- Muhammad Qasim
According World Health Organization (WHO), Pakistan is one of the 57 countries with acute deficiency of healthcare workforce and with no well-defined human resource development policy in place. The country is facing dual burden of communicable and non-communicable diseases with Doctor to patient ratio of as high as one doctor per 1254 population (WHO, 2013). The health care’s facilities remain overcrowded by patients, specially the public sector, which result in work overload and stress among the healthcare professionals. Medical officers (MOs) and Post graduate trainees have duty hours as long as 90 hours per week. Healthcare professionals under stressful condition and work overload are more prone to commit negligence and medical errors. The consequences of medical negligence range from a minor harm to loss of human life. This paper will discuss medical negligence, malpractice in relation to work overload in the light of ethical principles and theories. Moreover, some recommendation will be put forward to minimize negligence, establish proper reporting system and minimize work overload among healthcare provider.
A 27 years old male was admitted to the general surgery ward with gunshot injury. He was on injection Nalbuphine10 mg as per need. This patient was constantly complaining of severe pain. The assigned nurse assessed his pain and informed the doctor about his condition. She also informed that the patient has already received Nalbuphine up to its maximum limit i.e. four doses in the last 8 hours. The doctor was overwhelmed with the workload of ward and emergency unit as well. He told the nurse that the patient and his family are exaggerating the condition. Meanwhile, the doctor visited the patient and informed the nurse that he has reassured the patient and his family. After one hour, the patient developed breathing difficulty and went into respiratory arrest. Patient was resuscitated promptly for twenty minutes, but he did not revive, and hence expired. The family showed a strip of tablets Lorazepam 2mg, and added that two tablets are given to the patient on the advice of the duty doctor. It was found that the drug was neither mentioned in patient’s file nor was it verbally ordered to the nurse. The doctor requested not to report the incidence. Later on inquiry revealed that consequences occurred due to additive effect of concurrent CNS depressants.
In the above scenario, the patient was in acute pain, the family was worried about his restless condition. His cries and complaints were disturbing other patients in the units. Doctor was burdened with too many responsibilities and had to manage the patients in ward, recovery room, and emergency department at the same time. Being overwhelmed with too many responsibilities he advised two tablet of Lorazepam 2 mg per oral without mentioning in patient file without considering the prior high deses of Nelbuphine. Consequently, due to the additive effect of the concurrent CNS depressants patient collapsed, and after an attempt of unsuccessful cardio-pulmonary resuscitation (CPR) patient expired. This was violation of ethical principles of beneficence and non-maleficence.
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Moreover, the doctor’s intention was not to harm the patient however, he bypassed the nurse, did not indicate the order in patient’s file, and handed over written prescription to the father of the patient. The poor father brought the medicine and gave to the patient, which resulted in fatal consequences. It was breach in his duty toward his patient and violation of Hippocratic Oath (Cruess & Cruess, 2014). It is also evident from the scenario that doctor wanted to just keep the patient calm and get rid of his pain complain. So, he prescribed a high dose of another sedative medicine for the sake of his ease. Though his intentions was not to harm the patient and was also over loaded with too many responsibilities but, my question is, does work overload justify negligence which cost a human life?
Malpractice is negligence on part of an individual within a professional capacity. According to Beauchamp and Childress (2001) negligence is the absence of due care either intentionally imposing risk of harm or unintentionally but, carelessly in a given situation.
Principle of beneficence is central to healthcare and healthcare professionals are expected to be beneficent toward their patients in any circumstances. According to Mustafa (2013) “Beneficence refers to the promotion of welfare, denoting acts of mercy, unstinting love and selfless humanity” (p.2). However, in this case the doctor not only failed to be beneficent but also committed such an act which resulted in sentinel event. He prescribed the CNS depressant beside he knew that the patient had already received 40 mg of nelbuphine since morning. It was the commission of a maleficent act on his part which, resulted in loss of a precious human life (Beauchamp & Childress, 2001). Being in the professional boundary of a doctor, he was trusted upon by the patient and family and was expected to be beneficent toward patient in any case.
On contrary, it could be argued that, his intention was not to harm the patient. He just wanted to keep the patient in rest and pain free. In Addition, doctor was overburdened with other responsibilities. He had to take care of other patients so, on the bases of utilitarian theory he was justified to take into consideration the care of other patients as professional obligation. Additionally, it was not only the patient but also the worried family members and other patients in the ward who were disturbed due to his cries and complains. So his decision of prescribing sedative pills was for the benefit of large number of people (Beauchamp & Childress, 2001).
Though, his workload was more than usual, and he had to fulfill too many responsibilities at a time. However, it neither allows him to be negligent in patient care, nor permit him to violate Hippocratic Oath in which, he had promised that “he will lead his life and practice his art with integrity and honor by using his power wisely” (Zafar, 2006). His action was deficient as compared to a reasonable and prudent professional under given circumstances (Burkhardt and Nathaniel). Moreover his act was a serious carelessness and maleficent in nature for the client which cost his life. Such negligence is not justifiable on the basis of any legal or moral grounds.
Secondly, he bypassed on duty nurse who was responsible for the administration of the medication. It was breach of duty on his part to fail to enter the order in patient’s file. Being responsible for patient’s care, and employ of the institute, he was supposed to follow due course of actions of patient care. Moreover, the concurrence of opiates and sedatives would not have occurred if the doctor had followed proper procedure of prescription.
On other hand, it could be claimed that, the ultimate goal of his decision was to relieve suffering of patient. Violating proper procedure of prescription and administration was probably intended to provide prompt relief. However, the nurse could have moved with the doctor in his visit to the patient to argue on the dosage about concurrence. Furthermore, the doctor might have thought about giving prescription to the patient’s attendant will take less time and so prompt relief; he therefore broke the chain of flow of proper protocol.
The society expects professionally and morally sound decisions from the doctors. As a part of healthcare team, they are supposed to follow the policies and abide by the rules of the institute they work in. furthermore, “patients have the right to a quality of care which is marked both by high technical standards and by a humane relationship between the patient and health care providers” (Exter, 2009). In the scenario, the doctor’s noncompliance regarding proper procedure of prescription was below the acceptable standards and violation of his professional obligation. According to American medical association the doctor’s responsibilities include to be ever vigilant for the benefit of patient, and to bear their part in sustaining its institutions and burdens” (Cruess & Cruess, 2014). A large number of doctors’ misjudgments and medication errors are corrected by dispensing pharmacist or medication nurse if proper protocols are followed (Al-shara, 2011).
Finally, his request to the nurse about covering the incidence was a professional misconduct as this was a sentinel event. However, the nurse properly followed the virtue of veracity and dared to report the incident. Resultantly, the inquiry revealed that the additive effect of the concurrent CNS depressants was due to negligence in clinical judgment and careless behavior of the doctor.
It could be argued that the incidence occurred unintentionally, and its reporting could endanger the doctor’s carrier. In addition, reporting of the incidence could have cost his job and even his license of practice. Is it acceptable to take such risks in a country like Pakistan where there is already shortage of doctors?
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The negligent behavior of the doctor cost a precious human life, even though he requested the nurse not to uncover the incident. This could be measured a serious misconduct and makes his trustworthiness and moral integrity questionable. According Pakistan medical and dental council the physicians need to attempt highest level of competence and all necessary skills and knowledge, and they will be responsible for their actions (Zafar, 2006).Considering the nature of the event, it was the moral and professional obligation of the nurse to report the incidence promptly. Proper reporting system could prevent future mishaps. Nurse was right in her decision to report the incident on the basis of utilitarian theory for benefit of long number of prospective patients (Burkhardt and Nathaniel, 2008).
Healthcare providers need to be competent, skillful, and vigilant to provide efficient care to the patients. They should comply with the Hippocratic Oath and trust and expectations of the society. Sound knowledge of bioethics and Islamic ethics can make a difference and should be the part of curricula across the disciplines of healthcare. Proper policies, procedures and protocols need to be implemented and monitored for compliance at institutional, provincial and country level. The government must consider the establishment of new institutions and policy for staffing and scheduling of healthcare professional to cater the needs of growing population and minimize work overload. The proper reporting and analysis should be carried out following an incidence.
In the conclusion, malpractice on the basis of work overload could not be justified on any moral or legal grounds. Healthcare professionals should comply with the entrusted expectations of patients and society. They are expected to demonstrated optimal level of clinical and professional competencies and skills to meet challenges of the respective professions. Human life is precious and should always be respected.
Al-Shara, M. (2011). Factors contributing to medication errors in Jordan: a nursing perspective. Iranian journal of nursing and midwifery research, 16(2), 158.
Barach, P., & Moss, F. (2001). Delivering safe health care: safety is a patient’s right and the obligation of all health professionals.BMJ: British Medical Journal,323(7313), 585.
Beauchamp, T. L., & Childress, J. F. (2001). Principles of biomedical ethics. (5th ed.). New York: Oxford University Press.
Burkhardt, M. &Nathaniel, A. (2008). Ethics and Issues in Contemporary Nursing (3rd ed.) Australia: Delmar
Cruess, R., & Cruess, S. (2014). Updating the Hippocratic Oath to include medicine’s social contract. Medical education, 48(1), 95-100.
Exter, A. (Ed.). (2009). International Health Law and Ethics: Basic Documents. Maklu.
Scheffler, R. M., Liu, J. X., Kinfu, Y., & Dal Poz, M. R. (2008). Forecasting the global shortage of physicians: an economic-and needs-based approach. Bulletin of the World Health Organization, 86(7), 516-523B.
WHO (2007).Global Health Observatory Data Repository. Retrieved from World Health Organization website: http://apps.who.int/gho/data/node.main.A1444?lang=en
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