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Still Reeling From This

Posted

Specializes in Float Pool-Med-Surg, Telemetry. Has 8 years experience.

Fellow nurses, I recently was involved in a case where I feel that there was a terrible breach of ethics and it still has me upset. I will be vague to protect the privacy of those involved; there is a complicated back story but the gist of it is:

Patient is actively dying with no hope of recovery- not a candidate for dialysis and in severe renal failure, volume overloaded, profusely bleeding esophageal varices, tachypneic, sounds as though they are breathing under water- you don't need a stethoscope to hear it, looking miserable and exhibiting air hunger and pain behaviors.

MD refuses to write for comfort measures and withdraw futile treatments including IV FLUIDS on an anuric, volume-overloaded patient because they want to keep patient alive for the next-of-kin (who the patient had previously expressed was not the person they wanted making decisions for them but because the MD had declared the patient incompetent this wish was dismissed). Next of kin was supposed to come in the morning and still hadn't arrived by 8 pm. (I refused to continue the IV fluids and eventually MD relented)

I contacted the nursing supervisor and ethics and the Ethics on-call agreed with me and contacted the MD but nothing was done. I paged the MD about 6 times and they stopped returning my pages. The charge nurse and social worker got involved and paged the MD. Every single person agreed that this was cruel (including the MD) but the MD wouldn't listen and actually started a sentence "Ethics are nice but...."

I don't know how this ended as I left when my shift was over. I don't know what to do with this. This is a new MD and I know my relationship with them has gotten off to a terrible start-esp. since I went over their head and there will probably be repercussions for them. I also don't trust this person to act in the best interest of their patient now although I am going to do my best to start over with a clean slate.

This is my day off and I still feel drained and angry. I need to let it go. Words of encouragement would be nice. I hate feeling as though I have failed my patient even though I did everything I could think of.

JustBeachyNurse, RN

Specializes in Complex pediatrics turned LTC/subacute geriatrics. Has 11 years experience.

You didn't fail your patient. You kicked butt and advocated for your patient. You cannot control the response of others but you can follow protocol and move up the chain of command. If there is a debriefing perhaps an ethics & palliative/hospice care refresher class might be suggested.

Take a break. You did well with what you had to work with. You refused to carry out a ridiculous order-- fluids for a hypervolemic, anuric patients.

You may not have yet won the war but you won a few battles.

HouTx, BSN, MSN, EdD

Specializes in Critical Care, Education. Has 35 years experience.

Kudos to you. Your courage as a patient advocate exemplifies what nursing is all about. Just taking a stand - drawing a line in the sand and saying "no more" -- can make a huge difference. Maybe not for this patient, but I promise you that it did have a positive effect on everyone who witnessed your behavior. I once refused to participate in a futile code - terminally ill ICU patient had clearly expressed his wishes for 'no heroics'- knowing full well that it could result in loss of my job. But you know what? Not only did it NOT get me fired, the hospital chaplain (who was also involved) invited me to join the Ethics Committee case consultation group.

We're very proud of you.

You are awesome!! I am on the Ethics commitee at a large psych hospital so you can only imagine how many consults we do. It is strange to see how ingnorant this MD was in this particular case but don't ever let this deter you from speaking out again. If it feels right it probably is right.

Nice work!!

VivaLasViejas, ASN, RN

Specializes in LTC, assisted living, med-surg, psych. Has 20 years experience.

You absolutely did the right thing. If ever I am in a position like that of your patient, I hope I'll have someone like you looking out for my best interests and not the MD's license.

MECO28, BSN, RN

Specializes in Float Pool-Med-Surg, Telemetry. Has 8 years experience.

Thank you all. I am looking into how to get involved on our ethics committee because I'd really like to help prevent future cases such as this one.

LibraSunCNM, MSN

Specializes in OB. Has 10 years experience.

What a horrific experience for you to have to deal with. It sounds like you did everything right. Not every nurse would have the courage to keep going up the chain of command and refuse orders the way you did. I can understand why you're still reeling, but you deserve a huge pat on the back for your patient advocacy.

llg, PhD, RN

Specializes in Nursing Professional Development. Has 44 years experience.

You did your best to protect a helpless, suffering patient. Never regret that. Some battles are worth fight.

"Ethics are nice, but ..." Yeah, and that guy should get some.

HappyWife77, BSN, RN

Specializes in Gerontology RN-BC and FNP MSN student. Has 21 years experience.

You are awesome, and you rock. I firmly believe you will make a difference in the future related to this one incident.

It's normal for us to grieve certain situations at work....I wish I could have let certain things go over the course of my years, but it seems they mold us and shape us....make us more passionate about our stance. Such as this episode, it brought out the best in you....not the best in the doc.

Hopefully the situation will cause future patients to have more dignity with dying than if that doc is involved . You did good.

(((Hugs)))

You behaved with professionalism and courage to advocate for your patient who had NO VOICE themselves. I salute you for your willingness to stand in the gap and insist on what was right.

LadyFree28, BSN, RN

Specializes in Pediatrics, Rehab, Trauma. Has 10 years experience.

Thank you all. I am looking into how to get involved on our ethics committee because I'd really like to help prevent future cases such as this one.

Sending positive vibes you way. :up::up::up:

Whispera, MSN, RN

Specializes in psych, addictions, hospice, education.

you are awesome!

5:11 pm by MECO28

Fellow nurses, I recently was involved in a case where I feel that there was a terrible breach of ethics and it still has me upset. I will be vague to protect the privacy of those involved; there is a complicated back story but the gist of it is:

Patient is actively dying with no hope of recovery- not a candidate for dialysis and in severe renal failure, volume overloaded, profusely bleeding esophageal varices, tachypneic, sounds as though they are breathing under water- you don't need a stethoscope to hear it, looking miserable and exhibiting air hunger and pain behaviors.

MD refuses to write for comfort measures and withdraw futile treatments including IV FLUIDS on an anuric, volume-overloaded patient because they want to keep patient alive for the next-of-kin (who the patient had previously expressed was not the person they wanted making decisions for them but because the MD had declared the patient incompetent this wish was dismissed). Next of kin was supposed to come in the morning and still hadn't arrived by 8 pm. (I refused to continue the IV fluids and eventually MD relented)

I contacted the nursing supervisor and ethics and the Ethics on-call agreed with me and contacted the MD but nothing was done. I paged the MD about 6 times and they stopped returning my pages. The charge nurse and social worker got involved and paged the MD. Every single person agreed that this was cruel (including the MD) but the MD wouldn't listen and actually started a sentence "Ethics are nice but...."

I don't know how this ended as I left when my shift was over. I don't know what to do with this. This is a new MD and I know my relationship with them has gotten off to a terrible start-esp. since I went over their head and there will probably be repercussions for them. I also don't trust this person to act in the best interest of their patient now although I am going to do my best to start over with a clean slate.

This is my day off and I still feel drained and angry. I need to let it go. Words of encouragement would be nice. I hate feeling as though I have failed my patient even though I did everything I could think of."

I understand that you do not wish to provide too many details in order to protect the patient's privacy. I am wondering if the patient had an Advance Directive. I am wondering too what discussions may have taken place between the patient, the person with decision making authority, other family members, and the physician, that perhaps you were not privy to. From your post it is not clear what the patient wished to happen in this situation, or what was decided between the patient, the person with decision making authority, other family members, and the physician. It was clear in your post that you felt strongly that you needed to act in order to protect the patient from suffering (i.e. protect the patient from further care that apparently would only prolong the patient's life without possibility of cure, and would prolong their physical suffering), but I am wondering if the patient may have chosen to continue suffering to prolong their life until they could see a certain family member. Such situations are not unknown. Patients do have a right to choose to prolong their lives, even if there is no hope of cure. Much information is not given in you post, appropriately and understandably, in order to protect the patient's privacy, which renders the total situation ambiguous, and thus it is difficult to provide meaningful comment.

Edited by Susie2310

Barnstormin' PMHNP

Specializes in psychiatric. Has 4 years experience.

I read a quote once...."Life is good, Death is not bad" It resonates with me to this day, having seen bad deaths and good deaths.

I strongly feel that every person should have the right to die with dignity and control.... It is very important to have advance directives in place, and we as nurses have to have this conversation with our patients if it hasn't been addressed by the Doctor. I remember when I was in the ICU, a wonderful pulmonologist talking to the family of someone who should have been on comfort care, he was amazing in manner and approach on this difficult subject, I can only imagine how many times he had been through this with other families.

I think you were very brave and strong to have advocated for your patient in the face of possible repercussion. You are a nurse to emulate, and as another poster pointed out, an excellent example of how to advocate.

I read a quote once...."Life is good, Death is not bad" It resonates with me to this day, having seen bad deaths and good deaths.

I strongly feel that every person should have the right to die with dignity and control.... It is very important to have advance directives in place, and we as nurses have to have this conversation with our patients if it hasn't been addressed by the Doctor. I remember when I was in the ICU, a wonderful pulmonologist talking to the family of someone who should have been on comfort care, he was amazing in manner and approach on this difficult subject, I can only imagine how many times he had been through this with other families.

Patients should be able to die with dignity, according to their definition of a dignified death, and according to their wishes. As nurses our duty is to the patient and to their family/significant others if the patient wishes for them to be involved in his/her care. If a patient wishes to have a discussion about advanced directives, and opens the discussion freely, or participates in the discussion freely on the initiation of the physician without being coerced or pressured into the discussion, then all is well and good. Not all patients/family members wish to do this, or will wish to do this in a time and manner of their own choosing, and this is their moral and legal right, and is to be respected.

As far as a patient being placed on comfort care; it is appropriate for the physician to present information about the opportunities, or lack of, for curative care, but quality of life and the decision to prolong one's life, even if curative care is not possible, is a determination that can only be made by the patient, who may wish to make this decision along with trusted family members, who may serve as POA.

Perhaps not malpractice in the tort sense, but clear and obvious malpractice on behalf of that physician who should be thoroughly ashamed of himself.

I would seek out the opportunity to discuss this case with that physician in the hope of educating him to improve the lot of his future patients.

I am somewhat surprised that nobody up the MD chain of command chose to intervene on behalf of the suffering patient.

Been there,done that, ASN, RN

Has 33 years experience.

You did everything you could. It was a valiant effort and it was well done!

You are now aware of that physician's modus operandi.

Don't look back, look forward.. spend that energy as to how to prevent this from happening again.

Administration and the ethics committee already have a head's up , thanks to you.

Approach them with your concerns and develop a plan with them to work around future problems.

Good luck, you can do this.

You are still upset, because you truly care about the patient. If you didn't, you would be able to just "move on." You are a fantastic nurse and an inspiration to all of us, because we should never feel bad for advocating strongly on behalf of a patient (especially a patient that is so vulnerable and helpless). I'm sure if you were to look up your Nursing Philosophy that you made back in nursing school, you would find that you wanted to be a nurse who would do exactly as you have done!