What are the top 5 ethical dilemmas faced by nurses?

Be_Moore · Jun 25, 2009

Personally, my favorite is the 90 y/o with cancer who is found down in the field, intubated, started on pressors, and the family wants us to do "everything" because they are the "most special in the world." So they are so special that should his/her pressure tank, we should crank pressors until toes fall off? And should his/her heart stop beating we should break their 90y/o sternum? If that's what love is, I hope no one loves me should I live to be 90!

Woodenpug, BSN · Jun 25, 2009

Yeah, that's the most common one. Self determination vs. non malefeasence. Of course, true self determination should imply informed consent and therefore no broken bones in a futile cpr effort.

arelle68 · Jun 25, 2009

She was 96 years old. Her lungs were full of fluid. CHF. Her granddaughter asked me would I please get Morphine for pain. I assessed the pt not to be in pain. I stated perhaps she had anxiety, and went to get Ativan. I noted that the Ativan had been given two hours before. Couldn't give Ativan. Drew up a syringe of Morphine 15 mg as prescribed, and headed back to the pt's room. The granddaughter stated, "I think she just took her last breath." She was still breathing. Very, very shallow. Her heart was beating very rapidly. A flutter. Again, I assessed for breathing. No more. Assessed for pulse. It was gone. Then...I thought about the Morphine in my hand.

jnrsmommy · Jun 25, 2009

The terminally ill pt who has his DNR paperwork in order, whose wife watched him sign not 3 hours before, after a lengthy discussion about this being his wish. When he passed, having her scream "Do something!" and having to proceed to code him.

rachelgeorgina · Jun 25, 2009

beneficence vs non-malfeasance

patient autonomy vs patient advocacy

the provision of justice

i'm a student and just toke ethics and law in healthcare. we did three really interesting assignments:

1) pt has history of alcohol abuse, currently in remission. pt pregnant and shows no signs of drinking throughout pregnancy whilst monitored by her middie at home. upon birth of the baby, dr. tells mum that baby has fetal alcohol syndrome in order to scare her out of drinking. the baby doesnt have anything wrong with it. mother is exceptionally distressed and proceeds to hysteria. what does nurse do?

2) pt has Stevens-Johnson Syndrome with uncertain prognosis (50/50 chance). pt arrests, is unconscious vented and needs dopamine to maintain her BP constantly. pt disclosed to family and nurse prior to arrest that she doesnt wish to be kept alive should her become a "vegetable". she also has an advanced care directive stating that should she become terminal, she doesn't wish for life sustaining measures. nurse says to doc that perhaps we should discontinue treatment in accordance with pt and family wishes. doc says no. nurse hangs a bang of normal saline, labels it dopamine, pt arrests and dies. was this ethical?

3) does mental health legislation (in australia) violate pt autonomy, dignity? and does it enhance and enforce unrealistic stereotypes regarding the mentally ill. do nurses play a part in this?

Zookeeper3 · Jun 25, 2009

I'll just reiterate whats been stated, end of life care. Our doc's do such a poor job, in the face of families giving false hope because it's easier. As nurses, we paint another picture, we're there for 12 hrs. we know what is going to play out.

It's ICU or other nurses at the bedside that have the talk, did it last night.... full blown septic shock, on chemo, mets.... maxed on three pressers... "I will keep pounding on her chest, breaking more ribs, until you decide to let her go peacefully and tell me to stop, or until my breaking her ribs, pushing on her chest works no more, either way, the outcome is the same... ... how would she want to die?"

Being a patient advocate is the toughest part of the job, and the most worthwhile

zuzi · Jun 25, 2009

Start the investigations and treat the patient or start the hospice???

Lacie, BSN, RN · Jun 25, 2009

Working in chronic dialysis I see many times patients being referred for transplant evaluations. My boss states it's not our or the doctors determination if someone is too old or too ill with other co-morbities to make that decision not to refer. Consider this - 96y/o male with copd on continous O2, in a nursing home and alzhiemers to boot. We referred this patient for kidney transplant evaluation. This means the pt had to also make a 3 hour trip on way to the hospital the transplantation would occur if accepted. #2 scenario - 23 y/o with genetic TTP with 3 associated CVA's and hep C. Has been turned down by 3 other transplant facitilites but again boss insisted so we sent her to another for eval, getting her hopes up only to be turned down once again placing her back into a depression. Is it rational to put these people through all this?

Vito Andolini · Jun 25, 2009

Be_Moore said:
Personally, my favorite is the 90 y/o with cancer who is found down in the field, intubated, started on pressors, and the family wants us to do "everything" because they are the "most special in the world." So they are so special that should his/her pressure tank, we should crank pressors until toes fall off? And should his/her heart stop beating we should break their 90y/o sternum? If that's what love is, I hope no one loves me should I live to be 90!

How about 89?

79?

69?

09?

9 months?

First off, age is not necessarily the deciding factor. Diagnosis isn't either. It is more a matter of what the patient wants and what the family wants. As for pressors until toes fall off - again, there has got to be teaching and lots of it.

Finding someone down in the field is a lot different, ethically, than a hospitalized patient who crashes or a home care patient who crashes, the way I see it.

I agree about not wanting to be loved so much that they torture me.

In answer to OP's question: How about the case of a woman with a very rare pelvic tumor? I recall an attending bringing about 20 med students and house staff into the exam room and each of them stuck their fingers inside of her, trying to learn the feel of this tumor. They hurt her. She was crying. The nurse tried to comfort her. I feel she was gang-raped.

Yeah, I know everyone has to learn but there's a decent way to go about it. At the time, I was very young and inexperienced, so I did not intervene but if that happened today, I'd step in, block their access to her, and say, as soon as she was obviously becoming restless and uncomfortable, Enough. She's in pain. The rest of you can come back another time. Or I'd let the attending know ahead of time that there was going to have to be a limit to how many students could examine her at once. We'd work it out so I could keep my job and still protect my patient.

Vito Andolini · Jun 25, 2009

Lacie said:
Working in chronic dialysis I see many times patients being referred for transplant evaluations. My boss states it's not our or the doctors determination if someone is too old or too ill with other co-morbities to make that decision not to refer. Consider this - 96y/o male with copd on continous O2, in a nursing home and alzhiemers to boot. We referred this patient for kidney transplant evaluation. This means the pt had to also make a 3 hour trip on way to the hospital the transplantation would occur if accepted. #2 scenario - 23 y/o with genetic TTP with 3 associated CVA's and hep C. Has been turned down by 3 other transplant facitilites but again boss insisted so we sent her to another for eval, getting her hopes up only to be turned down once again placing her back into a depression. Is it rational to put these people through all this?

Does your boss benefit financially for referring them?

Vito Andolini · Jun 25, 2009

arelle68 said:
She was 96 years old. Her lungs were full of fluid. CHF. Her granddaughter asked me would I please get Morphine for pain. I assessed the pt not to be in pain. I stated perhaps she had anxiety, and went to get Ativan. I noted that the Ativan had been given two hours before. Couldn't give Ativan. Drew up a syringe of Morphine 15 mg as prescribed, and headed back to the pt's room. The granddaughter stated, "I think she just took her last breath." She was still breathing. Very, very shallow. Her heart was beating very rapidly. A flutter. Again, I assessed for breathing. No more. Assessed for pulse. It was gone. Then...I thought about the Morphine in my hand.

And? What's the end of this story?