Reference no: EM133303822

Assignment: Mary is the nurse taking care of Mrs. Carter, who has been in the Intensive Care Unit for many weeks, and who is dying. Mrs. Carter has Lupus Erythematosus, a chronic and usually fatal disease which has spread throughout her system. She has been on a respirator for weeks and appears to be unconscious, though sometimes she is rest- less, pulls at the tubes in her mouth and arms, rolls her eyes and mumbles incoherently. She does not speak any English, and even with her family or a hospital interpreter, it has not been possible to communicate effectively with her. Her disease, particularly in its final stages, is generally accompanied by pain, and Mrs. Carter does often appear to be in pain. She has not left any instructions about her wishes in the event of incapacitating illness (such as a so- called "living will") and none of her family recall her ever talking about being sick and incapacitated or dying.

At 57 years of age, Mrs. Carter is the matriarch of a close, large, and very concerned family who are still shocked by her illness and the grim prognosis. Although the physicians and nurses have told the family that Mrs. Carter cannot be cured or helped, and that she will die very soon, the family have begged the healthcare team to try a non-standard treatment which they have heard about. The team have promised to try this treatment for ten days. Even though they do not believe it will improve Mrs. Carter's condition, they reason that it probably will not hurt her, that they have nothing else to offer, and that at the very least it may help the family by assuring them that every possible therapy was tried in order to save their loved one.

Mary has taken care of Mrs. Carter during much of her hospitalization, and feels very close to her. She is very concerned about Mrs. Carter's apparent suffering, and would like to give her medication to relieve the pain.

Mrs. Carter's pain is such that it would not be alleviated by anything less than a narcotic analgesic, and there is a Doctor's Order for a narcotic pain medication to be administered as necessary. Such drugs, however, have the side effect of lowering vital signs as they produce relaxation. Since Mrs. Carter's blood pressure is already very pre- carious, and is being chemically maintained and controlled in order to keep her alive, Mary is afraid that if she gives her any medication for pain it would precipitate or hasten her death.

Aware of the family's grief, Mary wants to honor the team's promise to try the ten-day treatment they have asked for. Yet she is torn by her patient's suffering and by her own inability to fulfill her general commitment, as a nurse, to comfort and relieve such suffering.

Question 1: What factors must Mary weigh in deciding which of her promises should take priority? What aspects of the case could change that might lead her to change her priorities?

Question 2: "We know that her situation is irreversible," Mary says. Can we ever really know something like this for sure? What degree of knowing: is necessary for us to make ethically grounded decisions? To what extent, if at all, should we be influenced by our patients - or our own - hope for "miracles" (medical or otherwise?)

Question 3: Suppose Mrs. Carter were able to communicate, and expressed the wish to be allowed to die - would that be sufficient to resolve the dilemma? What if, in such a case, the nurses believe there is still hope that the illness can be cured and the pain relieved?

Question 4: How does one determine when a patient is competent to express his or her wishes? What if that expression is by "signals" rather than by a clear verbal statement? Some of the nurses, for example, felt that Mrs. Carter's tugging at her respirator tubes indicated her wish to be allowed to die? Do you agree? Are there ways you could try to determine the wishes of a patient in this situation?

Question 5: The staff do not believe the treatment requested by Mrs. Carter's family can do her any good. Does their keeping her in the ICU for 10 days conflict with the justice principle, since other patients may need the bed she is occupying? Obviously she needs the ICU's facilities to survive, yet in terms of prognosis, she cannot benefit from this care?

Question 6: If Mrs. Carter were your patient, and you were alone with her when she went into cardiac arrest, what would you do?