Consent and ethics

Nursing is fully aware of consent. We know that we need to have documentation that the patient accepts this treatment. It’s a no brainer. But, what if the patient doesn’t want treatment and the power of attorney does?

Prime example, you have an elderly patient that is obviously letting the family talk them into surgery. To no one’s surprise, it doesn’t go well. They end up sick. They have to remain intubated. They need an art line, central line, pressors, the works. Even on the ventilator they are adamantly shaking their head no to all the things you’re trying to do. They are fighting. They keep trying to pull away. They don’t want this.

Their family does.

The POA is who the doctors decide to ask for consent to treat. They completely bypass the patient. They’re intubated, they can’t answer for themselves right? If course the family wants everything done… So, everything is done. Is that fair to the patient?

Shouldn’t the patient be allowed to say no without having someone else choose otherwise? What is the fine line that decides when a patient no longer has the capacity to make their own decisions? Does intubation automatically take away that right? Does having a POA take away that right? If a patient is clearly communicating, even in the vent, shouldn’t we respect their wishes?

The nurse in me says yes. The nurse in me says to respect my patient’s dignity.

The nurse that’s been at the bedside for almost 8 years knows that that is normally not the case.

I have seen advanced directives ignored because the patient is unconscious and the family isn’t ready to let go. I’ve seen cases like the one mentioned above. I’ve seen doctors watch as the family is almost forcing a patient to go along with treatment and the doc just goes along with it as well. I’ve had to be a part of “moral distress” meetings because nurses were stressed over the ethical dilemmas involved in certain cases. When do we stop?

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Resident-splaining

One thing that absolutely drives me nuts is having a new resident come to the trauma unit, that I have worked on for almost three years, and “resident-splain” something obvious to me!

What is resident-splaining? It’s when a resident condescendingly “explains” something to you that they assume you know nothing about because you’re just a nurse…

I’ve had a resident (not a very good one at that) start to “explain” calcium in the blood to me. Why? Well, we had given quite a lot of blood products and I asked about giving some calcium as the ABG showed the ionized calcium was low. This is common. Massive infusions almost always drop the serum calcium due to the citrate used in the unit of blood (if this is new to you, here is an article that explains it rather well). Like I said, I know this. Trauma nurses are typically very aware of this because, you know, we give a lot of blood. Trauma… Bleeding… But hey, I’m just a nurse.

Now, she’s not giving me the calcium I need. She starts explaining calcium in the blood and why I should go by the ionized calcium instead of the calcium level on his BMP. Remember, I told her the ionized calcium on the ABG was low… Ionized. Calcium. The level she is currently explaining to me. That level. That’s not enough, she’s not even looking at me while she is talking and it’s in a very condescending tone.

Bruh.

I finally stop her with this statement: “I’m well aware of the purpose of an ionized calcium which is why I told you what it was on the ABG that I just ran (can you hear the attitude in my voice?). I don’t need an explanation, I need calcium. Can you order that or did you need me to throw that order in real quick?” Her:

*blank stare* “Oh, yeah I can put that in for you…” *quickly and quietly begins ordering what I need*

I had no more issues with her for the duration of her rotation on our unit.

It’s irritating. So so irritating. I’m far too outspoken to have someone resident-splain things to me. Don’t try me buddy…

Helpful hint

So you’ve put in an naso/oro- gastric tube. Great! Did you verify placement? If so, how? Did you immediately get gastric contents back when you aspirated? Did you listen and confirm placement in the stomach? Did you use the CO2 detector that some institutions have?

I ask because I ran into a situation in which an OG tube was placed in the ER before my patient was sent to me. Helpful. Thanks. Except it wasn’t helpful at all. My new admission’s abdomen was quite distended despite the OG tube. I connected the tube to wall suction and got nothing out. I changed the canister and tubing just to make sure it wasn’t something wrong on that end. Nothing. I listened and couldn’t quite say with 100% certainty that I heard it in the stomach. Hmm… Not sure I want to use this…

And then he vomited. A lot. And kept vomiting while I held the yankauer in his mouth to keep him from aspirating.

Nope, that OG wasn’t in.

So, I took it out and decided to try my luck at placing an NG instead of an OG. As soon as the tube hit 60 cm in depth contents start pouring out. No need to auscultate that! Hooked it to suction and in about five minutes I got a full liter of contents out of him. Oh look, his abdomen isn’t as distended now…

I say all of that to say this: verify placement! However you choose to do so, make sure you KNOW that the NG or OG is in the stomach and not curled up in the back of the throat. Have someone verify it behind you if you aren’t sure. If all else fails, take it out. I would rather you send me a patient without a tube than send me a patient with a misplaced tube.

Forever alone

Sometimes I feel “forever alone” when I am around non-nursing people. As a nurse I get to be a part of something amazing. I’ll always be proud I am a nurse. I don’t feel like my profession makes me better than anyone else. I do feel like my profession changed me.

I have seen death first hand.

I have had to hold back tears while a family kisses their 16 year old goodbye. I have watched a person suffer in the ICU because the family guilted them into remainding a full code, and endure multiple surgeries that ultimately wouldn’t fix anything, until they finally passed away in that bed. I have watched families lose hope as the transplanted organ fails. I have had to comfort patients after a devastating diagnosis.

I have had my ass handed to me at work.

I have worked 12 straight hours without being able to eat or even stop to pee. I have dealt with physical and emotional abuse at the hands of patients and their loved ones. I have been talked down to by medical professionals that feel they are above me thanks to a difference in degrees.

I hold it all in when I’m with family and non nursing friends. When people say my job is “easy” since I work nights and everyone is asleep, I just laugh. When people are certain I’m “paid” because nurses make “so much money”, I just stare blankly. I listen to people complain about their jobs intently while they dismiss my complaints because I knew nursing was hard.

It can make you feel alone.

It’s not all family members and not all non-nursing friends but enough to make me not talk about my job unless I am talking to a select few. It’s why the nursing community is so INVALUABLE to me. We can swap stories about the worst of the worst. We can laugh about some seriously dark sh*t with no judgment! We understand each other. The nursing community keeps me from feeling “forever alone”. Sometimes we are all we’ve got 😁!

Story time no.6

Sitting at the front nursing station when the door rings.

"Delivery for STICU!"

Delivery? It's one in the morning, what the hell is being delivered at one in the…

Oh.

Ohhhhhh…

THE LEECHES!

He's delivering the God forsaken leeches!

I am thoroughly grossed out. I hate leeches. I hate them with every fiber of my being. I can't touch them. I don't even want to look at them… but I need to open the box so we can put the squirmy bastards in their refrigerated tanks.

I managed to open the box. As you can see, I even managed to pick up one of the bags.

That's as far as I got.

Dude was far too squirmy and I was far too grossed out to do anything else with them. God bless our tech for being able to grab the box and take them away from me so she can put them away.

I'm a horrible charge nurse. I'll take that. I'm not touching those bastards though…

Story time no. 3

You ever have a patient situation hit you hard? It’s happening to me tonight. 

We have a patient going down to OR for organ harvesting. The patient had a severe fall with non survivable injuries. The family had the heart, the soul, the strength to say yes to organ donation despite the sudden death of their loved one. 

It’s hard to watch. It’s hard to see the children say their last goodbye’s. It’s hard to see their tears. It’s hard to listen to them thanking us profusely when we should be thanking them. It’s hard knowing that this is the last time they will see their loved one, connected to IV’s and intubated. It’s just painful. 

I know that this patient will bless someone else’s life. They aren’t dying in vain. I just wish they weren’t dying at all… 

The end isn’t always the end

I learned a lesson not too long ago. The end is not always the end. I got to see this first hand more than once.

A few months ago we had a trauma, pedestrian-vs-motor vehicle, that came to our unit with severe head trauma. The patient had a head bleed along with swelling. The CT scans did not look good. The MRI didn’t look any better. The patient and family were refugees from a war torn country, they spoke little English. The team began having “the talk” with his family. You know that talk, the one where they are pushing for the DNR because the patient is not expected to have any quality of life. Yeah, that talk.

The family would have none of it. We managed to stabilize the patient. They got the standard trach/peg combo. The doctors continued to speak with the family about the quality of life and the family continued to hold out hope. The patient ultimately managed to be transferred out of the hospital into a long term care facility. We were pretty much under the impression that they would just waste away in a nursing home, with no improvement in neuro status.

The patient came back to visit us, along with the family. The patient still has noticeable deficits but was able to fully communicate and even thanked us for our care. We had given up but they didn’t.

dont give up

More recently, our unit had a very sick vascular patient that coded during their surgery. The OR team got them back and immediately brought them to our unit (STICU). They coded again, the second code was worked for an extended period of time and then the team called it. They died. And then they decided death wasn’t really for them and their heart started beating again… spontaneously… after the code was called… while the team were having a moment of silence for the patient.

The medical team spoke with the family and let them know that even though the heart is beating, the patient has been “down” for an extended period of time and neurologically there is probably nothing there. The family decides it’s in the patient’s best interest to make the patient a DNR. The family begins saying their goodbyes and leave in expectation that the patient would probably code again within the next few days. Everyone is pretty much preparing for this patient’s end of life…

gointothelight

Except the patient…

That night, they opened their eyes to painful stimuli. Then it turned into opening eyes to name but no purposeful movement by the next day. By the third day or so they just woke the fuck up and tried to self extubate! All of us were pretty much like:

heart attack

They were completely alert, oriented, and by the end of the shift able to write questions on a piece of paper. Needless to say we were all kinds of confused, surprised, and impressed. We ended up nicknaming the patient “Lazarus”. Are we going to Hell? Yes. We are all well aware. I have a time share there.

The patient had a rough course. They were intubated, extubated, and reintubated multiple times before finally being trached and pegged. However, as I am typing this they are alive and are being prepped for long term acute care out on the floor. That’s right, the patient that we basically pronounced dead is instead going to LTACH soon.

These moments have taught me that it is not over until the patient decides it’s over. It has also taught me that maybe I shouldn’t give up so easily. My miracle patients are showing me there are still some things that we in medicine don’t understand. We don’t know it all. I am glad for that.

 

Story time no.2

It’s a work night. I’m charge. Typically I’m a black cloud. It’s the usual. One hour into my shift we are hit with two admissions. No biggie, we have the staffing for once! 

One of the new patients to come has a potassium of 7… Up from 6.1 two hours earlier. They are a renal patient on T/Th/S dialysis normally. They received their full four hour treatment on Tuesday and have been NPO for OR today. No one is really sure why the “K” is so high. So of course I can understand why they would prefer the patient be in an intermediate or intensive care unit to get emergent bedside dialysis. The step down is full so they came here. No problem, right? WRONG.

The patient’s significant other is PISSED

They want to know why they couldn’t just dialyze the patient on the floor where they were. Renal nurse and doc explain the significance of the high potassium, the possibility of a potentially fatal arrhythmia, you know, all the bad shit related to elevated potassium and why they need continuous monitoring right now. 

The S.O. is still pissed. 

Why?

They don’t like the room, we don’t have anywhere for them to sleep. 

Yep.

Forget the labs. Forget the safety of the patient. The room isn’t to their liking… 

Several seats… you need to have several seats…