A nurse expressed concern about her care of an elderly hospice patient.
The family of the hospice patient did not want the patient to have any comfort care, except for a prescribed sleeping pill and a prescribed opioid. The patient’s admitting diagnosis was C. diff.
The nurse’s assessment revealed the patient was alert, “oriented to self,” and vital signs were within normal limits. The patient denied any pain, was breathing normally and was sitting up in bed visiting with her family. She did state that she was thirsty.
One of the family members asked the nurse to administer a ”pretty heavy” amount of the prescribed opioid and sleeping pill, which were ordered PRN for pain or shortness of breath.
The nurse, knowing the medications were not needed and the amount requested “could potentially kill her,” instead gave the patient a drink of water.
The nurse told the hospice patient and family that she was giving the patient something to make her more comfortable before bed. She did not mention it was water or that it was not medication. The family seemed “pacified,” and the patient slept the entire night.
The nurse wondered if her decision was legally or ethically wrong.
A brief legal analysis
A nurse’s legal responsibility when caring for a patient in any setting is to provide care based on standards of practice. The nurse’s assessment indicated the hospice patient was not suffering because of her diagnosis, at least at that time. A family’s request to give a medication when not needed or when ordered only for a specific situation, was not, and could not, be heeded.
The nurse also was clear the request might cause the patient’s death. If she had given the requested medication and the patient died as a result of that administration, the legal liability would be hers and hers alone.
A second issue in this situation is the family’s request that the patient be given nothing but the two medications ordered. It is not clear why these medications were the only orders and no others were prescribed that would provide comfort care to the patient.
As you know, a patient retains the right to make decisions for himself or herself unless unable/incompetent to do so. This patient does not seem unable to make healthcare decisions, at least from what can be gleaned from the question.
Did the patient ever execute an advance directive? If so, is a family member named as her agent? This nurse would have a legal obligation to follow that directive. If one does not exist, then the patient makes his or her own decisions.
It is unclear why this patient is in hospice care. Although C. diff is a serious condition that can lead to death if not properly treated, the nurse’s assessment of the patient seems to point to the condition not being serious enough to require hospice care, based on the information in the reader’s submission.
The nurse might suggest palliative care is more consistent with the patient’s condition.
Regardless of the uncertainties of the situation this reader describes, the nurse was legally correct to refuse to give the patient the requested medications. She cannot follow a family’s request that is generally improper, possibly one without any legal authorization to do so, and one that might also cause the patient’s death.
The nurse would need to obtain clarification of the legal issues presented with the physician and the healthcare team as soon as possible.
A brief ethical analysis
I am not a nurse ethicist. However, I do believe the nurse was ethical in providing water to the patient. Note that she did not tell the hospice patient or the family that she was giving the medications ordered. Rather, she truthfully stated she was giving the patient something that would make her more comfortable before bed.
She also fulfilled her role as the patient’s advocate by placing her patient’s needs and well-being first, and then determining what her decision would be about the family’s request.
Her conduct clearly comports with the American Nurses Association’s Nurse’s Code of Ethics with Interpretive Statements.
Reaching out for help
It is not clear where the nurse was caring for the hospice patient — in her home, an established hospice facility or a healthcare facility with a hospice program. Regardless of the setting, the nurse seems to be without a resource or resources to resolve her concerns.
There is a wealth of information in nursing literature about the legal and ethical components of nursing practice. It is important to continue to learn about these components and incorporate them into your nursing practice.
When in doubt, seeking input from resources within your institution or from a trusted, knowledgeable source if not in a facility, is essential to helping meet legal and ethical duties when caring for patients.
Attempting to solve a legal or ethical dilemma or question alone is simply not wise.
One place to continue your learning about ethics in nursing is to review Nurse.Com’s digital edition, “How to Navigate Nursing Ethics.”
Are law, ethics compatible?
In my opinion, ethics and the law were congruent in this situation. The nurse met both of her obligations under these standards of professional conduct. What do you think?
Take these courses to learn more about hospice and palliative care:
Hospice and Palliative Nursing (CHPN®)
(15 contact hrs)
Prepare for the hospice and palliative nurse certification exam with this CHPN® certification test prep course. Become a specialist by mastering the knowledge required to holistically care for patients and families dealing with terminal conditions.
Identifying Pain in the Hospice Patient
(1 contact hr)
Hospice patients experience pain across multiple domains. Clinicians who care for hospice patients and their families need to be knowledgeable about the appropriate assessment and management of suffering in those experiencing serious life-limiting illness. This module will provide an overview of the different types of pain experienced by hospice patients and how to manage that pain.
Getting Started in Hospice Care
(6.5 contact hrs)
Dying in America continues to be misrepresented and misunderstood. Most people say they would like to die at home, and hospice care can make that wish a reality. This course describes the history of hospice as a social construct in the world at large and as a growing option for care at the end of life within the U.S. Key concepts in this course include the role of the nurse in hospice practice, the function of the interdisciplinary hospice team, the structure of the Medicare hospice benefit, hospice eligibility requirements, pain and symptom management, and care of the hospice patient before death. Information about reimbursement, documentation, and anticipated changes and additions to the hospice benefit are also reviewed.