Need some help with an assignment. Please. =)

i worked on a stepdown unit for some years. we had a patient who was transferred to us and made a dnr. she had end stage copd and was intubated and on a ventilator. she was alert and oriented. the problem was that she had already extubated herself once in an effort to end her life. since she was in the icu at that time, she was re-intubated and placed in wrist restraints. it was decided to transfer her to our icu stepdown and keep her in wrist restraints. the doctor had also written an order something to the effect of "do not allow the patient to extubate herself". however, we did have an order that if she managed to extubate herself again we were to do nothing and follow the dnr order. most of us were very leary of this and over the next few days there was a lot of discussion about this patient and what we were going to do. needless to say, when i had this patient, i was watching her like a hawk and making sure she was restrained properly. i didn't want her extubing herself on me.

the ethical issue here is that if she did extubate herself, we would be forced to watch this alert and oriented lady literally die before our eyes and do nothing. to my way of thinking we would be allowing her to commit suicide before our eyes.

i didn't just sit around and ignore this patient. i did talk with her a number of times. it was heartbreaking. she told me that she had come to this country after wwii and had no more living family. i verified this with information in her chart. she said she had no reason to live anymore. her disease was just too much to handle any more. she couldn't do anything. she felt she was better off dying. basically, she wanted to just let nature take it's course and she didn't want artificial support anymore. please understand that this was in the 1980s before advanced directives and living wills were required to be discussed with patients. i felt just as helpless as the patient.

it finally happened. i was on duty but another rn was assigned to the patient. her restraints were apparently not tied correctly or snugly enough. she got one hand loose and pulled her endotracheal tube out. the ventilator alarmed and several of us went to her room. watching this woman die was one of the worst experiences of my life. it took approximately 10 minutes. she spoke to us for the few minutes that she was conscious and told us she was happy and to please not stop her. i stayed with her. she was short of breath and eventually she became cyanotic, lost consciousness, her breathing eventually became agonal and she died. her wishes were observed.

i've always felt this was approved suicide and that the nursing staff was forced to be a part of it. i didn't like it one bit. i had a similar incident occur in a nursing home about 5 years ago when a patient decided to stop all hemodialysis treatments and died after 6 days. she was terribly depressed and no psychiatric consult was sought. of course, the thinking about these things has changed and it is acceptable that patients do this. however, it does put a great stress on those of us who care for these people. to my way of thinking they are in great stress and in need of psychological or psychiatric care before care is finally withdrawn. neither was done in either of these two cases.

now, some people on the forums know that i am currently undergoing chemotherapy for colon cancer. while i am not afraid of dying i do from time to time think about what i would do if faced with the fact that the cancer is winning the battle. at this point i feel that i would not want hospice services. perhaps my thinking on that will change. i do have an advanced directive and i have stipulated that i do not want any extraordinary measures done to stay alive. all i can say is that when you are talking about ethics there is never a clear answer. i also do not dispute that the patient's desires must be honored. what is hard is when the nurses ideas are in conflict with the patient.