Question

Ethical Dilemma Patient Case Scenario: New grad RN John has been working on his unit for the last 9 months on the night shift. He works on a small oncology (cancer) unit. Of the two RNs working in this unit during the shift (John and another new grad RN), John is more senior. Mr. T has been admitted/discharged out of the unit multiple times over the past 1 year. He has Stage IV Lung Cancer with metastasis to the brain, liver and bones. Mr. T has undergone several rounds of chemotherapy recently that have been ineffective for controlling his cancer disease. John has been told that his last admission to the unit was 3 month ago for a failed suicide attempt. John also learns during the shift that Mr. T has made several suicide attempts at home in the last few weeks. Mr. T was accepted by the hospice program within the hospital. He is currently being admitted for pain control and there are orders from the MD to start a Morphine IV drip to be titrated (adjusted) for pain. From viewing the chart John sees that per the order for the Morphine drip the parameters are to “decrease the drip rate for respirations less than 4 per minute”. Mr. T asks RN John to increase his drip several times throughout the shift. Even though Mr. T does not appear in any physical discomfort RN John goes ahead and increases the drip. His wife has been staying over in the hospital room during his whole admission with him. During hourly rounding John notes that Mr. Ts’ respirations are now 3 per minute and he is un-arousable. John turns off his IV drip and John tells the patients’ wife he will turn the drip back on if Mr. T arouses or shows any signs of being in pain, but that his respirations are dangerously low at this time. RN John reassesses Mr. T in 1 hour and notes that he begins to arouse, so John resumes his Morphine drip, but at a lower rate (it has been titrated/adjusted down per the order), and leaves to room to check on another patient. After 10 minutes Mr. T pushes his call button and upon RN John entering the room he starts yelling at John, saying John is trying to bring him back from death. Mr. T says, “I have a Do-Not-Resuscitate” order – you are supposed to let me die!” John tells Mr. T that he did not bring him back, but that by titrating his Morphine drip he stopped pushing Mr. T towards death.

1.) How do you ethically define what is happening in this scenario?

2.) Is there anything that could have been done differently or should have been done differently in this scenario?

3.) If you were the RN caring for Mr. T and had kept the Morphine drip turned on, would you be letting him die or causing him to die? Is there a difference? How do you justify your actions?

Answer 1

1. This is a case of an Ethical Dilemma. In the present scenario, RN John is following the ethical principle of beneficence and non-maleficence. If Mr. T loses his life due to an overdose of Morphine drip, then RN John can be held responsible for negligence which is one of the torts in Nursing. But since Mr.T wants to die and already finding ways to commit suicide, he's trying to blame RN John for going against his Right to Autonomy in the form of a DNR order. Ethical Dilemma is common among patients suffering from oncological and hematological disorders due to the chronic suffering that a patient has to undergo. For such patients, suicide, euthanasia, DNR is an easy remedy but can be against the ethics of healthcare personnel.

2. To handle a situation of ethical dilemma, RN John should be ethically competent. Ethical competence includes applying his knowledge, skills, and just being there for the patients. For the present scenario, RN John should approach an Ethical Committee and keep the committee informed about the updates of Mr. T. RN John can also compare the risk-benefit ratio to the patient comparing various theories, norms or values eg. theory of Utilitarianism, deontological theory and justify his actions based on these theories. Mr. T can also be advised to go for counseling sessions or group therapies for his suicidal ideation.

3. a. As an RN taking care of Mr.T, I would not keep the IV morphine drip running and would not have been letting him die. As an RN, I am primarily trained to save lives. My moral, ethical principles, values will not allow me to act which might harm or take the life of a patient.b. I would clarify with Mr. T about DNR orders when it can be applied and clearly state about the doctor's prescription for IV Morphine drip, its dosage, and nurses' action. c. I would also ask the wife of Mr.T to take the responsibility of acting as a Legal Guardian to take decisions when the patient cannot make his own. This would give an added benefit of safeguarding myself during such a dilemma. d I would also take the initiative in attending educational training on Ethical Dilemma so as to update my knowledge, skills, and improve my Ethical Competence as a practicing nurse.