Response discussion questions
RESPONSE
DISCUSSION 1
I work a hospice and oncology unit and we run in to many ethical issues in regards to end of life decisions. All to often the staff on our unit, myself included see patient's in significantly declining health that are hospice appropriate where family cannot come to terms with this decision and thus are not made hospice. Multiple times I have witnessed feeding tubes being placed and various operations being completed for only days later the patient to die. These dilemmas are terrible for us as staff to watch horrendous outcomes after educating the families of these individuals. I usually question families such as these. I ask them a simple question like this, what was important to your loved one throughout his/her life, was it using the lungs to convert carbon dioxide and oxygen and digesting nutrition, or was it more than this? If the answer was more than just these simple things then is it not a good idea to maintain the integrity of this loved one's life and allow them to exit this world with peace? This is a major crisis in America today, with about one-third believing that all treatment options must be carried out to preserve the body of their families (Noah &Feigenson, 2016, p. 737). Advance directives are one way to ensure each individual's wishes are met and to "express individual values and preference"(Noah, 2014, p. 55). Advance directives are an amazing tool in these instances as they help abide by the patient's wishes especially in the case of a living will. They help preserve the integrity of the individual. The problem is, that many patients do not have these in place.
In my practice education is the key way to deal with these scenarios. An interdisciplinary approach where representatives from the medical team, nursing staff, palliative care, and ethics can all meet with patient families has helped significantly in practice. The group approach allows for maximum education about prognosis and outcomes of treatment and thus helps the family to make the best decision based on the increased knowledge.
Sometimes it is not the family continuing care, sometimes it is the physicians. To improve the ethical climate at my place of employment I advocate for my patients. Ethics consults on these cases sometimes work as the suggestions and notes go on file. Without questioning, these doctors will continue with their own agenda. Ethics consults when doctors to not hear out my concerns as a nurse have proven helpful on several occasions as the consult draws light on the situation and thus the doctor feels more obligated to address the concern. The recommendation shows as a note on the electronic medical record and is visible to all. On several occasions doctors have changed their aggressive treatment approach based on these recommendations. My hospital also has ethics grand rounds quarterly highlighting key ethical issues within the hospital and how to handle them as professionals. Unethical end of life decisions are an extremely common dilemma I deal with at work and thus I recently joined the ethics committee in my hospital system to help promote a better culture of ethics in my hospital.
DISCUSSION 2 When I was emergency room director at a rural hospital in southern Tennessee, we had a larger than average patient population coming to the ER (emergency room) for pain treatment. Our community also had a high incidence of opioid overdose. The ER team started to notice that patients were requesting to know when specific doctors were working and noticed larger number of pills prescribed on prescription. The ER staff was frustrated and wanted to do something about this well-known epidemic. Tennessee is one of the top listed states for opioid prescription sales according to the Center for Disease Control (CDC) (Stempniak, 2016). When this issue was brought up in the boardroom, repercussion of refusing to write opioid medications for patients was discussed. Administration was happy with the number of patients seen within the emergency department and did not want to jeopardize patient satisfaction because of possible decreased reimbursements. The right thing to do is prevent opioid addition and overdose with in the community. The wrong thing to do is allow this behavior of overprescribing opioids to the community to justify increased patient satisfaction and reimbursement rates.
The emergency team and administration formed a committee to draft a narcotics policy for our emergency room that would limit narcotic prescriptions written. Chronic pain patients would not be able to receive prescriptions out of the emergency department, and only three days' worth of narcotics would be given to acute pain patients. Because this policy would impact so many people, we decided to start a community narcotic coalition consisting of the police department, EMS, community physicians, pharmacy's and chamber members. This policy implementation for our hospital and community narcotic coalition has definitely improved the ethical climate with in the emergency department. The ER team feels empowered with the fact that we are no longer feeding into the opioid problem are doing something about the epidemic. Guidelines for pain medication prescriptions have been posted in the hospital, community centers and physician offices to inform patients.
A study of pain guideline posters has shown that the majority of chronic pain patients believe it is reasonable to implement these posters, 7% of patients state they are intimidated and 2% state this would prevent them from receiving care (Weiner, Yannopoulos, & Chao, 2015).
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