Still Reeling From This

[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.

[messymissy]

Kudos to you for advocating so strongly for your patient!

You maybe surprised that you have earned respect, rather than anger from this newbie MD. I once was in a situation where I knew the "new" ER MD was treating a patient as a drug seeker. I tried on several occasions to have this MD, re-exam the patient. They refused. So I went over their head and my assessment was correct. Higher ups became involved, I became fearful of retaliation. I was very surprised when that MD, pulled me into a room and APOLOGIZED for not respecting my nursing assessment & judgement. I never had any further issues with this MD. I hope the same goes for you. If this MD has any brains, they will!

Focus on the fact that you did advocate for your patient, while they were in your care. We can only do so much during our shift. I know of some nurses, that would have blindly followed the MD's orders. That is the sad part.

Sending positive vibes and a big hug your way! ?

MissyRN

[MECO28, BSN, RN]

Also, for the record I am not one to demonize doctors. My spouse is one and about half of my social circle is comprised of them. I know they face decisions that I don't have to deal with. I know they have more medical education than I do. But this particular doc had such peculiar rationales for their actions and showed such little concern that I had to speak up.

[jadelpn, LPN, EMT-B]

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.

You are a strong patient advocate. We can advocate on nursing judgement. But here's the thing. We are absolutely not party to what conversations that the patient had with the MD, with the next of kin--so you don't really know. And "knowing someone for several days" be careful, as we do NOT want to get emotionally involved to the point that as a nurse we feel we "know what the patient wants".

With that being said, the MOMENT that a patient says "no heroics and /or I don't want such and so to make decisions" is immediately when you use your resources--hospice, social work--to immediately draw up a new advance directive, and there's even MOLST forms that get more into specifics. These are legal documents. He said, she said, I know--as well intending as it is, it is not in writing, therefore, not particularly valid.

I have had patients and family that have said "I do not want to die, I am not ready to die, so keep me alive, period." And have had paperwork to that effect. It doesn't matter what I want, it is what they want. If they change their mind, NEW PAPERWORK is done immediately. Before it gets to a place where the patient is unresponsive.

It doesn't say if the patient was medicated for pain. Just IV fluid. Conceivably, a morphine drip would have not been out of the question. To focus on going forward with what you have is a thought process as well.

We need to be ultra careful with ethical stands. And we need to be careful that the family dynamics, the patient situations and goals are not intertwined with our own ideal for a peaceful death. So to take a stand with a patient on day one, we need to have the conversations, the paperwork to back it up, and resources in place. It is difficult to do when the patient is in the active dying phase, and unresponsive at that point.

[MECO28, BSN, RN]

The patient had expressed not wanting invasive treatments during their stay. I was not emotionally involved in the sense of really liking this person; actually they were probably one of the rudest, crassest people I'd ever cared for and I had been hoping not to have them again after the first day I cared for them. However, the situation got to me; especially the refusing to treat pain and air hunger.

When the patient expressed not wanting heroics, I told the doc. The doc said they were not competent d/t encephalopathy and refused to come and talk with the patient while they were still able to make their wishes known. This could have been avoided before they got to the actively dying part but it wasn't.

Honestly, I'm glad for the constructive criticism but I'm human, this situation is still raw, and I need to let it go. Therefore, I'm done commenting because I feel the need to defend myself and my actions. I also can't give a few vital portions of this story without seriously compromising privacy. Posting on an online forum was perhaps not the best road to take but I am grateful for those of you who took the time to respond. Dropping out now and going out to enjoy my day- I'm going to read a book for pleasure that has nothing to do with nursing, hang out in a coffee shop, take a long walk and just appreciate being alive.

[~PedsRN~, BSN, RN]

You truly stood up and advocated for your patient.... you did what you were SUPPOSED TO DO, and honestly - I wish more nurses did it!!!!!

[~PedsRN~, BSN, RN]

PS - I think another important lesson we can all take away from this is: GET AN ADVANCE DIRECTIVE IN PLACE! While you're healthy and you know what YOU want. I don't want any doctor (or nurse, or even well meaning family member for that matter) deciding what my end of life care should consist of. :)

[betm, CNA]

You did an amazing job advocating for your patient!

[imintrouble, BSN, RN]

I didn't read all the posts. I just went with my first thought when reading the OP.

Dead people don't fill out satisfaction surveys.

Nurses don't fill out satisfaction surveys.

FAMILIES, survivors, spread the word about the competency of an MD.

The MD made the family happy.

As angry as I get at our docs, not a single one I know would have made a dying patient suffer. I'm so sorry MECO28 had to endure an entire shift watching something so painful.

You did what you could.