Share your feedback re: ethical nursing issues

Nurses Safety

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Hi! I will graduate from nursing school in May and would like to hear about ethical issues that practicing nurses (or even students in clinical) have experienced, and how you handled the situation.

I think this would be a very informative discussion.

My example is as follows:

A friend of mine was had a patient who required "comfort care only." He was dying, and his wife requested that all life-saving interventions be ceased. The doctors "allegedly" drew blood from him, but didn't want the wife to know what they did. My friend tells me that his prior lab values showed that there was no way that he would recover. She felt divided in this situation, in that she was in essence, the patient's advocate that day, but she didn't want to question the physicians. She kept the matter quiet.

I would love to hear about other ethical dilemmas/situations that other nurses have experienced! Thanks in advance!!!

Specializes in NICU, PICU, PCVICU and peds oncology.
Has anyone ever had to deal with an RN coworker who was using drugs? I couldn't imagine! I'd love to hear about more examples, if anyone else can share?!!

We just recently had a nurse suspended for diverting narcotics. Apparently there were several people who knew this nurse was addicted and working under the influence, but kept it to themselves. A Pyxis audit revealed abnormalities in morphine removed and actually given, no wastage noted, etc. It was all finally traced back to this one person, and she is now on a short-term disability leave while she undergoes treatment for her addiction. I was shocked when I learned of this, but then in retrospect I could remember times when I wondered if she was alright, because she'd have a sort of unfocussed look in her eyes. I always put it down to fatigue because I knew she had a lot of stress in her personal life. She must have been so desperate to take morphine from our unit, taking the risk that she'd get caught. I can't imagine being that way. I hope I never start looking at my coworkers with a suspicious eye. I too have a lot of stress in my life, and hope to God no one is looking at me that way either!

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I would not feel comfortable giving a placebo to a patient. I did YEARS ago, but it was'nt for pain. I agree after 50 everything aches more. Definately would not withhold even tylenol for anyone. I would'nt hesitate to report a nurse diverting drugs. I pity them, but it just isn't right. We had a resident at the nursing home who administrative team/Dr. decided to withhold nourishment. I work parttime and didn't fully understand why it happened at the time, but I can tell you this, I would NEVER do it again, unless the person was terminal and suffering.

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Specializes in Telemetry, ICU, Resource Pool, Dialysis.

I'm not sure, but I think giving a placebo is illegal unless the patient is part of a study where they're informed that they may receive one. It's basically lying to the patient. If I ever had a physician try to order one, I would be on the phone reporting him before the ink was dry.

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Specializes in Trauma acute surgery, surgical ICU, PACU.
Has anyone ever had to deal with an RN coworker who was using drugs? I couldn't imagine! I'd love to hear about more examples, if anyone else can share?!!

Twice. The first instance was handled badly by mgmt, imo. This was pre-pyxis, and no-one ever fully witnessed her do anything wrong, there was just a suspicious and damning pattern of narcotic use when she was on, and her wastes didn't always get co-signed. She was also on prescribed narcotics for a shoulder injury. She would come to work looking dragged out, tired and dopey. When she went for break, she would instantly fall asleep, and have to be shaken awake very agressively because she was so deeply asleep. One time, a patient had been on pca morphine and had good pain control. When this one nurse mixed up the new syringe, he lost all pain control and was in agony. He had to be taken to PACU, sedated and have an epidural put in.

This nurse was brought in for a meeting with management, but because all the proof they had was circumstantial, she denied everything, and they were powerless to discipline or fire her (we have a strong union). She took some "stress leave" time off after that, and when she came back, a large amount of narcotics was stolen from a unit she floated to on nights. She was never faced with any formal charges or disciplinary action by the hospital in connection with this incident, because she resigned voluntarily and went to work somewhere else.....

This whole thing tore our unit apart, because we were afraid for our patients, angry with the nurse - but we also had a lot of empathy for her, and wanted her to get professional help. It was offerend to her by management, but she was in denial and never took it. She had the narcotic problem as well as many problems at home and in her personal life.

That nurse went through several jobs, and we heard there were similar problems at the other hospitals. She committed suicide by overdose in the supply closet of the nursing home she worked at last year. Those of us who were working back then were all very upset and crying when we heard about her death.

The second time, it only happened for one day, but I was the charge nurse that day, and our manager was away. To have to call in another manager because the float nurse was dopey, staggering around, making med errors, and slurring her words was hard. I was so focussed on patient safety that until the manager arrived, I was trying to supervise that one nurse very closely, as well as do charge duty for the whole floor. It was very stressful.

I think the first occurrance was the most upsetting, and will stay with me for life. I would almost call it a "critical incident" because the second incident gave me nightmares and flashbacks of the first.

The true lesson is that nurses are not immune to problems like substance abuse. They deserve help, but these issues also involve patient safety, and so will of course be upsetting to co-workers. "I couldn't imagine" - don't put Nurses on a pedestal, we are human too. :)

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Since placebos do work for the relief of pain in some cases, they can reasonably be a legitimate course of treatment. However, most nurses are uncomfortable lying to a patient about what the medicine actually is. One solution might be to offer the placebo as a "homeopathic medication" ie: water.

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Specializes in CCRN, CNRN, Flight Nurse.
Since placebos do work for the relief of pain in some cases, they can reasonably be a legitimate course of treatment. However, most nurses are uncomfortable lying to a patient about what the medicine actually is. One solution might be to offer the placebo as a "homeopathic medication" ie: water.
I have never given a placebo, but I do believe in the power of the mind. I will talk up most any medication I give (ie: 'This is some really good stuff. It should make you feel better soon.'). I'm not lying to them. And if what I give them doesn't work, I will give more (if I can).

I work in EMS also. I've had several patients with long varieties of histories who complain about anything and everything hurting. If I can only give them a very small amount, I will take it up. Many seem to have gotten pain relief even before the medication hit their system.... just because of the power of the mind!

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As nurses, we need to be absolutely sure where we stand on our beliefs and be willing to go to the wire to defend our beliefs. I know where I stand on most issues I am faced with, I am willing to be educated and instructed on other issues if it is nonbiased and factual education. I always attempt to do,act, treat my patients just like I want my mother, hubby, kids to be treated. If I do not feel this is the case, I report my concerns to the HN and ethics person assigned to that unit. It usually is addressed in a timely and compassionate manner. Christ gave us the golden rule to follow and if we attempt to do this we usually know we are being the nurse and the person He meant us to be.

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Specializes in Neuro, Critical Care.

What does everyone think about slow codes/no codes? We had to write a paper on a situation in which a terminally ill cancer pt. clearly stated that she wanted a DNR...the Dr. ignored it and the pts family protested...our assignment clearly stated that the patient wanted a DNR, even wrote it on a piece of paper and gave it to the nurse...she was revived three times and each time reiterated that she wanted a DNR...the MD ignored (our assignment said he didnt think it was in her best interest?)...when the pt coded again the hypothetical nurse performed a "slow code" and the pt. could not be revived...the pt. never had a written order..what do you think the nurse should have done...

half of our class got this topic and the other half of us got another topic...I did not write on this topic...I honestly don't know what I would do...I would want the best for my patient, but I also would not want to do anything to jepordize my liscense since there was no official order...the scenerio also stated that the family was very upset and wanted all life saving measures to be pursued....does anyone know of a time or situation when a nurse implemented a slow code/no code and what the outcome was?

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Specializes in Telemetry, ICU, Resource Pool, Dialysis.

I've witnessed several situations where pts were coded "unethically" because family simply could not let go, and the doctors seemed unwilling to be blunt with them. I'm always amazed at these people who are so willing to sit and watch their 85y/o father with metastatic cancer, renal failure and sepsis be intubated, shocked and pounded on over and over again. Then they pull out their cell phone "Yeah, they got him back again, looks like he'll be OK for a while - poor guy, he was pretty upset when he woke up, but he'll settle down pretty soon." It makes me angry to stand there and bag someone who's looking up at you, shaking their head - like "why are you doing this to me?" I've even seen perfectly lucid patients say "don't ever do that to me again" get coded and reintubated because when they became unconcious family took over and wanted it done. I hope my kids have more respect and love for me if I ever end up like that - and respect my wishes - even if they don't like it.

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Specializes in Neuro, Critical Care.
I've witnessed several situations where pts were coded "unethically" because family simply could not let go, and the doctors seemed unwilling to be blunt with them. I'm always amazed at these people who are so willing to sit and watch their 85y/o father with metastatic cancer, renal failure and sepsis be intubated, shocked and pounded on over and over again. Then they pull out their cell phone "Yeah, they got him back again, looks like he'll be OK for a while - poor guy, he was pretty upset when he woke up, but he'll settle down pretty soon." It makes me angry to stand there and bag someone who's looking up at you, shaking their head - like "why are you doing this to me?" I've even seen perfectly lucid patients say "don't ever do that to me again" get coded and reintubated because when they became unconcious family took over and wanted it done. I hope my kids have more respect and love for me if I ever end up like that - and respect my wishes - even if they don't like it.

I agree with you totally. Since there was no written order could the hypotheitical nurse in my scenerio be sued or lose her liscencse?

My mom has already made it very clear what she wants to happen if she were ever in that situation. Im glad, it is hard to let go, but knowing what she would want makes the decision a little easier...

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Specializes in Telemetry, ICU, Resource Pool, Dialysis.
I agree with you totally. Since there was no written order could the hypotheitical nurse in my scenerio be sued or lose her liscencse?

My mom has already made it very clear what she wants to happen if she were ever in that situation. Im glad, it is hard to let go, but knowing what she would want makes the decision a little easier...

I guess that depends on what you meant by "slow code." In your scenario, did it detail what was done, and the time frame?

It is very hard to let go. It takes more strength to abide by a loved one's wishes than it does to cave in and have them coded because "What will I do without her/him?"

I had a patient once whose family I will never forget. Especially her daughter. This woman had end stage COPD, several occluded coronaries, renal problems. Her only options were to be intubated with dialysis (forever). She wasn't a candidate for surgery due to her other problems. She was totally lucid, and had decided that it was her time to go, I think she was in her 60s. She knew the process wasn't going to be short and sweet, and would involve some suffering. She didn't want Bipap either. She discussed this with her daughter. The daughter said she couldn't understand why she wanted to "give up on life" but because of all the sacrifices her mom had made for her during her life, she would honor her mom's wishes.

As the days went on, the mom got progressively more lethargic, with labored breathing. She had periods of confusion, and would occasionally get angry at the daughter for "hovering." The daughter never left her bedside. She sat there straightening covers, reading to her mom, swabbing her mouth, and asking for pain meds for her mom. Every couple of hours, especially after her mom had snapped at her, she would come out of the room, close the door and burst into tears. " I can't stand to see her like this. But I know she doesn't want the ventilator or dialysis." Then she would dry her face, and go back in. It would have been so easy for her to reverse the DNR order, and put her on dialysis - she was her mom's DPOA, but she never did. The love and respect she showed for her mom during those days just blew my mind. I'll never forget it. For every one like her, there are 2 who put Mom on the vent and go home for the night. The easy way out.

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Specializes in Neuro, Critical Care.
I guess that depends on what you meant by "slow code." In your scenario, did it detail what was done, and the time frame?

It is very hard to let go. It takes more strength to abide by a loved one's wishes than it does to cave in and have them coded because "What will I do without her/him?"

I had a patient once whose family I will never forget. Especially her daughter. This woman had end stage COPD, several occluded coronaries, renal problems. Her only options were to be intubated with dialysis (forever). She wasn't a candidate for surgery due to her other problems. She was totally lucid, and had decided that it was her time to go, I think she was in her 60s. She knew the process wasn't going to be short and sweet, and would involve some suffering. She didn't want Bipap either. She discussed this with her daughter. The daughter said she couldn't understand why she wanted to "give up on life" but because of all the sacrifices her mom had made for her during her life, she would honor her mom's wishes.

As the days went on, the mom got progressively more lethargic, with labored breathing. She had periods of confusion, and would occasionally get angry at the daughter for "hovering." The daughter never left her bedside. She sat there straightening covers, reading to her mom, swabbing her mouth, and asking for pain meds for her mom. Every couple of hours, especially after her mom had snapped at her, she would come out of the room, close the door and burst into tears. " I can't stand to see her like this. But I know she doesn't want the ventilator or dialysis." Then she would dry her face, and go back in. It would have been so easy for her to reverse the DNR order, and put her on dialysis - she was her mom's DPOA, but she never did. The love and respect she showed for her mom during those days just blew my mind. I'll never forget it. For every one like her, there are 2 who put Mom on the vent and go home for the night. The easy way out.

That is so sad. I so dread the day when I will have to make that decision...

Lets see, I can type up exactly what it said in our assignment...

Mrs. Sams, age, 85, was admitted to the hospital one year after an extended radical mastectomy. She had undergone a series of radiation treatments following surgery and was being treated for metastasis at the time of hospital admission. Her condition was considered to be terminal at the time of admission, and the physician had informed the patient's husband and children that Mrs. Sams was not expected to live very long. The pt. refused to take pain meds, and she was fully cognizant of the prognosis and aware of the rapidly deteriorating condition of her body. Mr. Sams accompanied his wife when she was admitted to the hopsital. He also observed Mrs. Sams giving to the admitting nurse a sheet of paper on which she stated that she did not want to be resuscitated if her heart should stop. Mrs. Sams was fully competent at the time of admission, and she was not taking any medicine which would have affected her judgement.

Following admission to the hospital, during a three-month period of time, Mrs. Sams continued to deteriorate physically, but she was still alret and oriented. Her family visited her frequently, and following a conference wiht the physician, demanded that Mrs. Sams be coded if she had a cardiac arrest. Mrs. Sams arrested three times and was coded. After the thrid time, the patient again wrote a note requesting that she not be coded and gave the note to the physician. The physician still would not write a "no code" order on the patients chart. Finally, a nurse who had been caring for the patient since the time of admission did a "slow code" after a fourth arrest, and staff were unable to resuscitate the patient.

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