In all my years of nursing there is one thing that I have found to be constant. Ethics. Health care practitioners are faced with ethical dilemmas on a regular basis.
Look at the ethical issues around stem cell or egg harvesting. Those are some of the more controversial topics but ethical all the same.
As an RN I have been witness to many situations that I questioned the validity of treatment or lack of treatment. It's such a hard call sometimes. I mean do we replace the hip of a 95 year old who has fallen? The questions that are posed from that are: What was their quality of life prior to the fall? What was their level of function will a new hip improve their quality of life?.....my answer would be yes....but then we have to ask ourselves what are the risks of surgery.....what was their health prior to the accident, do they have lung problems? Heart issues? Are they diabetics? What is their cognitive state? Those are all things that should and must be considered prior to surgery.
I had a situation the other day....a young male came in for dental surgery. His teeth were in such bad shape that if they weren't dealt with they could cause him much worse problems in the future. Unfortunately, he had mental health issues as a result of a previous head injury. The young man did not want the surgery,his parents thought it best that he have the surgery. He was belligerent prior to the surgery. He refused to undress I don't know how they managed to sedate him for the procedure but they did. He arrived in the recovery room and I knew we were in trouble. He was semi awake and already calling out and being verbally abusive. We anticipate and accept a certain amount of obscenity post op as often it is the drugs that are used during surgery that cause people to respond in a certain way.
When this young man started coming around....he didn't want to have anything to do with being in the hospital...he started pulling off his oxygen mask, the monitoring equipment... we attempted to calm him and eventually he would settle down, although briefly.....the unfortunate thing with this person is that he stopped breathing a couple of times and had what we thought were seizures......it was all very strange...the anesthestist was called and we ended up helping him with his breathing. He came around .....and again he was aggressive and did not want to be there......he was a big person and very strong......we ended up calling a code white on him(aggressive patient) and hoped that security would arrive in time to give assistance....this didn't happen....he pulled out his IV....jumped off the end of the bed.....left the recovery room.....punching holes into the wall. The patients mother was there......she asked people to back off.....she assisted him to the car and left.
Here's the dilemma......was he a candidate for the surgery? Yes....did he want the surgery.....NO....was he in a right state of mind to make that decision for surgery......Questionable.....should we have insisted he stay in the hospital and recover fully before leaving the hospital....my gut told me yes..... should we have restrained him until he was fully recovered......possibly.
I don't know if there are any clear cut answers to this. I know my colleague and I were very upset by what transpired. The anesthetist and the doctor came and spoke with us....explained that it wasn't the drugs that were given during surgery...that those drugs would have worn off by the time he arrived in the recovery room. So what was it, what caused this person to behave and act out that way and should they have performed the surgery?
I don't know that I have the answers to these questions....all I know is that sometimes I am faced with situations that push the ethical boundaries for providing care and treatment.
What do you think?
9 comments:
You bring up such thought provoking topics. I honestly don't know how that situation could be dealt with when the patient has mental health problems. If he's not capable of making decisions in other aspects of his life then maybe he couldn't make this decisions but even so it's tricky and I can see why it would be upsetting to everyone at the hospital.
The example of hip replacement with the elderly is one that hits close to home. I'm glad you brought up issues like what they were able to do before they needed a hip replacement.
My mother died at 65 but her mother lived to be 103. My grandmother was very active well into her late nineties. She had a hip replacement in her early nineties after a fall. In her case, the hip replacement gave her almost 10 more years of not being in a wheel chair.
She was in a wheel chair from around 101 until she died at 103 but had she not been given the hip replacement in her early nineties she would have been infirm almost 10 years before she had to be. I realize that's an extreme situation since frankly most don't live that long. Neither of my parents even lived to 73.
I know your job has some rewarding times but I can also see how stressful it can be. I think your patients are lucky to have someone as compassionate and thoughtful as you are.
I found this
I mean do we replace the hip of a 95 year old who has fallen? The questions that are posed from that are: What was their quality of life prior to the fall? What was their level of function will a new hip improve their quality of life?.....my answer would be yes....but then we have to ask ourselves what are the risks of surgery.....what was their health prior to the accident, do they have lung problems? Heart issues? Are they diabetics?
interesting RN.
My 82 year old father was crippled and in need of a new hip. He was in constant pain, couldn't walk, housebound. He took medication for his heart, his breathing, diabetes and the hospital kept putting him off for a hip replacement. He was taking so many pain killers he was constipated and unable to eat - he'd lost a lot of weight to the extent he looked like a skeleton. He told us (his children) if he didn't get the operation he didn't want to live and said he would stop taking all his medication and let nature take it's course. Against the advice of the anaethetist his surgeon went ahead and gave my dad a new hip, he had to sign a disclaimer for the anaesthetic. That surgeon has given my Dad a new lease of life - he has put weight back on, he goes out 4 times a week to his bridge club, he digs his garden and tells us every day how thankful he is to have been given this second chance of life.
Wow, what a day! I, too, don't have a black and white answer.
I have so much respect for people in the medical profession. I honestly can say I couldn't do it. It's thanks to wonderful people like you that take care of us when we really need it the most.
Working in anesthesia and mental health, I can tell you there are no easy answers to this.Our hospital decided to use only mental health nurses in rcovery rooms if the patient has a history of mental illness. These nurses were trained to wear both hats. (I was one of them) Of course anesthesia will always claim that the anesthesia was not the cause of the behaviors but when you think about it, a mentally ill person who has delusions or hallucinations and then wakes up from surgery is more disoriented than the average person and as a result will become more difficult to handle. Since anesthesia affects everyone different it highly possible that that was a major cause of this persons behavior.
As for hip replacements and other surgeries for eldery folks, my opinion is this: If there is even a remote chance of improving the quality of life, do it. Also one of the most important aspects of this is relieving pain.
We have a tough profession don't we, but the rewards are sure much greater than the drawbacks.
Somedays you and the other RN's that deal with this kind of thing actually need 'hazard' pay! It is a difficult question regarding when to do surgery for whatever reason......a decision that is probably best left to the patient/patient advocate and the physician! I wouldn't want to have to make that call!!!
Bless you for the help you provide to those who come under your care.....if I need a nurse, I would pick you, my friend!!!
Hugs!
When my Dad fell and broke his hip in the care home, he was in such agony for 4 days until they were able to operate! The doctors didn't think he'd make it through the surgery because of the anasthesia, but he did. However, he was very agitated when he came to. But, his pain was relieved and he managed to live another 10 days before passing away in the care home that he considered to be "home."
My feeling - if they're in pain, fix it!
I think he should have had the surgery but been more closely watched on a mental level. From what I understand people who suffer from a head truama that results in mental health issues are usually volatile. If it was know that he had mental issues maybe they should have been explored more fully before the surgery was performed. Does that make sense?
It doesn't sound like the Mom was much help.
Nursing is a tough business. I think each case is different and has to be evaluated on it's own. As nurses we are there to support the patient and family with the decsions they make. It might not be the decision we would chose and we can suggest other alternatives but in the end it's up to the patient or the patient's advocate if they are unable to make decisions for themselves. If it's something you truly believe is wrong or should be changed you always have the option of addressing the ethical committee where you work.
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