Ethical principles

End of Life Care and Decision Making: Part 2

Slide 1

Screen:

Please enter your name in the space provided:

Slide 2

There is a table with Elaine Mills information:

Name Elaine Mills Notes

Age 96 Female

Diagnosis / Findings o Dilated common bile duct Large stone in duct

o Serious infection Extremely high WBC count

o Elevated temp.

Surgical status Poor candidate Poor risk general anesthesia

Action Biliary stent placement Will need to be replaced every few months

Narrator:

Elaine Mills has remained in the LTC facility for the past several days. The biliary stent worked well for a few days to maintain her comfort despite the fact that the bile duct extraction did not occur. However, Elaine began experiencing mild discomfort after the evening meal yesterday. Her discomfort continued to escalate during the night until it has become unbearable to her. She asked to return to the hospital.

She has been brought in by ambulance as a direct admit to your floor. She appears to be weak and in extreme pain to the point that she is barely coherent but is asking for help.

Elaine:

Please help me! I don’t care what you do! Just make this pain go away!

Narrator:

You remember her from her recent admission and know that the same gastroenterologist is on call. Her daughter and son-in-law follow her in and the daughter appears to be quite distraught when she sees her mother and hears her begging for help. She also begins to cry and asks what you can do to help her mother.

Joan:

Please, my mother is in so much pain. Is there anything you can do for her? I hate to see her suffer like this!

Slide 3

Narrator:

Let’s explore some potential next steps. What should you do based on your prior knowledge of Elaine’s case?

Screen:

What should you do based on your prior knowledge of Elaine’s case? Explore both of the options to learn more.

A. You recognize that this is an opportunity to pursue the previously recommended course of treatment: Extract the contents blocking the common bile duct and replace the stent.

What ethical principle is violated? Enter your response in the space below and briefly explain your response. Be sure to save your response when you are done.

B. You get an order for pain relief for Elaine immediately. The time to discuss treatment is after pain relief is obtained.

What ethical principle is upheld? Enter your response in the space below and briefly explain.

Slide 4

Narrator:

You retrieve Elaine’s record from her prior stay, and you review it. Laboratory studies indicated an acute infection with a high WBC count and her elevated temperature. You remember also that she had been on massive doses of antibiotics prior to discharge on comfort measures. At any rate, based on her condition at time of discharge, lack of treatment since discharge, age, and current weakened state, you are fairly certain that her prognosis is poor. Anything more than comfort measures is likely futile at this point. The gastroenterologist has examined her and his notes also reflect these findings. However, she has come to the hospital seeking treatment. As her pain level decreases, her family steps out for a break.

Screen:

Name Elaine Mills Notes

Age 96 Female

Diagnosis / Findings o Dilated common bile duct Large stone in duct

o Serious infection Extremely high WBC count

o Elevated temp.

Surgical status Poor candidate Poor risk general anesthesia

Action Biliary stent placement Will need to be replaced every few months

Slide 5

Narrator:

When they are gone, Elaine weakly pulls you aside to talk.

Elaine:

Please, I really only want to be free of pain, but I know my daughter is devastated at the thought of my death, which is surely isn’t far off.

Narrator:

Suddenly, out in the hall, you hear her daughter arguing with someone. When you leave to investigate, you learn that she wants her mother’s “No Code” status reversed.

Joan:

I didn’t realize my mother would suffer so much and I can’t bear that. I absolutely refuse to stand for it! If this hospital and the doctors here won’t change the orders, I will move my mother to another facility as soon as I can arrange it. I will go to court if necessary.

Slide 6

Narrator:

You are the only one who heard her mother state that she is really ready to die and understands her daughter’s feelings. What can you do? Select the best option provided.

Screen:

What can you do? Select the best option below.

A. Do nothing. You are not in a position to change any orders. You’re the nurse and you follow orders after they are written. Maybe the doctor will change the No Code status, and maybe not.

B. Call security to take Elaine’s daughter away from the area. She is disturbing Elaine and other patients in the vicinity. Let Elaine have a few final moments without these histrionics!

C. You take Elaine’s daughter to a quiet area away from her mother’s room so Elaine is not disturbed by her daughter’s emotional outburst.

A: If the doctor does change the order, Elaine’s wishes are not being respected and only you are aware of this.

Can you live with this knowledge?

Back to questions

B: You may also be depriving both Elaine and her daughter of the opportunity to say their final goodbyes now that Elaine’s pain is under control.

Back to questions

C: Finding a quiet area where you can talk and explain what Elaine has just told you might provide the peace that Elaine’s daughter needs with her mother’s impending death. Consider how all ethical principles may be applied to this choice.

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