One of the difficulties in teaching logic at Carolinas College of Health Sciences was the perceived lack of relevance of the logic course to the interests of the health care students. In an effort to increase the connection between logic and the course of study I solicited cases from the faculty. Linda Horton, a nursing instructor, provided the following description of something that had happened to her that required critical thinking.

Michael Eldridge

The client is an 87 year old chronic lung patient. The client required an emergency room visit for respiratory distress and was intubated. Subsequently, the client went into Adult Respiratory Distress Syndrome (ARDS) and required surgical insertion of a tracheostomy and mechanical ventilation. The client is now on a step down intensive care unit. The client is in his fifth week of hospitalization and is lethargic, confused and doing poorly. All attempts to wean the patient have resulted in failure. The client appears to be ventilator dependent permanently. The family has been approached several times regarding withdrawal of life support. Part of the family agrees with the withdrawal and part of the family does not.

The physician wrote orders to decrease the client's pressure support and respiratory rate in increments over the next 12 hours. He also wrote orders to heavily sedate the patient and if the client cannot tolerate the ventilator changes to increase the sedation more.

The physician never discussed these orders with the nurse on duty or the nurse manager. Essentially, this could and most likely would result in respiratory depression and ultimately death.

The unit secretary took the orders and entered them. Respiratory therapy was contacted for the changes. The charge nurse was validating the orders and called for the nurse taking care of the patient to verify if the family was aware of these changes and if the physician had discussed these changes with her. Neither had occurred.

Respiratory therapy was in the room making the first set of changes when the attending nurse entered. They were stopped and told that these orders were on hold until the physician could be contacted regarding their potential outcome.

The physician's office was called and the ordering doctor was not on call and had left for the weekend. The on call physician returned the call and was very emphatic that the orders be carried out as written. The attending nurse refused to carry out the orders as written but encouraged the physician to come and make the changes if he would like. He declined the offer. The nurse manager and clinical director were notified. The nurse manager called the Ethics Committee and subsequently the orders were cancelled by phone until further discussion with the family could occur.

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Copyright © 1999, Michael Eldridge