone groan if anything "extra" is needed for the pt. This doc is notorious for being condescending, not listening, not answering pages, etc. If it is night, many times this doc will "blow you off" period. One night we had a pt of this doc and the pt had coded at change of shift and continued to deterioate through the shift. The doc never spoke with family on their wishes. By the am, it was clear the pt would die soon. Doc was contacted again, instead of shipping the pt out, doc opted to "talk" with family to change code status. Of course, only when pt was knocking at deaths door. Another instance, a family was trying to get a face to face with same physician to discuss withdrawal of support. Doc seemed to avoid them until the family cornered doc. Pt had not even been admitted a full week. heard doc later joking with other doc about family wanting to w/d support. With these examples, I have to wonder what gains this doc has(yeah I think money). My point is, that in neither was the wishes of the family followed. I understand that in many cases pts will not survive, but if they and/or the family had decided to "do everything" we need to honor that(including docs). And on the flip if it is decided to w/d then honor that. I personally haven't had these experiences with this particular doc and hope not to. And until recently, with management changes, don't feel it would have been productive. I guess my point is we are not the ones to dictate care. To me, if family or pt has stated they want everything done we need to honor that and vice versa.