Ethics as a New Graduate of Six

Ethics

As a new graduate of six months working night shift on a small cancer unit, I am faced with a dilemma. Mr. V has been in and out of the unit several times over the last few months. He has liver cancer and has gone through several episodes of chemotherapy. His wife has been staying with him since his admission. There are two RN's on this unit.

Mr.V recently joined the hospice program. His current admission is for pain control with orders to start a morphine drip to be regulated for pain control.

The only set parameters indicated by hospital policy are to decrease the drip when respirations are less than twelve breaths per minute. Mr. V has requested that the drip be increased several times during my shift. Even though he does not appear to be in any discomfort, I increase the drip. On my final round of the shift, Mr. V requests that the drip be increased again, stating that the pain is increasing. I note that his respirations remain stable at 12 breaths per minute.

An Ethical Question

This man is dying of liver cancer. For a while, morphine will control his severe pain. However, it may further reduce respiration. As a medical professional, I feel responsible to give this patient enough morphine to ease his suffering without causing him harm. However, I must consider the legal and ethical issues at hand.

On one hand, if I continue to increase his pain medication, I may be accused of overprescribing narcotics or hastening death. On the other hand, my patient has a right to proper pain management. For most terminally ill patients, pain can be controlled and, as a hospice worker, I am responsible to provide pain control.

In the past, many nurses did not fully understand pain control. As a result, many terminally ill patients were denied enough medication to relieve their pain because nurses were afraid of addicting patients or of killing them.

The medical industry and the public believed many untrue statements about the use of strong narcotic drugs, such as morphine. People were afraid that morphine would lead to problems with drug addiction and that drugs would lose their effectiveness after a long period of time.

Today, however, medical professionals know a lot more about pain control. The American Nurses Association's (ANA) Position Statement on Promotion of Comfort and Relief of Pain in Dying Patients completely supports the use of full and effective doses of pain medication for dying patients.

We now know that the pain control process involves using a "baby steps" approach. This approach uses small doses of analgesics, such as aspirin, then using stronger drugs, such as morphine, to maintain pain control. Medical standards dictate that pain medications should be given at regular intervals and in large enough doses to maintain a patient's comfort level and pain control.

Hospices and oncology services report that respiratory depression is uncommon in patients who are receiving opioids for the control of pain. Pain is itself a respiratory stimulant, and the opioid effect on the respiratory center diminishes rapidly with chronic use. If the patient is terminally ill and the dose of opioid required to produce comfort does happen to depress respiration, it is still reasonable to allow the undesired effect (respiratory depression) in order to achieve the desired effect"

In addition, according to the ANA, increasing a dying patient's dose of medication to achieve adequate symptom control is ethical, even if it causes the person to die sooner.

Goals of All Involved

Mr. V is in a hospice, where he is expected to die. The main goal of the hospice is to make the quality of the patient's life the best possible during his final days.

The main objectives of the hospice are to control pain and other symptoms caused by the disease and by the medications he is taking, and also to prevent depression if possible.

Because Mr. V is in a hospice, not a hospital, the nurses must focus on a comfort approach to pain control, rather than taking measures to cure or prolong his life. The fact remains that this man is dying and it is the responsibility of all medical professionals in the hospital to manage his pain properly.

Current research shows that using morphine to control a patient's pain will not make him addicted to the drug. In fact, research shows that uncontrolled pain contributes to terminally ill patients' physical, emotional, and mental deterioration. Therefore, I feel that it is both my legal and ethical responsibility to provide Mr. V with proper pain control.

The goals of the nurses involved and the hospice care are similar. It is of utmost importance to make sure that the patient can sleep undisturbed by pain. In addition, we want to ensure that the side effects from pain medications, such as poor respiration in this case, will be prevented or minimized.

It is also the goal of hospice care to make sure that the patient's family is educated regarding the pain control plan. Mr. V's wife should be involved in choosing the most effective and appropriate pain management for the child.

Mr. V's goals are unclear. Many terminally ill patients want assurance that their pain will be controlled as death approaches. He most likely longs for a peaceful death when it is time. However, he may be trying purposefully to speed up the process, requesting more pain medication when it is not needed.

Mrs. V may not prepared to face the reality of her husband's imminent death, but proper pain control must be discussed and implemented as part of the care plan appropriate to this patient. She most likely does not want to see Mr. V suffer any more than he has to and will probably support pain control for him.