Published Apr 7, 2003
Brief scenario: 75 yo, admitted for ulcerative colitis about 3 weeks ago, colon resection with colostomy about 1-1/2 weeks ago, admitted to our ICU, day later necrotic stoma, next day subtotal colectomy with ileostomy, now with comsumptive coagulopathy. Today this pt had a declining respiratory status. He has been lethargic, but very oriented. For the past couple of weeks he has been telling the nurses how tired he is and he doesn't want to fight anymore. His sats dropped in the low 80's and got them back up to about 95 with a 50% ventimask. Asked the patient if he got worse later on, would he want to be intubated, resounding NO! Spoke with the family who said he was not capable to make his own decisions and said they wanted everything done. Called the doc who first, promptly reprimanded me for not calling to increase his O2, then said give him narcan and 20 mg lasix (he had been given some MS about 6 hours before this happened. Gave both, no changes, pt still says he doesn't want intubation. Called doc back who said don't call unless there are respiratory changes, and I said if there are he doesn't want intubation and he is already feeling like he's smothering and can't breathe. Then said it doesn't matter, if he needs to be intubated we'll intubate him. Against the pts wishes? Yes. At this point I broke down crying and he asked how he was doing right now. So I told him, not well, he wants someone to tell him it's OK to die, he's tired, he doesn't want to fight, and he wants peace. He said he was on his way. Gets there, talks with the family, and still nobody asks this man what he wants. He then asks if we can go "have a talk". We go into a private area and he wants to know how long I've been in the unit and then proceeds to say that this man is not capable of making his own healthcare decisions and that if I want to call my lawyer and do something about it go ahead, but he will be intubated if that's necessary. So I tell this isn't about lawyers, this about trying to be an advocate for my pt. I've been his nurse for 3 days now and I don't see that he is getting any better, in fact he's getting worse. He said he had a great level of functioning prior, and he is "salvageable". I asked what he thought his level of functioning would be if he made it through and did he really think this man would survive being put on the vent, he already has no will to get better. He told me he didn't have a crystal ball so he didn't have any idea. If it came to the point where he's on the vent and things are looking like they won't improve, then he'll discuss a DNR status with the family, but until then the man will be intubated if it's necessary.
Then he calls back about 15 min after he left and told the night nurse to not give the family any information about the patients care. If they have questions, he will be by in the morning and they can talk to him because he's tired of having to correct all the wrong information given by the nurses.
So here I am, feeling like I failed my patient. I'm supposed to be the voice for my patient and the eyes and ears for his doctors and nobody's listening, and that is making me hurt and very angry.
I can't sleep, this all just happened this evening (at shift change of course) and I really just needed to get this out.
The nursing supervisor is aware of all this as well as my charge nurse and another nurse who witnessed my patient saying what he did and didn't want.
Oh, and BTW, for whatever it's worth, he has an advanced directive.
Hellllllo Nurse, BSN, RN
So sorry you are going through this. You did not fail your pt. The doc, his family and the medical system are failing him. If you have an ethics committee or hotline at your hospital, this is a situation for them.
I have also had pts who've suffered for political and/or legal/liability reasons. It really just sucks.
canoehead, BSN, RN
The system sucks. You did what I would want you to do as my nurse. Is the family aware of how he feels?
Tweety, BSN, RN
Thanks for taking care of this patient and caring. It's a bad situation. Take care.
jnette, ASN, EMT-I
Wow. That's really too sad.
What ABOUT pts.' rights, anyhow? Geesh, we're drilled over and over and over on this topic in school. and then you get in the real world and find out it doesn't hold water? What a crock.
I feel for you. AND him.
Let us know how it goes from here. Would be interested in the final outcome.
Zee_RN, BSN, RN
Yep. Happens all the time.
When I do in-patient databases and ask the question "Do you have an advanced directive?" and they patient responds YES, I always always always tell them to be sure their family members are well aware and completely understand their wishes because the LW means nothing in the face of an opposed family member. Many times they are amazed to find out that the LW is not a legally binding document.
And, of course, I have seen the patient change his mind about intubation when faced with extreme respiratory distress...and that's fine. Ideally it should be whatever the patient wants. I have also seen extreme measures taken for the hopeless case because that IS what the patient wanted. I feel bad for those family members, too, who want to end the suffering but know that the patient wanted everything done.
There are no easy answers. You did the right thing, though.
Thanks for the support.
I called the unit this morning and spoke with this pt's nurse. He is doing better this morning, on 3L NC and sats are 98-100. He said he has a real positive attitude this morning. I was glad t hear he was doing so much better. I also called my supervisor this morning to let her know what happened last night and she was in full support of what I did and just advised me to know when to back down since most docs know little or nothing about death and dying. I'm still upset and wish I hadn't shown that weak side to the doc last night, but she told me to let it go. So I'm trying.
purplemania, BSN, RN
you are very brave and acted as a real advocate to your patient. You also acted according to ICN and ANA Code of Ethics. The MD ought to be written up and a complaint made to ethics committee to prevent this from happening again. Ask the comm. what are the legal implications if pt. improves then he, or family, sues because his autonomy was denied?
gwenith, BSN, RN
I;ve said this beofre and will say it again usually the doctors who have the most trouble with allowing a patient to die have not come to terms with thier own mortality,
ceecel.dee, MSN, RN
That doc is only treating symptoms...taking mechanical action. You are taking great care of the whole patient. You are a good nurse!
God save the doctors who have forgotten that they are there to benefit the patient, so they must know what the patient wants, and stop thinking that THEY are God!
I think the other thing I would do is sit down with the patients' family and show them his advance directives and ask them why they do not think he is capable of making these decisions for himself.
The Family are the ones who have the issues; and they are the ones who want us to violate his rights. Being open with them and then LISTENING to their issues may help resolve some of these problems.
In my opinion, the doctor is between a rock and a hard place himself. If he should honor the patients' wishes against the families' wishes, then he may view himself as being open to a law suit (not to mention that if the patient dies, so many MDs feel they "lost" the patient-- so many doctors were not taught that death is a natural and final process of life).
KUDOS! to you for being such a strong patient advocate. That is what our patients need from us...to stand up for them to protect their rights. Doctors really have no clue when it comes to patient rights or death/dying. All they see is a chance to practice their skills that they may other wise not get to do and that is so pitifully wrong. I would suggest that the next time that happens and it is in the middle of the night, report it to the night supervisor...follow the chain of command and take the complaints through the appropriate channels and in the AM, take it to your hospital ethics committee/ And write up an incident report that the doctor refused to abide by patient wishes. It takes a psych evaluation with 2 doc's signatures and a court judgement to declare someone incompitent and unable to make medical decisions. Stick to your guns and kepp taking such excellent care of your patients. I would like a nurse like you to take care of me or my family in such times.
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