The Goal: To develop nurses' critical thinking, clinical judgment, and confidence as patient advocates by exploring different perspectives of a real-life problem nurses encounter in practice and applying biblical truth and ethical principles.
The Situation: An RN arriving for her work shift observed a bedraggled-appearing woman, huddled on the lawn, inject herself and go limp. The nurse, now at the entryway to the Emergency Room (ER), grabbed a gurney and called staff for assistance. Once inside the ER, the semiconscious woman was becoming cyanotic. She was triaged for a life-threatening overdose of an opioid and immediately treated with Narcan(R) (naloxone hydrochloride), an antidote to opioid-induced toxicity. After a brief episode of hypotension and vomiting, the patient stabilized. She refused to be admitted to the hospital or a drug abuse treatment program and left.
The Ethical Dilemma: "Several countries in different regions have started distributing naloxone to people likely to witness an opioid overdose" (World Health Organization, 2014, p. 2). Narcan(R) is an opioid antagonist that reverses the opioid effects, including respiratory depression, sedation, and hypotension (Adapt Pharma, 2017a, p. 9). In the U.S., Narcan(R) Nasal Spray 4 mg is available in pharmacies to patients, families, and caregivers without a prescription, except in Nebraska (Adapt Pharma, 2017b).
The issue has been raised about the overdose (OD) problem getting worse, as Narcan(R) offers addicts a "safety net" (Ingram, 2017). As Narcan(R) has become more widely available, increased costs to treat OD have precipitated a crisis for healthcare facilities, cities, and states' Medicaid programs. There is concern that without medical oversight or available treatment programs, drug abusers will develop a false sense of security and may take even greater risks, such as mixing heroin with painkillers like fentanyl or tranquilizers like carfentanil. These mixtures require multiple doses of Narcan(R) to reverse opiate effects.
Point:
* One of the nurses recognized this woman as a frequent repeat patient. "She is just getting bolder in her addiction. Now apparently she's started shooting up right outside the hospital because she knows we have to treat her."
* The ER nurse manager stated, "I'm really upset when I think of the many times I see nurses pulled away from caring for other patients to care for OD patients and then have the patients just walk out. We're so short-staffed as it is! I wish we could turf them."
* The medical director of the ER thinks the Emergency Medical Treatment & Labor Act (EMTALA) is open to interpretation and is pushing to set a limit on the number of times any given patient can be treated with naloxone. "We're enabling patients now."
* The hospital administrator noted, "A significant portion of the hospital's charity budget is being used for OD patients."
Counterpoint:
* An ER staff nurse remarked, "I feel the tension and frustration in the ER every time we have a patient like this. But I couldn't not treat! I look at it as helping people stay alive long enough to survive until they can turn their life around."
* Addiction is a complicated disease and should be treated as such. Would providers consider withholding life-saving treatment from the heart patient who chose not to follow healthcare advice? Or, the smoker who chooses to continue to use tobacco despite well-publicized risks?
What Do You Say: Jesus often healed and responded to immediate needs. Jesus instantly reached out and touched a leper, saying, "Be clean" (Matthew 8:2-3). He also told his disciples to forgive endlessly, just as God forgives (Matthew 18:21-35). Nurses are not able to instantly heal those with diseases or addictions, but are called to care as Jesus cares. We must care for our feelings through spiritual nurturing and reflective practice to avoid entering despair and anger. Nursing care is valuable work that may require repetitive treatments without ever seeing a patient cured of the underlying disease or behavior.