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Have not I commanded thee? Be strong and of a good courage; be not afraid, neither be thou dismayed, for the Lord thy God is with thee whithersoever thou goest.”                    KJV (Joshua 1:9)


Nurses are more
Than people in white.
They are mediators,
between human suffering
and human wellness;
Where what they do
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E. V. Stankowski, RN
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Title: The Decision to Withdraw Care / Clinical/Ethical Exemplar
Author: Heather N. Miller, RN

Date Posted:

May 3, 2011

The Decision to Withdraw Care

As a nurse, there are those few patients that stay forever in your mind. Due to either the family or the patient they make a lasting impression. Several months ago I admitted a patient that had been in an automobile accident. She was an 88 year old restrained, female driver. She received multiple bilateral rib fractures, bilateral pneumothorax, liver laceration, and a small cerebral hemorrhage. She had been intubated due to respiratory failure and had bilateral chest tubes.

When I received report from the ER, the nurse told me that the family stated that the patient was a DNR, but the family was going home to get the DNR paperwork. The patient at this point did not have a hospital DNR. I received the patient at about 4pm, she was intubated and her vital signs were stable at this point. .

After she had been there about thirty minutes, her blood pressure dropped to the 60’s systolic. We received an order to hang a normal saline 1 liter bolus and to draw a stat H&H. The doctor had also stated on the phone that he thought the family was going to decide to withdraw care on the patient. During the normal saline bolus her blood pressure rose to normal limits and stabilized there. When we got her lab results back her hemoglobin was 6. We then received an order to transfuse the patient with 3 units of PRBC’s. .

The patients son and daughter-in-law had come up to see the patient in the mean time. They had the paperwork they said was the DNR. The papers they brought were actually a living will that stated that she didn’t want to live by feeding tubes if she was in a non-recoverable state. It also stated her son to be the health care surrogate decision maker. The doctor came up to talk to the family about the patients condition. He told them that she had extensive injuries and due to her age he didn’t think she would recover from them. If she did recover from them, he said it would take months for her lungs to fully recover. The family stated that they wanted to give her a couple of days to see how she would do, but if she didn’t improve that they would withdraw care. .

The next day, the family made her a DNR, but still didn’t want to withdraw care at this point. A few days later, the patient had improved slightly, but the entire family had decided that they wanted to withdraw care. The doctors were informed of this, but at this time didn’t think it was ethical to withdraw care due to the patients living will. They thought that eventually she might recover and her living stated that she didn’t want to be kept alive if she was in a non-recoverable state. .

The ethics committee got involved in this case. I explained to them how the family was approached in the beginning about withdrawing care and that now that the family wanted to withdraw care they were being denied there wishes. After a few days, they all decided that even though her living will didn’t clearly state it, she would not have wanted to live like this. The doctor’s and ethics committee agreed to let the family have their wishes and to withdraw care on the patient. .

I was very upset with how this situation was handled. The fact that the family was approached with withdrawing care in the beginning, and then to have it denied to them I don’t think was fair. It took a lot for them to make that decision. It made the family feel as though they were doing something wrong.

About the Author: Heather N. Miller, an RN for 9 years, presently works in PACU at a trauma center in Florida. Her past nursing experience also includes Neuro ICU. She is married to a Firefighter-Paramedic and is the mother of 2 beautiful little boys.

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