Share your feedback re: ethical nursing issues

pricklypear · Jun 30, 2005

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.

UGGGGG...that scenario seems so common. Since your scenario doesn't give details of what a "slow code" is, it's hard to comment. Unless someone saw staff delaying, or witholding care, it would probably be hard to say anyone did anything wrong.

I've seen the same scenario happen a few times, and can never understand it. How can you profess to love someone, yet put them through such torture. Some people seem to worry more about their pets suffering than their family. (Not advocating euthanasia in any way!!) Think about it. If people had insurance for their dog, and cost wasn't an issue, how many people do you think would put the family pet through several emergent intubations, CPR, etc...?

Pediatric Critical Care Columnist · Jun 30, 2005

ELKMNin06, the answer to the question is in the question, at least ethically. This lady was in full control of her faculties when she was admitted. She indicated that she did not want resuscitation. She is the only one in this case whose wishes, ethically, should be considered. She knew what she was doing and chose the option she was most comfortable with, and that was to allow nature to take its course. She was assaulted each time she was resused and the physician was culpable because he ignored her decision in favor of the family's. He could be held accountable in court, but of course the family would never do anything like that since they were the ones pushing for resuscitation. The nurses and hospital could file complaints with the medical association and he'd likely be sanctioned. I would find it very difficult to go against someone's clearly stated and clearly understood wishes, and would be inclined to do what the nurse in your case study did. I would be inclined to watch the patient "in the hope of a reversal" for a while before initiating any response from the code team, and perhaps discuss each step of the code as it unfolded before acting on anything. This would slow down the pace enough to bring the situation to its logical conclusion.

GrnHonu99, RN · Jun 30, 2005

ELKMNin06, the answer to the question is in the question, at least ethically. This lady was in full control of her faculties when she was admitted. She indicated that she did not want resuscitation. She is the only one in this case whose wishes, ethically, should be considered. She knew what she was doing and chose the option she was most comfortable with, and that was to allow nature to take its course. She was assaulted each time she was resused and the physician was culpable because he ignored her decision in favor of the family's. He could be held accountable in court, but of course the family would never do anything like that since they were the ones pushing for resuscitation. The nurses and hospital could file complaints with the medical association and he'd likely be sanctioned. I would find it very difficult to go against someone's clearly stated and clearly understood wishes, and would be inclined to do what the nurse in your case study did. I would be inclined to watch the patient "in the hope of a reversal" for a while before initiating any response from the code team, and perhaps discuss each step of the code as it unfolded before acting on anything. This would slow down the pace enough to bring the situation to its logical conclusion.

I agree. Ethically, I think I would have done the same. My profs were telling us that even though the choice she made was ethical, it wasn't legal...and she could be sued.....I guess that is why they used this example for an ethical dilemma. So sad...I guess I thought that if you were lucid and actively functioning that the MD HAD to abide by your wishes...does this really happen in the field? Are there patients that want a DNR and the MD won't sign off on it or put it on the chart? I surely hope not. Also, I would like to know if anyone knows a nurse that was sued or sanctioned over a case similar to this?

On a seperate note, how many nurses out there carry malpractice insurance...our teachers say that they reccomend it. I was just wondering how many nurses actually carried it...?

ZASHAGALKA, RN · Jun 30, 2005

Unfortunately, the survivors get preference over the dying because the dead can't sue. I had this mental exercise with myself long ago and decided that 'slow codes' were completely unethical.

If the patient wants everything done, or if the patient can't speak for themselves and left no directive, and the family want everything done, then I break ribs.

(it's not my fault they left such an important decision to surrogates, but somebody with a 'vested' interest in the patient's wishes has to be a decision maker otherwise, you have to assume full code.

I don't subscribe to futile care theory (FTC): experts should make decisions in the best interest of society based on life expectancy and quality of life regardless the individual's preference. FTC's premise is that this is a societal issue that shouldn't be in the hands of an individual, so, you're DNR when your doc decides you are and you have no say. Before you dismiss FTC; it's coming. It's already here on the fringes. In 10 yrs, the majority of ethics concerns on this site will involve FTC.)

If the patient expresses a DNR desire, that's the way it is. Period. Unless it's absolutely imminent and I don't have 15 minutes, if the doc refuses, then I have 3 options:

1. If it is imminent within 15 minutes, as I'm marshaling resources, I'll argue with the doc. I'm not afraid of raising my voice. I'll threaten ethics and peer review actions if he doesn't relent. I have used this phrase in the past: "You have only 2 choices here doc, answer to these family members RIGHT NOW and do what's right for your patient, or answer to your peers later. And I promise that if you don't act now, I WILL ACT LATER."

2. If IT IS relatively but not IMMINENT imminent, I go to chain of command. I have informed docs that, if they don't change their mind, then they'll have to justify it to the chief of staff because that's where I'm going, and I'm going there now. At that point, so far, the docs have changed their minds (placating family is the easy way out, but it's not easier that justifying your actions to a peer review committee.)

If a doc didn't institute a DNR, I'd call the house and start immediately moving towards the chief of staff's involvement.

3. If IT'S NOT imminent, I ask for an immediate Ethics Committee determination on the issue.

In an extreme case, which I haven't had, I would refuse to participate. My hospital has provisions for refusing to provide care based on 'conscientious objection'. And that would certainly be one.

I make my reputation on providing critical care to critical patients. If I only pretended to provide that care, then what makes me any different from the car mechanic that 'pretends' to work on your car?

~faith,

Timothy.

pricklypear · Jun 30, 2005

...I guess I thought that if you were lucid and actively functioning that the MD HAD to abide by your wishes...does this really happen in the field? Are there patients that want a DNR and the MD won't sign off on it or put it on the chart? I surely hope not.

Yes, it happens. I see it more in the smaller hospital I'm at now than I did at the major center at which I used to work. I've seen probably 3 MAJOR examples of this happening in 3 years. Doesn't seem like a lot, but even 1 is too many. That's one person who suffered against their will and needlessly.