deteriorates
Harry’s condition deteriorates
Despite maximal interventions, Harry’s condition remains poor.
highly interventional treatments, including CPR.
medical interventions.
appears distressed and in pain. You think Harry may be dying.
Harry’s condition.
and does not know Harry.
conservative approach, and the daughter’s objection to this.
to attend. He instructs that Harry be maintained on all active measures including...
until the regular team can review on their rounds the next day.
highly interventional treatments, including CPR.
medical interventions.
appears distressed and in pain. You think Harry may be dying.
Harry’s condition.
and does not know Harry.
conservative approach, and the daughter’s objection to this.
to attend. He instructs that Harry be maintained on all active measures including...
until the regular team can review on their rounds the next day.
You are working on the ward that afternoon and note that Harry remains on highly interventional treatments, including CPR. His condition appears to be deteriorating despite the ongoing maximal medical interventions. You observe him to be confused and agitated, pulling at IV lines, and he appears distressed and in pain. You think Harry may be dying.
Around 6pm you page the on-call neurosurgical registrar to discuss Harry’s condition. The registrar who is covering the on-call page works for the other team, and does not know Harry. You convey the opinions of the consulting medical teams relating to a conservative approach, and the daughter’s objection to this.
The on-call neurosurgical registrar is frustrated by the call and says he is too busy to attend. He instructs that Harry be maintained on all active measures including continuation of the IV heparin infusion, and for escalation of care and CPR until the regular team can review on their rounds the next day.
What would you do now?
Contact Harry’s daughter and explain to her that if we perform CPR on Harry we could break his ribs and cause him suffering
While there are always potential risks associated with CPR, wherever possible, discussions such as this should be conducted in person, gently, and with compassion – Explore another option
Contact Harry’s daughter and persuade her to change her mind about the no CPR order, as you believe Harry is dying
Despite your belief that Harry is dying, conveying this to his daughter for the purpose of changing her mind about ‘no CPR’ may be premature, and appear insensitive. Conversations such as these should be coordinated and considered. Further, decisions regarding CPR are medical ones (as explored earlier). – Explore another option
Escalate your concerns to someone else, as you believe Harry is being harmed by the decision to continue with the current treatment plan
This would be reasonable if, from an ethical or professional perspective, you are uncomfortable with the outcome of the discussions about Harry’s care. Escalation options include:
- The Nurse Unit Manager or senior nursing staff such as a Clinical Nurse Consultant, Clinical Nurse Specialist, or Clinical Nurse Educator
- The After-Hours Nurse Manager
- The senior general medical person on site, such as the senior medical registrar
- The admitting medical officer or consultant
- Another Senior Medical Officer who has been involved in the patient’s care, or who may be able to assist in advocating for Harry’s wellbeing – Click close and proceed to the videos below, or explore the other options before continuing to these.
Document conversation with the on-call neurosurgical registrar in the clinical record and leave it at that; it’s their responsibility now
We are responsible for our own actions and inactions in our professional roles, particularly where there is a risk of harm to patients. Arguably, this approach may not satisfy our ethical and legal obligations to Harry- Explore another option
Report the on-call neurosurgical registrar to the Director of Surgery
Although this may seem reasonable, it is not necessarily indicated. While we may disagree with the neurosurgical registrar’s decision and reaction, people can defensibly arrive at a different clinical decision when faced with the same clinical circumstance. Further exploration and understanding are needed – Explore another option
Contact Harry’s daughter and explain to her that if we perform CPR on Harry we could break his ribs and cause him suffering
Contact Harry’s daughter and persuade her to change her mind about the no CPR order, as you believe Harry is dying
Escalate your concerns to someone else, as you believe Harry is being harmed by the decision to continue with the current treatment plan
Document conversation with the on-call neurosurgical registrar in the clinical record and leave it at that; it’s their responsibility now
Report the on-call neurosurgical registrar to the Director of Surgery
You can watch the videos below or choose to explore more of the above options.
Dr Jan Maree Davis from SESLHD Palliative Care talks about how we might recognise clinically that someone is dying.
Professor Ian Kerridge from Sydney Health Ethics discusses how we determine what is ‘best’ for a person in the clinical context, and briefly considers the complex idea of ‘best interests’.
Dr Jan Maree Davis
“How do we know when someone is dying?”
Prof Ian Kerridge
“How do we determine what is ‘best’ for a person, and what should we do where there is uncertainty or disagreement about ‘best interests’?”