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The following course content

Introduction

This CEU will explore everyday ethical decisions that those in nursing management commonly face; case studies will be used to broaden your thinking on how to make ethically sound choices. 

Scenario

You are a nurse manager in a mid-sized community hospital Emergency Department (ED). You recently asked your staff for an EMS liaison nurse. The advance directives need to be followed. 

“Most ethical codes address common elements, such as beneficence (doing good), non-maleficence (not harm), respect for patient autonomy, confidentiality, honesty, distributive justice, and respect for the law” (1).  

As part of nursing management, it is vital that we are aware of the various ethical dilemmas we will face throughout our careers and how we can appropriately respond.  

Case Study #1

A 78-year-old man collapsed at home; his wife did not know CPR but called the ambulance, which took 30 minutes to arrive. The man had a MOLST (Medical Orders for Life-Sustaining Treatment), which stated he did not want CPR or Resuscitation to be performed.  

The presence of a MOLST goes along with respect for autonomy. The person completing the MOLST is stating their preference for resuscitative efforts, which are to be applied when that person becomes incapacitated (5). This principle of autonomy is based upon respect for an individual to make decisions about their healthcare (6). 

• Did the wife not accept her husband’s wishes? Should she have called the ambulance instead of the police or family Physician?
  

The wife was not under a legal obligation to call an ambulance. In the case of an attended death, a call to the primary Physician or local police is required. Family members want benevolence, in this case, CPR, but does that override the MOLST, which said no? 

At the wife’s behest, the ambulance staff started CPR, placed the patient on an artificial CPR Device, “thumper,” bagged the patient, and started an IV for drugs. 

• Should the ambulance staff have started CPR for a patient in asystole for at least 30 minutes with no ongoing CPR?
  

The ambulance crew may have also been acting out of the principle of beneficence, which has the fundamental goals of medicine (9): 

• Preservation of life 

• Restoration of health 

• Relief of suffering 

• Restoration or maintenance of function 

New York State Protocol 

In New York State, all EMS personnel are guided in their thoughts and actions by the New York State EMS Protocols. 

The Cardiac Arrest Protocol in New York State for EMS providers states: 

“For patients that do not meet the ‘Extremis: Obvious Death’ protocol criteria or otherwise excluded by a DNR/MOLST order, see also ‘Resources: Advance Directives/MOLST/DNR” protocol.’ 

For patients unable to consent, including the unconscious, determine the presence of valid MOLST, eMOLST, or DNR forms at the scene or Signed ‘Medical Orders for Life-Sustaining Treatment’ (MOLST) form or Electronically signed eMOLST form or Signed New York State approved document, bracelet, or necklace or Properly documented nursing home or nonhospital DNR form • If MOLST, eMOLST, or DNR (document, bracelet, or necklace) is not present – begin standard treatment, per protocol • If MOLST, eMOLST, or DNR (document, bracelet, or necklace) is present, and is valid for the patient’s clinical state (e.g., cardiac arrest), follow the orders as written, inclusive of either terminating or not beginning resuscitation. 

Any appropriate directive indicated on the MOLST or eMOLST should be honored, including the directive not to transport the patient to the hospital • A MOLST is still valid even if the Physician’s signature has expired” (4). 

Reflection on the Scenario  

After reviewing the New York State EMS Protocol, was the ambulance crew from the case study justified? Why did they not heed the protocols’ directions or call medical control for advice? Are they afraid they will be confronted if they do not initiate resuscitation? Did they communicate effectively with the patient’s wife about the active MOLST? 

“Studies have now shown that a prehospital emphasis with on-scene CPR until the return of spontaneous circulation (ROSC) results may optimize care for the patient” (7). 

“Studies have shown that the survival rate declines when the duration of CPR is greater than 10 minutes without ROSC and rapidly declines after 30 minutes” (7). 

These studies have been incorporated into the EMS protocols. The best practice is to “stay and play” for at least 20 minutes. Medical control can be considered, as well as advice if the patient remains in asystole. CPR by hand or “thumper” is not effective during ambulance transport. 

“When making decisions in the resuscitation arena, many factors must be considered, including potential benefits of resuscitation (restoring life to the patient, a sense of closure and resolution of guilt for the survivors) and possible risks (financial and resource investments, resuscitation to suboptimal quality of life, etc.) (2). 

Most ambulance services are volunteer-based; however, paid employees must carry all the necessary supplies to perform resuscitation; in this scenario, no financial implications directly affected their decision to resuscitate. 

The ambulance transported the patient to the nearest hospital ED, where full resuscitation efforts were underway. Upon arrival in the ED, the patient was moved to the Code Room, where resuscitation efforts were continued. 

The ambulance report indicated the patient had a witnessed collapse, no CPR for 30 minutes, IV and CPR continued en route, aAsystolecurrently on the monitor, Epinephrine 1mg x 3 doses given total. Upon a physician’s exam, pupils were fixed and dilated. The patient was moved to the stretcher, and staff began to cut off his clothing. The patient is emaciated and weighs no more than 90 lbs.  

The ED nurses hook the patient up to the monitor and AED. The once barrel-chested man now has a crater where the thumper continues compressions. Every rib has been broken. There is a circle of abrasion where the thumper contacts the skin, and the EMS crew forgot to put the protective skin pad down. The patient has now been unresponsive for almost an hour. Two large-bore IVs are placed, and two saline bags are pressure bagged in. The resuscitative efforts continued with quality CPR, intubation, and IV drugs. The patient responded with no pulsatile rhythm, blood pressure, or neurological response. 

Those in nursing management will experience this scenario more than once throughout their careers, and we must understand when our interventions are appropriate and when they are not, especially when there are DNR and MOLST orders in place. 

“Physicians experience considerable uncertainty about what is and is not ethically and legally permissible. A valid legal reason to withhold CPR and ACLS measures is a written advance directive that states the wishes of the patient or the determination of the primary Physician that resuscitation is neither desired nor appropriate” (8). 

The doctor decides to intubate. Intubation was difficult because of the throat mass, but the respiratory therapy staff is now at the bedside to manage the ventilator. The thumper is turned off, another round of epinephrine is administered IV, and the patient miraculously has a pulse. 

• What is the current risk to providers who choose to intubate?  

• Extensive scarce PPE is needed to protect the physicians and nursing staff. Was the use of scarce resources justified? 

Suppose spouses or other survivors demand care despite a MOLST being present. In that case, this helps explain why medical staff working with patients near the end of life have grown increasingly disenchanted with advance directives, including living wills and powers of attorney for health care.  

“Despite all attempts and modern measures, the majority of resuscitative efforts remain unsuccessful, and only a small minority of patients are returned to their previous health status. Therefore, the appropriateness of CPR has been questioned, especially concerning individual outcome and patient preference” (2). 

The Physician decided to transfer the patient to a tertiary care hospital for further treatment, still in an unstable rhythm with little or no blood pressure or neurological improvement. 

• Should the transfer have been done? Was this a good use of resources?
  

A treatment that does not improve the patient’s prognosis, comfort, well-being, or general state of health should be considered futile or, even better, inappropriate. 

In the 1990s, an objective criterion for medical futility was described. Any interventions and drug therapy with less than a 1% chance of survival were considered futile.  

• Was the continuation of CPR in the ED a futile process? 
  

The patient did not survive. 

The local ambulance service has one crew on duty after midnight. If that crew is called for interfacility transport, ambulance services are not readily available in the community.  

• Was this transport morally justified? 

Decisions about appropriateness involve moral judgments about proper or reasonable care. 

Is resuscitation of a patient with a MOLST right or good care? Does patient autonomy not come into the ethics of choice here? The decisions of Emergency Physicians are often linked to their fear of litigation or criticism. Are there metrics that drive reimbursement that guide physician choices? If so, is that morally right? 

What about the cost of resuscitating a patient? In 2005, Medicare expenditures of $58 million were estimated to result from unsuccessful resuscitations annually in the USA (3). 

Ethical choices were made throughout this case. The moral principle of autonomy was ignored, and beneficence was used, at what cost? The outcome was death. It costs the ambulance crew money and causes a lack of job satisfaction. It cost the Physician nothing, the hospital lots of money, and potentially the whole of society money that could have been better spent. 

For those in nursing management positions, we must consider these ethical principles and the following outcomes (ambulance crew, hospital staff between both facilities, community members, etc.).  

Case Study #2

You are the DON at a medium-sized community hospital. The ED notifies you that they have a 30-year-old with COVID-19 related respiratory failure that needs ICU admission. Additionally, they have an 83-year-old with presenting similar COVID-19 related respiratory distress who also needs ICU admission. 

The dilemma in this scenario is that there is only one ICU bed available currently. After realizing this, you quickly scan the ICU bed availability from the regional database, there are no beds available. 

You go to the ED to speak with the nursing team. 

Ethical Choices in Day-to-Day Operations

Step 1: You begin to discuss the needs of both patients with your nursing staff, and who should receive the one available ICU bed.  

Nurse Management Speaks to Staff

Step 2: The 30-year-old patient has just required intubation, and the 83-year-old patient is being managed with high flow oxygen.  

The nurses agree that the 30-year-old should get the ICU bed, and the 83-year-old patient will go to PCU; they are the first on the waiting list for the next available ICU bed.  

Ethics Guide our Actions

Step 3: The next day, an ICU bed becomes available. The PCU nursing management is notified, and the 83-year-old patient will be transported to the ICU; she is now failing.  

Communication

Step 4: At the end of the month, as a leader in nursing management, you hold a get-together for EMS, ED, PCU, and ICU staff. You all review the cases from the past month, the success cases, and ethical choices involved.  

You reward the staff with a plaque.  

Recognize and Reward

Step 5: It is important to communicate openly and honestly when ethical choices are required that guide our actions and reward your staff for the last-minute decisions they must make daily. Following ethical guidelines may not always feel like the right thing to do in the moment, but ensuring we are respecting a patient’s autonomy and their wishes is vital. 

Conclusion

Our professions values, standards and ethical code guide our day-to-day decision making ,at the bedside, and in leadership roles. It is no wonder that nursing is often cited as the most trusted profession. We will often encounter situations that may make us question our own beliefs, or are misaligned with the standards of our profession. When in doubt, referring back to the American Nurses Association Code of Ethics or confiding in a trusted mentor can help steer us back in the right direction.

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