PDF of Reflections 0213

Ethics in medicine is a very controversial subject. Health care providers, especially in the hospital setting, should understand ethical guidelines and the use of the ethics committee if they are ever faced with an ethical issue that has an unclear answer. This became apparent to me when I was rounding with pediatric Hematology/Oncology at Mott Children’s Hospital in my last semester in the Pediatric Nurse Practitioner-Acute Care program at Wayne State University. 

An 8-year-old male patient with history of stage IV rhabdomyosarcoma of the abdomen and pelvis presented to the emergency department (ED) with severe anemia 2 weeks prior. The patient was found to have polymicrobial peritonitis and sepsis, and he also was in acute renal failure from obstruction. His condition worsened over the next week. Bowel necrosis was so severe that the patient perforated through his abdominal wall and was spilling intestinal contents. The patient was receiving packed red blood cells and platelets daily to replace his losses from hemorrhaging. His pain was difficult to control even with a multidrug regimen of ketamine, methadone, lorazepam, and fentanyl, and the only option left was a pentobarbital coma. The pediatric intensive care unit (PICU) physicians felt that further transfusions would be medically futile and wished to stop the intervention to avoid prolonging the patient’s suffering. The parents disagreed and refused the idea, wanting to continue doing whatever was necessary to prolong the boy’s life.

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After discussing the case extensively with the primary team (oncology) and consulting out to Children’s Hospital of Michigan, Beaumont Hospital, and St. Jude Children’s Research Hospital, everyone agreed that palliative care was the best option; further transfusions would only delay the inevitable. In addition, the ethics committee was consulted and, after reviewing the case, agreed.

Although the physician is ultimately the person who decides whether to discontinue care, the nurse practitioner (NP) plays a critical role in the decision. Medical futility is an extremely controversial topic with many different aspects to what is right and what is not. This point in the disease process is an incredibly difficult and confusing time for a patient’s family, and the NP is in a unique position to provide explanations and objectivity so the family remains feeling supported.