I review the patient’s risk status and lab history, and will offer an acceptable minimum (e.g., a CBC and an ALT q4 months; office visits q6 months). I also advise patients of labs that offer special discounts and health fairs, and suggest ways to negotiate fees. Patients usually find this acceptable, because I am willing to work with them. I sleep better at night.
To agree to provide the prescription without following minimum guidelines suggests that such guidelines are in place only to support my income and the healthcare industry. What is unsafe is simply unsafe. How is it that something is only medically necessary if the patient is well insured? It either is or isn’t necessary.
I developed this gestalt after a situation when I was a hospital nurse. I had an elderly patient who had suffered a cerebrovascular accident and had significant dysphagia and was “Comfort measures only.” After an emotionally charged family meeting, the family determined that feeding her by mouth was nurturing and comforting and if she aspirated and died, this was acceptable since the intention of their actions was the provision of comfort. I, however, refused to be the person to feed her, but welcomed the family members to feed her. I did not want to be the person who performed the act that could result in her death. It was different for the family members to feed their own relative. However, if a registered nurse is feeding a patient, it is considered a nursing task. Would I have agreed to feed my own mother if I was sure that this is what she would have desired? Absolutely. But this was not my mother; this was a patient.
A similar scenario is encountered when a patient receives CPR, including intubation, only to have it discovered later that the patient had refused intubation in his or her living will. Not placing the tube is an act of omission; removing the tube is an act of commission. The end result is the same, yet in the first scenario, the provider has allowed the patient to die naturally; in the second scenario, the provider has removed life-sustaining treatment that was already in place, resulting in death. This is more difficult to consider.
Quite provocative!
Kimberley M. Morris, MSN, APN
Arthritis Specialists of Northern Nevada, Reno, NV
The Authors Respond
This is a thoughtful commentary on our inaugural column, which appeared in the July issue (p. 1) by Kimberley Morris of Reno, Nevada. Not only does she raise several interesting points concerning the case presentation, hers is the first response to the column and thus we thought it should be published in full.
