Decision Making with a Neonatal Ethical Dilemma

• Natalia Perdomo

Introduction

Ethical dilemmas have been at the forefront in the healthcare industry. Nurses are constantly faced with situations in which difficult decisions must be made. It is crucial to determine at what point autonomy outweighs patient wellbeing.

Gather Data

The ethical situation presents a woman delivering a baby in a country hospital after suffering complications. These complications cause inadequate oxygen delivery to the baby. The baby is supported by nutrition and hydration and currently in an unresponsive state to verbal and tactile stimulus. The NICU staff and nurse have never experienced this situation in the past and are unaware of how to proceed. The parents are in a state of extreme grief while the staff feels overwhelmed and uncertain in regards to a solution. Information not presented in this case includes reassessment of Apgar score, gestational age, weight of infant or type of delivery as well as mother’s medical history.

Key Participants

The key participants in this dilemma include the parents, the NICU staff and the nurse who is primarily responsible for the mother’s care. When considering the mother’s perspective, it is crucial to understand the many factors that play into her thought process. She has been through a difficult labor and is stated to be weak and grieving. When asked to make a decision, she feels competent enough to make a valid decision. The father, who is also grieving, agrees with his wife, who is in a distressed state. Both parents are saddened by the condition of the infant and feel there is no choice other than to discontinue life support measures because they value quality of life and do not want their infant to endure suffering any longer.

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The NICU staff, who pride themselves in valuing patient autonomy, want to be as supportive as possible and perform in the best interest of the patient. The nurse and staff agree that the mother does not have decision-making capacity at the time of the decision. The nurse demonstrates an ethical struggle, as she needs to fulfill her supportive role towards her patient. She feels that by not offering enough information, she cannot assist the parents in making the best decision or intervene due to her lack of knowledge.

Statement of Ethical Problem of Conflict

The ethical conflict rests on the nurse in this case. The conflict is whether she should support the decision of her patient to discontinue nutrition and hydration or whether she should seek out alternative options to convince her patient to reassess her decision.

Review of Literature

When dissecting a situation such as this one, it is critical to understand the key points in their entirety to determine the most effective approach. According to Conde-Agudelo and Romero (2012), an amniotic fluid embolism (AFE) is known as a rare and fatal obstetric condition associated with severe symptoms such as sudden cardiovascular collapse, respiratory distress, altered mental status and fetal distress. It is currently the second leading cause of maternal death in the U.S. and must receive prompt and aggressive treatment by a multidisciplinary team. The fetal distress caused by AFE results in hypoxia of the neonate, which in consequence may cause life threatening injuries and lifelong disability. Anju, Naijil, Paulose, Roshni and Shilpa (2012) state that hypoxia may cause multi organ failure and functional damage especially to the cardiovascular and central nervous systems. The authors also note that because hypoxia has the potential to induce neuronal death in vulnerable brain regions, impairment of cognitive function can be detected later in life.

In addition to the effects of the AFE, it is crucial to understand the hormonal process contributing to the emotional state in the postpartum period. After a woman gives birth, the levels of estrogen and progesterone decline rapidly. Harvard Medical School (2011) explains that due to the plummet of hormones immediately after birth, emotional instability may result as these reproductive hormones interact with neurotransmitter systems that affect mood and mental health. Expected post partum emotions, according to Turner (2012) include feelings of tiredness, anxiety, tearfulness, lack of energy and insomnia.

There are many laws that serve to protect the rights of the infant and child. The United Nations Declaration of the Rights of the Child (1959) states that the child “shall be entitled to grow and develop in health; to this end, special care and protection shall be provided both to him and to his mother, including adequate pre-natal and post-natal care.” Although care and protection of the infant is essential, there are always exceptions. In the court case Miller v. HCA (1990), a premature infant was born with multiple complications and a poor prognosis. The parents made it clear they wanted no measures taken to save the infant. However, the physicians intervened regardless and initiated life sustaining measures. These parents valued quality of life and disagreed with life sustaining measures due to likelihood of severe and permanent physical and mental impairments in the future. When their autonomy was not respected and the infant was kept alive, the parents became responsible for the life of a child with severe disabilities.

Aladangady and Rooy (2012) clarify that babies with poor prognosis should have treatment decisions made jointly by the health care team and infant’s family while considering the best interests of the baby and current clinical condition. Ethics committees in hospitals serve as resources to the providers as well as the patients and should be considered as they provide ethics education. However, Gaudine, Lamb, LeFort and Thorne (2011) assess barriers to requesting an ethics consult, which include consult worsening the situation, unhelpful consultations, solutions conflicting with good practice and working with unqualified ethics consultants.

Supporting Principles or Theories

Burkhardt & Nathaniel (2014) define autonomy as the “freedom to make choices about issues that affect one’s life, free from lies, restraint, or coercion” (p. 60). This principle respects each individual and highlights his or her uniqueness and value within a society. There are four basic elements that determine autonomy. The autonomous person must be respected, have the ability to determine explicit personal goals, have the capacity to decide on a plan and have freedom to autonomously act upon choices made. Children, fetuses and individuals with mental impairments are not considered autonomous; therefore, they are unable to make informed choices.

The principle of beneficence according to Burkhardt & Nathaniel (2014) requires that nurses act in ways that will benefit their patients by doing good. There are three major components within this principle, which include doing or promoting good, preventing harm and removing evil or harm. By striving to act in ways that are morally and legally correct, it allows the nurse to gain trust from her patients as well as from society.

Within the context of the situation, the two ethical principles presented oppose each other in regards to the ethical dilemma of the nurse. By supporting the decision to discontinue hydration and nutrition, the nurse is respecting the patient’s autonomy. The baby does not possess autonomy and therefore, cannot make decisions. The parents possess the right to make decisions as they see fit and the nurse must respect their freedom. The nurse abides by the principle of beneficence by choosing to seek out options to provide the best possible alternatives within her scope of practice. By doing this, she can educate the parents and give them an opportunity to make an educated decision, which may facilitate reassessment of the decision to prevent any further harm to the neonate.

Desired Outcome for All Participants

The desired outcome for the situation presented is for the country hospital’s NICU staff to work together and form a plan of care that is in the best interest of the neonate. The plan of care should be discussed with the parents and they should feel confident with their informed decision. Once the plan is discussed with the parents and they are in agreement, the NICU team will work together to implement the plan.

Options

The nurse may support her patient’s wishes to have life sustaining measures withdrawn in the infant. Within the mother’s current emotional state, this action may seem as the most reasonable but down the line, she may feel extreme guilt and regret. This decision may trigger moral distress amongst the nurse and NICU staff due to their lack of knowledge and guidance in the situation. However, by supporting the decision the nurse demonstrates respect for patient autonomy. If the infant is disconnected, the staff may speak to the parents about providing palliative care and donation of the infant’s viable organs.

The nurse may also choose to reassess both mother and baby for a week due to the mother’s initial lack of decision-making capacity. This option violates patient autonomy as the parents wish to disconnect hydration and nutrition. By keeping the baby in its current state, it may cause difficulties for the parents as they value quality of life and disagree with life sustaining measures. However, this option provides the nurse with an opportunity to intervene, consult specialists, research and learn about the mother’s condition and most effective implementation. By reassessing both patients for a week, it buys the infant some time to recuperate from birth trauma and allows the mother to reach optimum health in order to make a rational decision.

Another option that may be considered in this situation is to consult the hospital’s ethics committee. Since the nurse is unsure of whether to support parents or encourage them to reassess their decision, she may call in a third party to intervene. This option also goes against the patient’s wishes and may cause them to lose trust in the nurse, which may result in stress on the patient-nurse relationship. The patient and her husband may also refuse to speak to the ethics committee altogether. However, if the patient and her husband consider the option of speaking to an ethicist, it allows them to discuss their decision-making process and values with an unbiased party. By incorporating another person who was not initially involved in the situation, it will assist in relieving some distress the staff feels in regards to the dilemma.

Decision and Justification

The best decision in this case is for the nurse to reassess both the patient and infant for a week due to the mother’s initial lack of decision-making capacity. Although this choice goes against the autonomy of the mother, it is a decision that is made in the best interest of both the mother and the infant. Extra time allows the nurse to obtain research about AFEs and clinical manifestations to better aid her patient. As stated earlier, one of the main symptoms of an AFE is altered mental status, which may explain why such a rash decision was initially made. The nurse is aware of the altered mental status and must intervene due to the principle of beneficence. During this time, the nurse may consult with a neurologist to observe the mother’s neurologic status and monitor for any impairment. Furthermore, the nurse may consider consulting a neonatologist to determine possible treatment options and prognosis of the infant.

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This option serves as the most effective over the others because it involves the most thought out process. The option to support her patient’s wishes and autonomy is not in the best interest of the mother or baby, as the nurse is aware of the mother’s lack of decisional making capacity. It is the nurse’s responsibility to do good within her scope of practice and seek out the best option for her patient; this option does not allow her to do so. Requesting an ethics consult would involve more staff in this very delicate situation and most likely negatively affect the nurse-patient relationship by further upsetting the patient and her husband.

Effectiveness of Decision

The decision that is chosen by the nurse is effective because it involves the implementation of a plan that is carried out by the staff, as well as other collaborative means such as neurology and neonatology. This decision provides the nurse with an opportunity to research options with the patient’s best interest in mind while providing the patient with the prospect of healing. Meanwhile, the infant may receive an appropriate evaluation to determine likelihood of survival. If after further assessment possession of decisional capacity is confirmed, along with confirmation of infant’s unchanged state, the parents may then restate their wishes to disconnect nutrition and hydration as they strongly value quality of life. At this point, the nurse may feel confident in her decision to support the patient’s autonomy as the appropriate measures were taken.

Conclusion

This scenario is one of many in which a nurse may be faced with a difficult decision. Assessment is the key component in determining whether or not autonomy outweighs patient wellbeing. Once a conclusion can be deferred, the nurse can then implement the most effective plan of care.

References

Aladangady, N., & Rooy, L. (2012). Withholding or withdrawal of life sustaining treatment for newborn infants. Early Human Development, 88, 65-69.

Anju, T.R., Naijil, G., Paulose, C.S., Roshni, T. & Shilpa, J. (2013). Neonatal hypoxic insult-

mediated cholinergic disturbances in the brain stem: effect of glucose, oxygen and epinephrine resuscitation. Neurological Sciences, 34(3), 287-296.

Burkhardt, M.A., & Nathaniel, A.K. (2014). Ethics and issues in contemporary nursing (4th ed.). Clifton Park, NY: Delmar Publishers.

Conde-Adudelo, A. & Romero, R. (2009). Amniotic fluid embolism: an evidence-

based review. American Journal of Obstetrics & Gynecology, 201(5), 445e1-445e13.

Declaration of the rights of the child. (2014). In United Nations Cyber School Bus.

Retrieved, from https://www.un.org/cyberschoolbus/huma nright s/resources/child.asp

Gaudine, A., Lamb, M., LeFort, S.M. & Thorne, L. (2011). Barriers and facilitators to consulting

hospital clinical ethics committees. Nursing Ethics, 18(6), 767-780.

Harvard Medical School. (2011). Beyond the “baby blues.” Harvard Mental Health Letter,

28(3), 1-3.

Michigan State University. Case Study: Miller v. HCA. Retrieved from

https://www.msu.edu/course/hm/546/miller_v_hca.htm

Turner, S. (2012). Postpartum emotions. Midwifery Today, 12(5), 33-36.