Still Reeling From This

Nurses General Nursing

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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.

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.

Specializes in psychiatric.

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.

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!

Specializes in ER.

This doctor is looking out for himself, and you are looking out for this pt. Bravo...you did the right thing, the only right thing that you can and should do as a nurse. You've done all you can, and probably the ethics committee will agree with you. Things may change for the better after this...maybe when a pt expresses their wishes, hospital policy will dictate getting it in writing ASAP? (Living will, DNR, etc.) so that this situation can be avoided.

Specializes in Trauma, Teaching.

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.

The OP said the pt had previously asked for no heroics, the next of kin was not the pt's desired POA, and it was the MD who had forced the next of kin issue by declaring the pt incompetent and disregarding the pt's wishes.

Bravo OP! Keep up the good fight.

The OP said the pt had previously asked for no heroics, the next of kin was not the pt's desired POA, and it was the MD who had forced the next of kin issue by declaring the pt incompetent and disregarding the pt's wishes.

Bravo OP! Keep up the good fight.

Here is the OP:

Aug 25 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 don't see the words in the above OP that say the patient had previously asked for no heroics.

How do you conclude from the above that the doctor "forced the next-of-kin issue?" The next-of-kin may not have been the decision maker, and may not have been desired by the patient as their decision maker, and according to the OP the patient expressed that he/she did not want the next-of-kin to be the decision maker, but the next-of-kin may have been a valued relative of the patient, who the patient would have wished to see. In the OP, we don't have enough information to really know what is happening, hence the points I made in my post above.

Specializes in Trauma, Teaching.

you are correct, I thought I had seen a no heroics statement, but it is not there.

in the absence of an advance directive, if the patient cannot speak for his or herself, then the next of kin will often become the proxy.

I don't disagree with your take on this- from your description it certainly does sound as if going to comfort measures only was the appropriate course.

However, if the patient couldn't speak for his or herself and didn't have an advance directive and the next of kin wanted to continue treatment, I can see how this put the physician between a rock and a hard place.

I admire your clarity and resolve in this issue, and I think you did the right thing. I'd just caution you to not pass too harsh of a judgment on the physician since you were not the one in his/her shoes. Things aren't always so black and white.

Specializes in Float Pool-Med-Surg, Telemetry, IMCU.

Susie, you make valid points and trust me when I say, I would have supported the MD's decision if I hadn't known from several days with this patient that beyond a shadow of a doubt, they did not want heroic measures or even to be in the hospital in the first place. Also, I had other people in the patient's life, (who, granted were not the next-of-kin) calling and telling me, the MD, and the social worker that the patient had expressed many times that he/she did not want any invasive treatments and wanted to die at home. Even the next-of-kin expressed that they did not want their family member to suffer and even though they would have liked to see him/her before they died, they wanted the patient to be kept comfortable first and foremost.

The MD took it upon himself/herself to keep the patient alive for the next-of-kin who I was later told arrived hours too late. The MD ignored the ethics representative (an experienced MD), the patient's nurse, the charge nurse, and the social worker. And most importantly, he/she ignored the implied wishes of the patient from numerous sources as well as conventional wisdom: you do not continue to perform invasive procedures on an actively dying patient when those procedures will do NO GOOD and may cause additional discomfort. And you sure as heck don't refuse to treat pain because it may shorten the actively dying person's life.

So what I take from this is this: get your affairs in order, appoint a DPOA and draw up a living will. Tell the people in your life that you love them. And everyone deserves comfort at the end of life.

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