Case Study 3

You are looking after Doris on an evening shift on an acute medical ward. Doris is a 67-year-old
female with a past medial history of metastatic ovarian cancer. She has metastasis in her liver,
bones, lungs and kidneys. Her direction of care is currently palliative with an emphasis on comfort.
She has 4 adult children, all of whom are very close to Doris and visit her regularly. She has 9
grandchildren who also visit regularly and enjoy spending time with Doris during her last months and
days alive.

Doris presented to ED 4 days ago in severe pain which her palliative care regime was unable to treat
effectively at home. She was transferred to your ward where more aggressive pain management was
commenced and Doris and her family decided she would be more comfortable with in-hospital
palliative care rather than transferring home again, where her palliative care had previously failed. A
subcutaneous butterfly is inserted and a continuous subcutaneous infusion of morphine is
commenced at 5mgs/hr. Doris is also charted for PRN morphine 2.5-5mg, with no maximum dose to
be given to ensure comfort.

At the start of your shift you assess Doris and you notice that she is no longer conscious, her
breathing is irregular and her pulse thready and irregular. You provide mouth and eye care, pressure
area care, ensure that she is warm and that the family are also comfortable. During this time, Doris is
unresponsive to voice, occasionally moves her fingers as you roll her, and does not resist or grimace
when you are providing care. You are confident that Doris is comfortable.

At 6pm the after-hours Nurse Manager (NM) contacts your ward as the emergency department is
full and there is an 23 year old female called Sarah with viral cardiomyopathy who needs to be
admitted to your ward urgently and they want to know whether it is likely that Doris will pass away
soon so that the bed can be used for the new patient, Sarah. You tell the NM that you do not know,
Doris does not look close to dying at this stage. The NM, satisfied with this response, tells you they
will try to find a bed elsewhere in the hospital to transfer Doris to in order that the Sarah can be
admitted to an acute medical ward. Sarah would be better suited to the acute medical ward as the
nursing staff can provide a higher level of expert care to her here.

An hour later the senior registrar arrives to assess Doris. Doris is breathing more erratically, her
pulse is very weak and it looks like she may die in the next few hours. The senior registrar is also
gravely concerned for the Sarah in the emergency department and is eager to get her on to a ward
to provide more comprehensive care to her. As the emergency department is currently so busy, the
registrar is concerned that Sarah will get overlooked. The registrar requests that you administer an
additional 10mg of subcutaneous morphine to Doris, in 2 x 5mg boluses to ‘help her on her way’.

You inform the registrar that you are not going to do this because you feel that this is not
appropriate for her condition. You tell the registrar you do not think that Doris is in pain and
therefore does not require additional morphine. The registrar tells you that there is a lot of research
suggesting that people who are in comas still have strong pain sensation and can remember their
pain when they wake up. There is also a lot of evidence to support that nurses underestimate the
pain experience of people who are unconscious. He insists that we do not know confidently that
Doris is not in pain and he feels it would be compassionate to provide her with additional pain relief
just in case there is pain which we do not know about. He tells you he would like you to administer
the morphine as a kindness to Doris, to ‘prevent any more suffering’ and ensure that she has a
peaceful death.

Q1: Which ethical principles are challenged in this case study and how?

Justice- they are not being fair to Doris as she is unequally important than sarah

- Tranfering her so sarah can get her bed and receive the best treatment

Beneficence- NM and Resgistaar are

autonomy- her rights of meds is taken away from her as she is unresponsive to care. Her rights of
natural death is also challenged

Q2: Identify the legal issues raised.

- Medication overdose
- Patients consent
- Equity
- Patient safety

Q3: How does the slippery slope argument apply to this case study?

Q4: Considering at least 2 different ethical theories, outline some possible actions the nurse may
take in responding to this situation.

Q5: What will you do?