Question

Mrs. R., an 87- year- old patient, has a past history that includes coronary artery disease, a previous stroke, and advanced Alzheimer's disease. Ten days ago, Mrs. R. was hospitalized for aspiration pneumonia and has been ventilator dependent since being admitted to the intensive care unit in a small rural hospital. Family members visit daily and have repeatedly voiced their concern to the nursing staff about the continued ventilator support that Mrs. R. is receiving, most notably the fact that Mrs. R. would never have wanted such care. They also note that Mrs. R. has not recognized them in past months and that they plan to visit less in future days, but can be contacted should any change in Mrs. R.' s condition occur. Her primary physician has practiced in this community for multiple years; he is well known for his reluctance to discontinue any type of life support for any patient. When questioned, Dr. G.' s consistent response is, if this were his frail 92- year- old mother, he would prescribe the very same treatment for her. Dr. G. has now requested that the nurses talk to the family about moving Mrs. R. to a major medical center, where she can receive more advanced care, including vigorous rehabilitation and physical therapy, so that she may eventually return to a long- term nursing care facility. How might the nurses in this scenario respond to the physician's request? How would this scenario begin to cause moral distress among the nursing staff, and what are the positive actions that the nurses might begin to take to prevent moral distress?

Answer 1

"They may forget your name but they will never how you made them feel ."

- Maya Angelou

Dr, Authur Kleinman said, " There is a moral task of caregiving, and that involves just being there, being with that person and being committed. When there is nothing that can be done, we have to be able to say, Look, I am with you in this experience. Right through the end of it." In the above scenario, Mrs R. who is critically ill, have nothing more that can be done in a medical center. She needs more advance supportive and a long term care to sustain life. Taking decision about proceeding a treatment or terminating it, is not the responsibility of the nursing staff. Its the decision of the treating physician and family members jointly. So when Dr. G request the nurse to talk to the family about moving Mrs.R to a major medical center, she should show her readiness to do so. She should agree to talk to the relative but the need of the higher medical aid should be explained firstly by the doctor himself.

Such cases tend to develop a moral distress among the nursing staff as she knows that the ventilator is just supporting the patient's life and she would not survive if its removed. But she is also concerned about the family members who wish to see their patient well but is does not support the use of ventilator.There is nothing that more can be done for Mrs. R. The family members concern regarding the use of ventilator therapy and the doctor's reluctance to discontinue life support creates distress among nursing staff to accept which treatment modality will be the best for Mrs. R.

In order to prevent such distress,

• Firstly a nurse should understand her limitation in making decision for the patient's treatment.
• Secondly, nurses are supposed to deliver care irrespective of age and the medical condition. Even though patient's condition says that nothing more can be done, a nurse have to give a good quality care till the end of life.
• The nurses can explain the available treatment modalities for such patients despite of the patient being treated in higher centers or rural hospitals.
• The consequence of weaning the life support should be informed to the family members and they should be allowed to make the decision.
• The nurses should give adequate support and care to the patient till the patient is transfered to a higher center.