Ethical issues in emergency medicine: death & dying

Discussion board post for NURS603 Facilitating Inquiry, posted on November 24, 2022. Post is in response to thread about ethical challenges in my field of nursing.

Thank you for bringing up the issue of client choice versus family decisions, especially surrounding critical care and end-of-life. In the clinical setting I work in, in the emergency department, this is a common issue as well. It is probably one of the most challenging positions a nurse can find themselves in when the family is insisting on treatment which the client refuses. It becomes even more challenging if the nurse is aware, or has their own impression of what the best course of treatment for the patient really would be, and either the patient or the family do not understand what the decision they are making really means.

I had a direct experience in this matter a couple of years ago when my grandfather arrested due to hypothermia, was taken to a hospital, and resuscitation was started. When I arrived at the hospital, I found them in the middle of doing CPR, and was shocked to discover that they had been trying to resuscitate him for 3 hours because his body temperature was so low that they technically could not declare him dead before rewarming, which was taking a very long time.

My father, as POA, had been unable to make a decision because, as the doctor explained it to him, there was a potential that my grandfather still had brain activity since his body was so cold. He was giving my father what I perceived to be false hope. As a nurse, however, with experience in critical situations, I knew 3 hours was too long, and I knew that my grandfather would never be coming back, so I explained to my father what the doctor seemed to not have the courage to tell him - they did what they could and it was time to stop.

That experience changed everything about my perspective on resuscitation and end of life care, and I carried it with me when I was redeployed to a COVID ICU where patients were dying daily and many of the doctors did not paint the gruesome picture of slow death well enough for patients' families to make an informed choice. Some doctors are great at it - to the point, clear, no sugar-coating, but others offer too much hope, in my opinion.

Through the scene of my grandfather's body full of tubes and wires everywhere and a man pounding on his chest that flailed from obviously broken ribs, coupled with my nursing knowledge, it was clear to me that for that 80 year old man with dementia, even if he did have some brain activity left, the quality of life he would have would not be something he would choose for himself. I think if people knew what dying in an ICU is really like, many people would also never choose that for themselves either.

My nursing colleagues often joke, morbidly, that if we ever end up in that state, one of us has to pull the plug for them if our families won't do it. But the reality is, the ethics of providing care in nursing goes beyond the desires of the patient or of the family. Sometimes the ethical dilemma is from nursing experience itself, knowing what certain care entails, and knowing that you cannot truly paint that picture for the patient or their families because it would cross a line between informing and coercing. The provision of care, in these situations, may be at odds with a nurse's own values, causing a profound ethical dilemma. Perhaps this ethical challenge is also a factor of nursing burnout, which would coincide with accelerated rates during COVID with such a concentration of people dying slowly while families held out hope. Certainly not a light aspect of nursing.