Running head: CLINICAL DECISION ANALYSIS 1

Medical Surgical Clinical Decision Analysis

Taylor Hughes
University of New Hampshire














CLINICAL DECISION ANALYSIS 2
This semester during my medical-surgical clinical rotation I got to experience
how the health care team gets involved during ethical situations. It was very
interesting to see the different dynamics involved when there is an ethical issue on
the line. There are so many people involved and nothing can happen unless
everyone is on the same page. This can be very difficult in these situations because
not everyone is on the same page, which leaves the patient in limbo until everyone
comes to an agreement. I found it hard to watch this situation unfold because the
only person suffering was the patient, who could not speak for herself.
The patient I took care of was a 94-year-old female who had come to the
hospital a few months prior due to a myocardial infarction. The patient was in the
ICU for a few weeks and had multiple complications while there. Once she was
discharged to the medical-surgical floor the patient did not heal well. During this
time she became very deconditioned. One of the main reasons for her deconditioned
state was due to the fact that the patient did not want to except care. Everything that
was done for her she refused and would fight the staff if they tried pursuing
anything. The patient was very stuck in her ways and did not want our help. She
came off as though she did not want to live anymore.
This state of mind brought upon a bad spell of depression for this patient.
Her attending physician tired putting her on an antidepressant to help her healing
and state of mind. However, the family did not want her on these medications due to
previous attempts with antidepressants failing. As her depression worsened she
ended up refusing all medications and would no longer eat. She also would not
communicate with the staff or her family.
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It was then determined that she was no longer in the right state of mind to
make medical decisions for herself and her DPOA was instated. Her son was her
DPOA and he was very persistent in making sure that his mother lived even if it was
not what she wanted. Her living will stated that she did not want artificial nutrition
to keep her alive nor did she wished to be resuscitated should the need arise.
Although the patients wishes stated that she did not want artificial nutrition it was
up to the son on whether or not a nasogastric tube would be placed to help feed and
medicate his mother.
Prior to my shift of taking care of this patient two previous attempts to put in
an NG tube were failed. Both times the patient pulled out the tube and put up a fight,
resisting the insertion. Upon the start of my shift with this patient I got report that
her body weight had dropped drastically since her initial admission, multiple
systems were starting to fail including her kidneys and liver, and her blood sugars
through out the night had been drastically low. On top of all of this her PICC line had
to be taken out due to a blood clot and the Sergeant that was going to put in a PEG
tube refused to due to her condition.
Going into this situation my nurse warned me that it would not be an easy
day. Decisions were going to have to be made and her family was not going to be
happy about any of them. There were basically two options for this patient. Option
one was to give her artificial nutrition to keep her alive and option two was to put
her on comfort measures. Seeing as she did not handle the processes of artificial
nutrition previously we knew that option was almost already out of the picture.
Also, even if a NG tube was placed that would only be a temporary fix. This patients
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prognosis was not good and no matter what we do to help her it would only prolong
her life for so long.
The physician, nurse, and I went into the patients room and explained her
current health status and stated the two options to her son. The physician
mentioned that in her living will she wished not to receive artificial nutrition as a
means of prolonging life. The idea of comfort measures was posed to the son as a
valuable option. The physician explained that she believed that his mother would
benefit greatly from being on comfort measures. She clearly did not want the
treatment that was being offered and the extensive measures we were taking were
only upsetting her. It is not the teams ideal situation to make this patients last
moments distraught and upsetting. We wanted to make her comfortable and
relaxed.
When the idea of comfort measures were proposed to the son he freaked out.
He believed his mother was nowhere near ready to pass away, despite what the lab
work and her physical condition said. He also did not care what her living will said
he wanted her to get artificial nutrition. The physician tried reinforcing that she
was so deconditioned that the artificial nutrition would only be a temporary fix. She
already had multiple system failure and it was inevitable that her time would come
sooner than later. Regardless of what was said the son did not want to hear it and he
insisted that we put in the nasogastric tube and start the tube feedings.
The physician, nurse, and I left the room and talked about what our next step
would be. The physician was very angry that the family was refusing to believe that
their mother was dying. It was upsetting to her to have to go through with inserting
CLINICAL DECISION ANALYSIS 5
the NG tube and artificially feeding the patient because she knew inevitably the
patient would not survive. Depict what the physician felt she told the nurse and I to
proceed. Though she did insist that we only try putting the tube in one time and that
we make the family stay so they could see how much their mother did not want it.
As the student nurse taking care of this patient it was tough to do something
that I knew the patient did not want. I personally did not get to put the NG tube in
this patient but I did help assist. During the situation I felt awful and I could tell the
nurse and everyone else assisting felt just as awful. This patient had not talked to
anyone in weeks and as we were preparing to do it she was crying and telling us to
leave her alone. The son was watching and did not care that his mother was crying.
He just kept trying to calm her down and telling her it was for the best. The nurse
warned the son that she was only going to try inserting the tube once and if it did
not work then she was not going to torture his mother. He insisted that it was fine
and to just do it quick.
The other second nurse, that was helping assist us, and I held each of the
patients hands so she would not resist. I felt so guilty holding her hand, almost as if I
was restraining her. As the nurse slipped the tube down the patients nose the
patient was crying and gagging. Luckily the tube went it easily. Afterwards though I
felt so guilty because the patient proceeded to cry for the rest of my shift. We had to
make her a one to one with a LNA because we knew if she did not have someone
watching her she would rip the tube out like she had previously. The LNA watching
her said the patient did not move or talk for the whole shift she just laid there
lifeless and cried.
CLINICAL DECISION ANALYSIS 6
After leaving clinical that day I felt like an awful person. It was as if I was
restraining the poor lady to keep her alive. This woman was not going to live much
longer regardless of her receiving artificial nutrition and during her final moments
she was going to be even further depressed. The whole situation was making this
women have a very poor quality of life. This is against everything I believe in.
During the situation I kept thinking to myself that I did not want to be apart
of this. I wanted to just say no and leave. I felt enraged, I wanted to just speak up and
yell at the son. It was frustrating because the son was making the health care team
out to be the bad people. He thought that all we wanted was to kill his mother. As a
health care provider it was so obvious to me that this was not our intention, yet no
matter what was said the son would think so. I wanted to tell the son that we were
trying to help her and he was the one making her suffer. Instead of saying anything
though I just kept my mouth shut and held the patients hand. I was so upset the rest
of that clinical day because I did not want to be apart of that situation.
Later on thinking back about my thinking during that situation I realized that
it was not fair on me to be so judgmental. This family just loved their mother and it
killed them to let her go. The obviously did not want to see her suffer but in their
minds dying was worse than suffering. They could not come to terms with the
inevitable and that is very hard for a lot of people to do. I should have been more
understanding and supportive for the family. I have never been faced with their
situation and I should not have been so quick to pass judgments. They were going
through a hard situation and they were doing the best they could at the time.
CLINICAL DECISION ANALYSIS 7
The hardest part about this whole situation was I found out the next week
that the patient had passed away three days after the NG tube was placed. This
upset me even more due to the fact that the patient could have been comfortable
and relaxed during her last breathes. Instead though she was upset and distraught.
Although I know I should have been more supportive toward her family it still
bothered me greatly that their mother had to suffer during her final moments.
If I were in this situation again I would have gone about informing the family
differently. Showing and giving examples to them might have been more effective
than just telling them. Showing them research or different lab values and explaining
what each what meant could have cleared things up. This could have helped them
come to terms with what was actually happening. Also, developing a better nurse-
client relationship could have helped the family accept what was happening. During
the situation the family was very hostile toward the staff and vice versa. If a better
relationship had been formed the outcome for this patient may have ended better.
The final thing I would have done differently would have been getting the ethics
committee involved. There was clearly an ethical issue involved between the two
parties. The ethics committee could have helped clear up the situation and made it a
more legal situation.
During my time with this patient I did not actively do much but it made me
self reflect on my own practice beliefs. I truly was uncomfortable with the situation
and if I was the nurse I would have not gone through with inserting the NG tube. I
would have had to ask my charge nurse to reassign me. This situation also involved
patient quality outcome due to the fact that we knew what her outcome was and we
CLINICAL DECISION ANALYSIS 8
wanted to make the best of it. Depict trying to make this patients quality outcome
the best it could be we were hindered in out abilities to succeed.
Everyone involved in this situation was on a totally different page. There was
a lot of tension and hostility between both parties. This lead to no one wanting to
agree on what was best for the patient. Each party wanted what they thought was
best and no one took the patients thoughts into perspective. I think there was a lot
of things that could have gone differently through out her time at the hospital. There
was a lot of miscommunication between everyone, which ultimately lead to this
patient having a poor quality of life at the end.
Looking at the clinical guidelines and research has also helped me figure out
what would have been the best clinical practice in this situation. In the future I will
definitely take these points into consideration. The General Medical Councils
guideline (2010) has evidence for the best treatment and care toward the end of life.
According to this guideline if the DPOA involved in a patients care asks for
something that the doctor considers not clinically appropriate then it is up to the
doctors digression whether or not he/she goes forward with the request. If the
doctor explains why the request is not favorable and the DPOA still insists, than the
doctor still has the right to not perform the task at hand (p. 18-19). In the case of my
patient I think that it would have been wise for the physician in charge to have told
the family all of the reasons why placing the NG tube was not clinically practical. If
they still disagreed with her than she had the right not to go forward with placing
the tube. She should have stuck with what she believed in and the patient could have
had a better quality of life.
CLINICAL DECISION ANALYSIS 9
The General Medical Councils guideline (2010) also states that in the case of
a disagreement that cannot be mutually solved a non-biased second party should
become involved. This may include an independent advocate, a more advanced
colleague, a second opinion, a case conference, or the ethics committee (p. 30). The
National Collaborating Center for Acute care (2006) also says that if there is doubt
as to what is the best action for the patient legal advise should be sought (p.72). As I
said previously, if I were to be involved in a situation like this again I would have
gotten the ethical committee involved. It is not fair to any party involved in this
situation that have to live with doing something that is unethical to them. By having
a mediator it helps alleviate tension and solve the issue in a manner that is
expectable to both parties involved.
Another valuable piece that could have been useful in my situation is
establishing a better relationship with the family. According to the General Medical
Council (2010) a good way to handle this situation is to encourage the DPOA to
think about what they may want for themselves if they where in this situation. Also,
help them to discuss their wishes and concerns (p.32). By having the DPOA put
themselves in the patients shoes it takes out the biasness of the situation. It allows
them to think about what they truly would want in this situations and not just focus
on the thought of the death of their loved one.
The National Collaborating Center for Acute Care (2006) recommends not
giving Enteral nutrition to those patients in the final stages of life where treatment
would just prolong the dying process and would take away the patients comfort and
dignity (p.72). This guideline also recommends that if a patients illness is in the
CLINICAL DECISION ANALYSIS 10
terminal phase such measures should not be taken to prolong survival unless it is
relieving symptoms (p. 72). In the case of my patient the NG tube was not being
used as a symptomatic relieving mechanism, it was used to prolong life. This patient
was in the terminal phase of her life and the NG tube was still placed, this took away
her comfort and dignity.
Both of these clinical guidelines made me realize how differently this
situation could have gone had the team stepped back and looked at what the best
practice is. I truly believe that if the physician stuck to what she believed in and said
no or perhaps is an ethic committee got involved this patient would have had a
much more comfortable and dignified death. It saddens me that I had to take part in
not allowing this patient to die with dignity and if a situation like this arises again I
will definitely speak up and look at what the evidence says. Every patient has the
right to receive the best practice available and the only way to give this is to know
what the research says.









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References
General Medical Council. (2010). Treatment and Care Toward the End of Life: Good
Practice and Decision Making. Retrieved from http://www.gmc-
uk.org/static/documents/content/End_of_life_9_May_2013.pdf
National Collaborating Centre for Acute Care. (2006). Nutrition Support for Adults:
Oral Nutrition Support, Enteral Tube Feedings, and Parenteral Nutrition.
Retrieved from
http://www.nice.org.uk/nicemedia/live/10978/29981/29981.pdf