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Coping with 'slippery slope' questions.

First there was Dr. Jack Kevorkian with his very high-profile mobile suicide service. More recently, voter-supported legislation in Oregon has provided guidelines for physicians whose patients are seeking professional help to end their lives. Now the news is full of reports related to the confession of a Glendale, California respiratory therapist who claimed to have hastened the deaths of between 40 and 50 comatose DNR-designated patients who were in his care. Unfortunately he is reported to have implicated others who encouraged his activities. And, perhaps as a consequence, the hospital in question has laid off all 40-plus members of his department.

What is a chief patient care executive to do? How can one best help a confused and demoralized staff cope with the ambiguities and ethical minefields associated with such reports? And, how can you help them deal with the inevitable questions from patients and their families?

Years ago, long before the high-tech interventions that are so readily available today, people often died with dignity in hospitals. In many cases, the signs of impending demise were quite clear and family members could be offered the opportunity to sit vigil. The hospital staff (usually the nurses in reality) tried to keep the patient clean and comfortable and provide opportunities for the family members and friends to say their last goodbyes. The hospital chaplain or the patient's clergyman would often be part of the support system. All of us would try to encourage the family to speak to patients who appeared nonresponsive, as we understood even then, that hearing was frequently the last thing to go. With no DRGs to tell us that the patient had to be discharged quickly, there was minimal pressure to speed up the process. Later, when the advanced life-support technology became available, family members would often insist that heroic measures be employed and/or that patients who were totally inappropriate for transfer to the ICU must be admitted there. Another complicating factor could be that some health care institutions may have over treated the terminally ill because this generated revenue.

Many Messages

Today hospital employees everywhere are bombarded with conflicting and confusing messages both from within and without the health care establishment. The Hippocratic oath speaks of first, doing no harm. But who is to say that patients are not being harmed if they have signed explicit advanced directives mandating "no heroic measures" and are nonetheless subjected to invasive and painful death-prolonging procedures because their spouse, children, and/or significant others can't agree on the course to be taken? Nurses, doctors, and other health care workers are faced with these dilemmas every day.

Think for a moment of the NICU nurse who is asked by devastated parents what to do after their premature infant has had a second extensive brain bleed. What about the staff in a sub-acute unit or SNF who are aware that a terminally ill patient would be best served by a hospice approach, but who are stymied by a physician and/or family members who cannot let go.

I believe it is such situations, among so many others, that permit self-designated "angels of mercy" and de-facto freelance euthanasia to exist. The publicity about the purported events in Glendale, California has certainly given rise to a great deal of anxiety and even paranoia in the public arena. Some under-scrupulous lawyers may have a field day preying on the litigious impulses among those who think they may reap a windfall by suing hospitals where their loved ones have died.

Strategies for Nurse Leaders

Even though the self-confessed mercy killer has not been charged as we go to press, what strategies can be employed to assist our organizations and staffs to deal with these complex issues?

* First, check for mechanisms that ensure that your organization has a real ethics committee and a process in place with a clear path for those who wish to discuss their concerns and questions in safety.

* Make sure that these issues, and any related concerns, are brought up as part of every employee orientation and periodically thereafter.

* Check with your organization's legal counsel and clergy representatives when designing or updating your policies and procedures related to any ethical issues.

* Assure that access to the drugs commonly used in the anesthesia department and powerful pain medications on the units are carefully monitored and controlled.

Last, but hardly least, all of the institution's top leadership must work together to ensure that all clinical department managers have a viable forum in which to discuss their questions and concerns about end of life/advanced directive issues. This is essential if managers are to provide assistance to families and staff members.

If any readers have a program in place that has helped guide their staff through the morass of ethical and moral issues raised by this so-called "slippery slope" debate, please let us know so we can share it with the field. Hopefully some institutions have designed and implemented programs that help clinical staff respond to the patient's and family's concerns about the care of the terminally ill. Write a letter or an article we can publish here at Nursing Economics. Now that would be a real public service.
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Author:Curran, Connie R.
Publication:Nursing Economics
Date:May 1, 1998
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