Top ethical concerns to RNs

imintrouble, BSN, RN · Nov 12, 2015

If there are s/s of distress, any distress, any SOB, any minute movement I can chart to justify the med I'm giving, I'll do it. If the patient's arm falls off the bed when the pillow's moved I'll give the med. Why can't my fellow nurses, Hospice nurses, understand the very real ethical quandary I find myself in, working acute care as opposed to Hospice.

Libby1987 · Nov 12, 2015

If there are s/s of distress, any distress, any SOB, any minute movement I can chart to justify the med I'm giving, I'll do it. If the patient's arm falls off the bed when the pillow's moved I'll give the med. Why can't my fellow nurses, Hospice nurses, understand the very real ethical quandary I find myself in, working acute care as opposed to Hospice.

My dad unfortunately had to die in the hospital because we couldn't get hospice set up fast enough, he was admitted as a palliative care patient and was under the same conditions as a hospice patient, why wouldn't your patients be as well?

imintrouble, BSN, RN · Nov 12, 2015

My dad unfortunately had to die in the hospital because we couldn't get hospice set up fast enough, he was admitted as a palliative care patient and was under the same conditions as a hospice patient, why wouldn't your patients be as well?

I don't know. I only know we don't have Hospice patients. I'm not a Hospice nurse. Besides, my complaint is not palliative care, it's killing the patient.

I'm not a psych nurse either. That was # 3 of my ethical complaints.

CountryMomma, ASN, RN · Nov 12, 2015

Allocation of scarce resources, especially in populations that continually squander them.

Lack of discussion in the lay population on what exactly a code consists of, and what that will do to a 94 y/o terminal COPDer or FTT.

Broken multi-payer system that has more cracks than the streets of Detroit and is incentivised to deny needed care to maintain obscene profits.

The treatment of Native Americans by both staff and the IHS.

Jensmom7, BSN, RN · Nov 12, 2015

I know exactly what you're asking, but I don't want to hijack the OPs thread. I have no problem medicating a dying patient. None. Zero. I'll do it in a heartbeat. If there are signs of some kind of distress. Some movement, any movement.. Moaning. Something I can point to to justify the 4 mg of Dilaudid the family wants me to give. When the patient hasn't moved, except to breath, for hours.
When the family has specifically said they want Grandpa to "die in the hospital", instead of at home.
Hospice and med/surg are not the same. You and I are both nurses, but the arena we work in is different. With different rules and expectations. Even different laws.
Let me again be clear. I'm talking about the patient whose only movement for hours is their chest rising and falling, and the famly request for pain med/Ativan is to very plainly make them die faster.
Again, in a patient's home the rules are different, than when they're an inpatient in an acute care hospital. You have a family who are all on board with the decision for the loved one to die.
All I have to have is one family member who looks at me like Dr Kevorkian. There are no signs of pain, distress, discomfort, and I push Ativan and Dilaudid, just because it's ordered.
How do I justify that?

Actually, unless it's a specified inpatient Hospice unit (ideally covered by dedicated Hospice staff), CMS doesn't accept "wanting Grandpa to die in the hospital" as justification for GIP (General Inpatient). Imminent death is also not justification for GIP as long as the patient is comfortable. There have to be symptoms severe enough that the patient needs closer monitoring than they would get at home.

It sounds like the Hospice agency either wasn't as involved with the family regarding information concerning EOL care as they should have been, or they were playing the system.

They recently closed a big agency in my state for overuse and misuse of GIP. That may have been the reason for having to push those meds without symptoms being present.

It's a shame you were put in that position. Believe me, I'm on your side when it comes to a situation like that. We work to give the least amount of medication necessary for the patient to be comfortable. And actually, stuff like that IS an ethical dilemma, so no hijacking happened!

FYI, you can call the Medicare Hotline number any time if you suspect fraud. That's why I asked the questions I did, to get a better picture of what was happening.

Libby1987 · Nov 12, 2015

I don't know. I only know we don't have Hospice patients. I'm not a Hospice nurse. Besides, my complaint is not palliative care, it's killing the patient.
I'm not a psych nurse either. That was # 3 of my ethical complaints.

You have a very valid point about working outside of our scope/training/preparation. It can be scary to have what I would call a Med-surg patient in the home setting, happens all the time now with the tighter admission protocols.

Jensmom7, BSN, RN · Nov 12, 2015

There are alot of things worse than death.

I'm going to totally regret being drawn into any interaction with you, but just a few things:

1. Do you actually understand what "agonal breathing" is?

2. Do you understand that management of the symptoms of agonal breathing at EOL is completely justified and in no way means that someone has been "medicated to death"?

3. Per your above comment, are you advocating assisted suicide (a completely different debate, no judgement, merely requesting clarification of a rather ambiguous statement)? Because contrary to popular belief, that is not what either palliative or Hospice care are about. At all.

imintrouble, BSN, RN · Nov 12, 2015

I hadn't thought of that perspective. I can't imagine being a HH nurse, having to take care of a patient that was clearly not well enough to be discharged from the hospital. Or not well enough to be at home, but could not be admitted. Maybe all of us are being put in positions we couldn't have imagined even 10 years ago.

I was responding to Libby's post. My quote didn't work

LDAthleteNurse, BSN, RN · Nov 12, 2015

I hadn't thought of that perspective. I can't imagine being a HH nurse, having to take care of a patient that was clearly not well enough to be discharged from the hospital. Or not well enough to be at home, but could not be admitted. Maybe all of us are being put in positions we couldn't have imagined even 10 years ago.
I was responding to Libby's post. My quote didn't work

I agree.

allnurses Guide · Nov 12, 2015

I'm going to totally regret being drawn into any interaction with you, but just a few things:
1. Do you actually understand what "agonal breathing" is?
2. Do you understand that management of the symptoms of agonal breathing at EOL is completely justified and in no way means that someone has been "medicated to death"?
3. Per your above comment, are you advocating assisted suicide (a completely different debate, no judgement, merely requesting clarification of a rather ambiguous statement)? Because contrary to popular belief, that is not what either palliative or Hospice care are about. At all.

Just got back from a hospice conference and your post was timely.

Our state recently passed a Death With Dignity law allowing Physician-assisted suicide.

It has put hospices in a tough position.

We had an Oregon nurse talk about options for hospices since Oregon has had that law for awhile now.

I guess my concern is what I've fought for years - the idea that hospice comes in and kills patients with Morphine Sulfate (or another drug).

Now some folks think we should hitch our wagons to physician-assisted suicide. It hurts my heart.

Why not just let another "agency" handle that and keep hospice the way it was intended; the way it started?

We do not "kill" people with drugs. We manage symptoms at end-of-life and we don't kill anybody.

2k15NurseExtern4u, BSN, RN · Nov 12, 2015

There are alot of things worse than death.

This..

**NickiLaughs, ADN, BSN, RN** · Nov 12, 2015

A lot of the points above are so valid.

I worked ICU and keeping a pt alive for months on a vent, trached, pegged with family who would visit once a week or so and continue on insisting care. One time, I had this absolute ridiculous family and I made sure to turn them while they were there to see the bedsores. We were turning per protocol but this patients entire body was just breaking down no matter what we did. They were terminal. The family got to hear this persons moans. I grabbed a very good intensivist who was great about talking to families regarding end of life and thankfully after many tears they allowed us to make this person comfortable and disconnect the vent.

i feel that nurses encounter ethical delimmas daily and that's one of the things that makes us all amazing. We push through and we keep fighting for what's right for the patient.