Further Light and Knowledge

How about this as an ethical dilemma? (I've been trying to write something up about the queer issues but I only get so far before I hit a wall... and I know I know, I didn't want to write about end of life care stuff, but this isn't really about that, plus it happened while I was working)

Patient comes in with stroke affecting left side brain, non-communicative, unable to move, unable to assess level of awareness etcetera. The patient had an advance directive filled out before hand that said something to the effect of "Do nothing for me... no PEG or NG tube, do NOT go out of your way to save me" basic let-me-go-if-I'm-a-veggie stuff. Two daughters, one the POA, thought otherwise.

Because the patient was admitted with problems affecting the brain and had initially exhibited poor level of awareness by the time he was aware and could answer questions by nodding his head or writing down what he wanted on a piece of paper he already had a PEG tube in because of the daughter and other measures had been made to keep him alive.

One particular night I was sitting in the neuro-step down unit (a step up from CCU) as a 1:1 with a different patient. The nurse and I were chatting outside the rooms when she got a call from the daughter requesting her dad's hand be tied down to force him to wear the bi-pap that he was constantly removing with his good hand. The nurse said "no, he doesn't need it." and he didn't, his O2 saturation was at 96% on room air, his breathing was non-labored and he hadn't had any periods of apnea since coming to our floor from CCU 3 days previous. The daughter was livid. Yelled, screamed, cussed at the nurse, and said, "if he dies it's your fault" then hung up the phone. 10 minutes later the doctor called and basically said, "i don't care, just tie his hand down so this crazy woman stops calling me while I'm trying to sleep."

So what's an appropriate response? Refuse to restrain the hand and report the doctor? (this doctor's an ass by the way) Lie to the daughters and say the hand was restrained? Restrain the hand when he obviously doesn't need it and it will do nothing for him? At the point above we now had an order for restraints, but it was a needless order that added to the patients discomfort (doubly since he didn't want the bipap on and the restraint was humiliating). Both daughters exhibited a horrible inability to learn and listen to reason related to their father's care... and just for shits and giggles I'll add that they stayed with their dad and read the bible to him for 3-4 hours a day, the man was covered in old tattoos by the way and gave me the impression that he was about as religious as a watermelon.

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I'm not sorry, I like to get laid. --Mercury

I took roughly 1/3 of my available vacation for the year to chase 12- and 13-year old boys through the woods. --Mcarp

"unable to assess level of awareness"

I would go by the advance directive. DNR does not mean "do not treat". It only means "Do Not Resuscitate". If the guy specifically said, no bipap or oxygen or so forth in his advance directive then I wouldn't apply the bipap and wouldn't restrain the guy. If not, then I would go by what the POA or next of kin wanted. The restraints would be appropriate if the guy was confused and pulling off the bipap but not (IMO) if the bipap was not necessary. If he didn't need the bipap then what is the point of the restraints? You then get into an area that could be considered assault or something along those lines.
(assuming the AD said nothing about bipap or oxygen)
What I would do: get an oxygen saturation monitor with alarm and leave the guy on room air or nasal cannula (whatever is appropriate). Call the daughter back and tell him that you have a doctor's orders for restraints if needed to prevent her confused father from removing therapeutic equipment. Tell the daughter you will use the restraints as a last resort if the bipap is needed and until then you are closely monitoring her father with continuous oxygen saturation monitoring and frequent checks to make sure he is getting enough oxygen. I'd tell her that her father's safety and comfort are top priorities of care and that I will weigh the necessity of bipap vs restraints based on those priorities.

Again, for me, it all depends on what the advance directive says. If it says no supplemental oxygen or something along those lines (and the doctor is giving you an order for bipap/restraints) then you need to call your hospital ethics line and report the situation.

my 2 cents

ETA:"Because the patient was admitted with problems affecting the brain and had initially exhibited poor level of awareness by the time he was aware and could answer questions by nodding his head or writing down what he wanted on a piece of paper he already had a PEG tube in because of the daughter and other measures had been made to keep him alive."

Sorry, I misread this part.
1. Is he oriented x3?
2. After he was a/ox3: Did he want the peg tube? Does he want the tube feeds to continue?
3. If he wasn't a/ox3 at the time of peg insertion and stated in his advance directive that he didn't want a peg tube: Why was one put in?

It seems to me that there should be an ethics consult on this either way. IMO, doctors are afraid to go against the wishes of the family because they are the people who will try to bring a law suit later on down the road.

However, with a stroke: you don't always have a clear picture of the person's level of functioning in the first couple of weeks. The swelling in the brain must go down and usually the patient is either worse or better compared to when they first came in vs 2-3 weeks out depending on the type of stroke and the area of the brain the stroke occurs. So perhaps "other measures ...to keep him alive" might be appropriate depending on one's interpretation of the advance directive with wording like "vegetative state".

Its not uncomplicated.

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All views expressed by jahedgpeth are the sole property of jahedgpeth inc. and subject to change by edit without notice.

Number 3.
I didn't get a chance to look at his chart (who has time when you're ancillary staff and have a hundred things to finish at the same time?) but was told by multiple nurses that his advance directive (from a previous hospital visit) directly stated no life saving measures were to be taken to save his life especially r/t to tube feeding. For some reason he was not a DNR at the time, and the health-care team had a hell of a time convincing the daughters that just because we wanted him DNR it did not mean we were going to unhook him from everything and let him die, but merely that we wanted him DNR so if he did code that we weren't going to take any extreme measures to resuscitate him.

The doctor mentioned during rounding while the patient was in CCU that it wouldn't be a bad idea to throw a bipap on the guy at night especially since he had had some periods of apnea (but no previous known history of apnea), the daughters seemed to interpret it as "your dad needs to be on a bipap or he'll DIE!!!!!" And no amount of explaining, even from the doctor who said it, would convince them otherwise. Whether it was some weird anticipatory grieving process or if there really was something off kilter in their thought processes they absolutely refused to listen to reason.

Since he was in our neuro step-down unit he was hooked up to a monitor that constantly monitored his O2 saturation as well as his breathing rate and pattern, and his heart rate and rhythm. And the nurse told the daughter this as well, as well as telling her that she, the nurse, only had 3 patients to care for so she was constantly with him and able to keep an eye on him most of the time. So the restraint was placed per the doctors order if it was an "assault situation" (as you mentioned above, jahedg) who was the person committing assault? The doctor, the nurse or the daughter? Ultimately the doctor would face the brunt of it if an ethics committee was involved and the nurse would be held responsible as well for not questioning the doctors orders, but could there also be legal ramifications towards the daughter?

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I'm not sorry, I like to get laid. --Mercury

I took roughly 1/3 of my available vacation for the year to chase 12- and 13-year old boys through the woods. --Mcarp

I'm not a lawyer so perhaps one of the great legal minds of FLAK could make up for my lack of knowledge in this area. From what I understand:
1. No legal ramifications for the daughter.
2. Legal ramifications for the nurse and doctor if they knew of the advance directive and went against it (in some cases civil and/or crimminal).
3. Possible battery charges any time you as nurse/doctor perform invasive medical proceedure without proper consent from the patient or the patient's representative (next of kin/PoA).
4. As a patient advocate you have a responsibility to see that the wishes of the patient are followed to the best of your ability. Knowingly participating in anything the patient doesn't want goes against advocating for the patient.

Some families can be a challenge in these situations and this case is not black and white. As a nurse, I'd contact the ethics committe. A neutral objective third party can often be helpful to see the big picture.

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All views expressed by jahedgpeth are the sole property of jahedgpeth inc. and subject to change by edit without notice.

Families like these make me cringe and I often try to avoid the room as long as possible when they're in there. Seriously, if your (generalized) parent is 89 years old, just suffered a massive stroke (or whatever) that likely he/she will never fully recover from and they'll now need to spend the remainder of their lives in a Long Term Care facility lying in bed and drooling while you come and visit them once or twice a week for an hour at a time, and you make the conscious decision as a POA to put them in that position... I hope there's a hell, cause there is a special place reserved there for you.

Thanks for pounding this out with me Jahedg, your input helped keep me on track.

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I'm not sorry, I like to get laid. --Mercury

I took roughly 1/3 of my available vacation for the year to chase 12- and 13-year old boys through the woods. --Mcarp

FWIW,

Having recently gone through the death of a relative (my brother) where I was next of kin. I've got to say that I was impressed with the nurses in the ICU for how professional they were. They were honest, forthright, and compassionate. All things that I needed at that time dealing with the death of my brother, and making decisions on when to terminate care. So to all you nursing types out there. Let me offer you all a thanks for doing a wonderful job.