As a critical care nurse, I am often confronted with difficult situations and sometimes placed in compromising ethical predicaments. It is a constant struggle to ensure the safety of the patient while respecting the wishes of the ordering physician. Over the years, I have cared for many patients and had memorable moments that have forced me to evaluate my moral reasoning and ethical standards as a nurse, but there was one particular patient who made a lasting impression on my values and ethical beliefs as a health care provider.
After an already hectic day in the Intensive Care Unit (ICU), it was around 5:00 p.m. when we were put on notice that a patient was being transferred to the ICU from the floor. The details of the transfer at that time were very vague. Moments later, the phone rang and it was the transferring unit calling with the report. The patient was a 56-year-old male who was originally being treated for complications associated with a brain tumor. Scans revealed that the patient’s cancer had metastasized to several areas throughout his body. During the course of his treatment, he underwent several surgical procedures, including a tracheotomy due to prolonged intubation. Overall, the patient’s prognosis was poor and his hospital stay was arduous. The patient experienced residual neurological deficits and was currently unresponsive to external stimuli.
Despite best efforts, the primary neurology team was unable to fight the inevitable and the patient’s future appeared bleak. In an attempt to preserve the patient’s quality of life, the team discussed end-of-life wishes with the family. The option of providing the patient with Comfort Measures Only (CMO) was included in the discussion. The reporting nurse confirmed that the family finally agreed to the CMO and Do Not Resuscitate (DNR) orders, and the patient was treated accordingly. The palliative care team was consulted, and the patient was transferred to the palliative care suite for family privacy and comfort.
At this point in the report, it had become unclear as to why the patient was now requiring an escalation in care to the ICU. As the nurse began to reveal the details of the situation, my confusion turned into shock and amazement. The patient, who had been placed on CMO approximately 12 hours prior, was now a full code. The patient’s family rescinded the CMO and DNR order after 12 hours. The reporting nurse described that one of the attending surgeons was not comfortable with the events that transpired. The attending physician discussed his concerns and hopefulness for the patient to recover with the family. In fact, the physician felt so strongly about his beliefs that his enthusiasm was spread to the patient’s family and they ultimately changed their minds regarding CMO/DNR status. The orders were rescinded and the patient was made a full code.
The patient emergently arrived to the ICU with full medical support at his bedside. The respiratory therapist was bagging the patient via the tracheostomy tube, while we quickly placed him on telemetry monitoring. The patient’s oxygen saturation was only 65% on the monitor, and he was quickly connected to the ventilator and placed on 100% FiO2. His skin was cool to touch and ashen grey. His body lay frail and flaccid in the hospital bed. After placing him on the ventilator, there was little to no improvement in the patient’s oxygenation status, which remained 50% to 60% on the monitor. The consulting ICU team was immediately notified of the patient’s arrival.
The additional nurses in the room were helping to draw lab work and perform other ancillary duties. All of a sudden, the deafening alarms of the monitor started to radiate throughout the room and a once recognizable heart rhythm had transitioned to a bradyarrhythmia and then asystole. A code blue was announced overhead and chest compressions were immediately initiated. During chest compressions, every thrust of the patient’s chest felt like ribs breaking underneath my hands. Advanced Cardiovascular Life Support (ACLS) resuscitation was already in progress by the time the code blue medical team arrived at the bedside. The coronary care unit resident led the code and we went through the ACLS algorithms accordingly. The pulmonary critical care resident was at the bedside as well. After a few rounds of chest compressions and medications, the patient had a recognizable heart rhythm, but we soon noticed inflation to the patient’s chest cavity. The team suspected subcutaneous air from a pneumothorax. The pulmonary critical care resident requested setup for a chest tube placement and a right pleural chest tube was inserted and secured. Some relief of the subcutaneous air was appreciated.
Unfortunately, return of the patient’s rhythm was short-lived, because the team and I could no longer palpate a pulse and the patient was in pulseless electrical activity. Chest compressions and resuscitation were restarted. Throughout all the commotion and the events that were occurring, I kept asking myself: “Are we doing the right thing for this patient?” I noticed the chaplain in the doorway and asked him to please locate the family as soon as possible. Luckily, the family was waiting just outside the ICU doors. I asked one of the physicians in the room to discuss the patient’s condition with the family. I took a moment and looked up from the patient and observed a woman with a worrisome look on her face. I already knew who she was, and by the look on her face I could tell that this was not what she wanted for her husband. Shortly after, one of the physicians returned to the room and made the announcement that after this round of ACLS, if no response, we would call it per family request. Thus, with no return of circulation and asystole on the monitor, the patient was pronounced deceased. The chaplain was called into the room with the family and they were allowed to spend private time with their loved one.
Upon reflection of this patient’s case, I had many mixed emotions about the course of events, which ultimately determined the patient’s final transition period. The decision to make a patient a CMO/DNR is not one that is made lightly. It is one of the hardest decisions family members have to make for their loved one. In my opinion, it is a selfless act to ensure their loved one’s final hours are spent peacefully and without additional pain and suffering. The events that occurred on this memorable evening taught me a great lesson about being morally courageous.
I once read a very powerful article written by author Colonel John S. Murray, who defined morally courageous individuals as being “prepared to face tough decisions and confront the uncertainties associated with their resolve to do the right thing despite the consequences they may face.” He further stated that moral courage “requires a steadfast commitment to fundamental ethical principles despite potential risks.” I hope to continue to build a nursing career that encompasses these principles and upholds a strong moral standard. I have made the commitment to my patients to do what is in my power to protect them and protect their wishes.
Candilla Davis, RN, BSN, CCRN, has been a nurse for almost nine years and is currently employed as a critical care nurse at Tampa General Hospital.