Case Study of Ethical Dilemma in Nursing

Ethics and Nursing

Jacqueline Glover defines ethics as “the formal process of intentional and critical analysis with clarity and consistency” (Glover, . For most of us, ethics comprises the basis of our moral judgments. It helps makes situation-appropriate decisions when there is a conflict of interests. Not only it is important for us to maintain ethical considerations all along our intrapersonal relationship, but also vital for us as professionals to engage in the process of ethical reasoning, as it makes every person accountable for their actions and decisions both as humans and professionals. Throughout the course of time various ethical models and reasoning approaches have been developed to facilitate the resolution of ethical conflicts, help professionals mitigate potential tensions between personal and professional values.

The field of nursing has come to be one of the most vulnerable spheres where ethical dilemmas require structured and careful analysis. That is so as nurses work in a fast-paced, technical environment. The decisions have to be made quickly and effectively. While making decisions and dealing with tense situations RNs have to keep in mind that they need to establish patient trust exhibiting compassion and empathy at the same time accomplishing reaching the most appropriate decision (Ulrich et. al, 2010).

The Code of Ethics for Nurses puts forward six key ethical principles of nursing, which include nonmaleficence (being a competent professional and report any suspected abuse), beneficence (being compassionate, take actions towards the well-being of patients), fidelity, autonomy, the totality and integrity (2014). Some staple ethical principles that go without saying include respect towards patients, maintaining their dignity and protecting their rights. Nurses are also to establish an environment of mutual trust and respect with their colleagues in order to ensure a healthy and productive work environment. In case any ethical conflicts arise, each of these principles should be taken into account and carefully evaluated so that decisions do not jeopardize any of those (Beauchamp & Childress, 2012).

As it has been mentioned, nurses work in the field of science and medical innovations dealing with patients and other medical professionals, hence, there is an abundance of potential ethical conflicts they might encounter ranging from dilemmas related to life and death up to interpersonal misunderstandings. Some of the most heated and common ethical dilemmas related to the right to health and access to health care, cloning, and reproduction, quality of life for people with terminal illnesses, principles of confidentiality and disclosure of information in emergency cases,  pain management and assisting death in terminally ill patients. All of these ethical dilemmas are quite subtle and there is a thin line between the professionalism of a nurse and well-being of patients or another party involved in the conflict.

A case study of an ethical dilemma that could happen in your practice arena

In clinical practice there are numerous cases when a nurse or a physician has to make decisions for the patients when they are unable to do so or advise the best possible medical treatment.  According to the ethical principle of autonomy, patients have the right to make decisions affecting their bodies. Nevertheless, a patient’s decision-making capacity also plays a vital role. Some patients have decision-making capacity. A patient may fully accept the nurse’s suggestion of treatment or refuse it without causing harm for himself/ herself. Similarly, a patient may lack decision-making capacity concerning the available treatment choices and hence his/her opinion will not coincide with that of a healthcare professional. There also exists the third option when a patient does not have decision-making capacity and he/she has a representative to make choice on the patient’s behalf (Elliott, 1992).

Within the course of my practice as a registered nurse, there have been many ethical dilemmas when a physician or a nurse are trying to balance the consideration and respect towards the patient’s right to autonomy with the ethical principle of beneficence and nonmaleficence. When the issues of patients’ rights and autonomy are in conflict with the concepts of beneficence and non-maleficence, a logical question of “when may a healthcare professional ethically and legally override a patient’s expressed a desire for treatment of nontreatment?” arises.

While dealing with such subtle cases, it is necessary to consider a number of precedents and legal statutes. Such as, competent patients (that is patients with clear decision-making capacity) have a right to refuse treatment. This is supported by US statues and case law. Nevertheless, even if the patients fully understand the situation, a healthcare professional should adopt an educational model. That is he should educate and inform the patient as comprehensively as possible clearly putting forth benefits and risks of the suggested treatment/ no treatment along with any possible recommendations.

In case the patient refuses care, it is the healthcare professional’s duty to attempt to discover the reasons for the refusal, in a sense, discern the real reasons behind the refusal. As in any sphere of professional performance, here as well the key is to avoid miscommunication and misunderstanding. This is necessary to understand whether there are many ways to compromise or negotiate the patient’s decision. If a healthcare professional wishes to discuss the given situation with any of the patient’s family members, clergy or any other mediator to seek help or assistance from them, he might do so, however, still first, it is necessary to get them patient’s permission for such actions.

Throughout my professional performance, I have personally come across a case when the patient totally refused the suggested care without giving any justification or basis for such a decision. The patient, an 83-year-old lady has been living in her apartment alone for a long time. The patient’s landlady and a cousin being concerned with her health and well-being contact Adult Protective Service asking for a medical evaluation. The patient has not allowed healthcare professionals to conduct a full evaluation, however, she answered some questions and has agreed to a limited health check.  It has turned out that the patient has lost a lot of weight, has memory gaps, experiences frequent falls and is physically unable to maintain proper hygiene. The patient was moving unsteadily holding onto handy objects in order not to fall down. Nutrition was quite sporadic, with irregular mealtimes. The patient has not contacted and seen a physician for many years. The major issue related not to the health of the patient but to her mindset, as she was deeply convinced once she shares her health issues with anyone she would turn into a burden both for her relatives and physicians. The medical team which has conducted the examination has come to the mutual agreement that it is necessary to conduct a further evaluation in order to asses cognitive and functional status for most likely hospital admissions.

This case has been a vivid example of how the patient’s autonomy can conflict with the healthcare professional’s ethical principles of beneficence and nonmaleficence. Our team has dealt with the case through extensive discussions. Our team has used participative ethical decision-making model. It is a seven-steps analytical model which helps to brainstorm the ethical dilemma coming up with a creative and innovative solution. In the outcome, our team has agreed that forcing the hospitalization for this example case given the patient’s refusal for treatment would only frighten and disorient her. Such kind of solution will be only the last resort choice. At the same time leaving the patient to the course of life she was leading would have been against nursing ethical principle of beneficence (Parker, 2007).

The solution we have mutually reached was appointing a psychologist consultant who could establish trust with the patient and help her overcome her psychological distress and re-establish her values towards life. Trough such regular consulting sessions, the psychologist was able to explain the risk of falling at home. Later with the help of a nurse, they have demonstrated some basic safety precautions, such as how to move around the house safely with a walker addressing such needs as proper nutrition and hygiene.

Conclusion

In clinical practice, physicians have to make decisions protecting their patients’ best interests and at the same time follow personal and professional ethical principles. Ethical standards are crucial in helping nurses make informed decisions while evaluating consequences of their actions. It might seem that assigning healthcare treatment is  simple practice based purely on the results of medical examination, however, in actual practice specialists come across cases where the patient may total refuse the suggested treatment, or there might be a conflict in their views because of different cultural backgrounds. Yet, even in such challenging cases, a healthcare professional should treat the case with respect towards the patient and find the solution which would be optimal. One of the models which can guide and facilitate the process is participative ethical decision making model. The purpose of this model is to involve more than one healthcare professional into a discussion of a specific case through brainstorming sessions and a seven-step questionnaire. This helps approach ethical dilemma with innovative and creative thinking benefiting all the parties involved.

References

• Beauchamp T.L., Childress J.F. (2012). Moral principles. Principles of Biomedical Ethics. 7th ed. New York, NY: Oxford University Press: pp. 99-288.
• Elliott C. (1992). Where ethics comes from and what to do about it. Hastings Cent Rep 22(4):28-35.
• Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 7th ed. New York, NY: McGraw Hill; 2010:74.
• Parker, F. (2007, November 26). Ethics the Power of One. American Nurses Association.
• Ulrich, C. M., Taylor, C., Soeken, K., O’Donnell, P., Farrar, A., Danis, M., & Grady, C. (2010). Everyday ethics: ethical issues and stress in nursing practice. Journal of advanced nursing, 66(11).