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 care 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.

Questions:

How might the nurses in this scenario respond to the physician’s request?

What ethical principles have potentially been violated in this scenario?

How would this scenario begin to cause moral distress among the nursing staff?

What are actions the nurses can take to have moral courage in dealing with this situation?

Answer 1

In this scenario the physician personally is against stopping any life saving measures. But as a nurse caring for the elderly patient, need to work for the patient and advocate for the patient.
At the bedside, it is not uncommon to hear statements like "We can’t just let mom die," or "Mom would not have wanted to live like this." When families of different dying persons voice these statements and the statements are reflective of the dying person’s wishes and also within the scope of nursing practice, there is no conflict. But members of the same family often express conflicting statements, or perhaps no one has asked the dying person what is wanted related to end-of-life care.
"The nurse’s primary commitment is to the patient, whether an individual, family, group or community" In the conflicting statements given above, remember that if you are the nurse caring for the dying person, your first duty is to that person. Secondly, your duty is to the family, that is, to help the family understand the wishes of the dying person.
"The nurse supports patient self-determination by participating in discussions with surrogates, providing guidance and referral to other resources as necessary, and identifying and addressing problems in the decision-making process"
As patient advocates we can advise, foster, and facilitate early discussions about end-of-life issues, thus helping individuals make informed decisions. Early discussions also help family and significant others to discuss beliefs and values with the elderly person when death becomes more imminent.