Any decision should be based on ethical principle that protects the best interest of both the patient and the health care provider. This paper will outline a critical incident which occurred in one of my clinical experience in intensive care unit ICU. It presents the clinical case, identifies the ethical dilemma, and discusses the principles that apply to this situation.
Mrs G was a year old woman who was brought to emergency department ED after her carer found her in respiratory distress. A chest radiograph revealed a right lower lobe consolidation. Based on her old notes it was found out that she had been recently admitted for investigation of significant weight loss and it was found to be a result of advanced bowel cancer ,with lungs, bone and brain metastases. I was then tasked to look after this patient for that shift. After knowing the brief history of the patient from my team leader, I was then asking the doctor of what do we do for this coming admission?
Are we going to intubate and ventilate this patient in case she developed respiratory failure? And what are the chances of her recovery from this critical illness? Has it been discussed to the next of kin before the plan for ICU admission? Relatives need to be involved in discussions about end-of life issues so that they are fully aware of the appropriate decisions to be made; and that all parties involved understand the situation McDermott, During my conversation with her she mentioned that she had a distant relation with her mother and not had been in contact with the patient over the past 3 years.
But despite of all that she still wanted that everything done I then told her the need to speak the medical staff and the meeting was arranged for her later that day. In this case, a clinical ethical dilemma has been identified. He was able to reach the son by phone and discussed to him the planned course of treatment. He son stated that his mother would not want any aggressive measures, and he agrees to comfort care for the patient.
He said he will speak to his sister about her concerns and will join the arranged meeting later that day.
A Doctor’s Dilemma: A Case of Two “Right” Answers - The Hastings Center
In analysing a clinical ethical dilemma, the first step is to further characterize the situation in terms of the underlying ethical principles that apply and the possible related ethical concepts that may be involved for example advance directives Alfandre, To understand the decision-making process in this case, one must consider the ethical principles of autonomy, beneficence, normaleficence, and justice. Even if more treatment was attempted for his individual systems, death was the expected outcome for Mrs G.
Therefore the aim of good critical care medicine should be to establish a meaningful tension between the aim of preserving life and making a peaceful death possible Callahan, At the meeting later that day, I could feel the emotional tension between the son and daughter, and being the nurse that involved in the care of their. In this situation the ICU consultant was concerned about providing additional medical treatment that the patient may not have wanted.
I believe that without compelling reasons to override Thus the team aims to continue with comfort care including oxygen, frequent suctioning, and pain relief for respiratory distress. As the nurse that looks after Mrs G, I also wanted to provide the care that is in her best interest as possible. Making her more comfortable and free of pain is an example of this principle During the end-of-life dilemmas, the stress of illness and dying can create a tension that makes barriers to communication even if there was an advance directive Tulsky, During the meeting, since both the son and daughter were present, the consultant starts the dialogue about the value of comfort care and its importance with dying patients.
Emotional statements about end of life are difficult to express yet provide crucial information to family members that can help create consensus around the next medical decisions and course of action. This is the ethical question raised in this case scenario. The decision of not resuscitating Mrs G was influenced by this principle. Instituting full cardiopulmonary resuscitation measures to a patient who is terminally ill could have a devastating effects and contributes to poor care at the end stage of their illness Edmonds, According to a recent study by Redman and Fry on ethical issues in nursing practice, prolonging the living-dying process with inappropriate measures is one of the most profoundly disturbing experiences that we nurses face and witness.
I do feel that aggressive treatment to the patient is a violation of this principle as what exactly what the daughter wanted. The doctor decides to quietly observe. The doctor decides to remain silent. She is getting morphine to relax her breathing and manage her pain. This is part of the dying process and we are making her comfortable. The ground work should be there for you, and you should be familiar with it. If your workplace does not have policies that address making ethical decisions, you may want to refer to the suggested Guidelines for Ethical Decision Making in Patient Care, included later in this course.
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It may be helpful for your use and can be adapted to fit your institution. Patient J, a man 35 years of age, was involved in a fight and sustained a large laceration to the center of his forehead. The patient presents to the emergency department alert and oriented without significant findings other than the cm laceration. However, his speech is slurred, and he readily admits to drinking 10 beers during the last few hours.
The emergency department is very busy with more urgent cases, and the patient becomes impatient because of the wait. Patient J wishes to leave, but is urged by the ED staff to wait and is told that he should not drive. He is clearly lucid and states that he will not wait any longer and intends to drive himself home. Using the acronym R.
R: Risks of medical treatment. In this case the proposed treatment bears little risk to the patient. Few people have life-threatening complications from laceration repair; therefore, the chance of the patient experiencing untoward harm from the procedure is remote. O: Opinion of the patient. Why does the patient want to leave the emergency department?
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Does he understand the risks and benefits of the procedure? Is he competent to make this decision in his intoxicated state? L: Life quality. Will not having the laceration repaired significantly affect the patient's quality of life? Would an unsutured wound healing for an extended period affect the patient in his profession and render him unable to earn a living? For example, would he be unable to wear required safety equipment, such as a helmet or goggles, because of the laceration? Is the patient involved in a profession, such as acting, where a potentially disfiguring scar could affect his career?
E: External factors. Is there any obligation on the part of the healthcare team to third parties i. The conflict in this case is between the patient's right to autonomy and self-determination and the staff's concern for his well-being and the safety of others. From both a legal and ethical standpoint, competent adults have the right to decide whether they will accept medical treatment. This right relates to the ethical principle of autonomy and the legal doctrine of informed consent.
In their professional education, nurses and physicians are frequently taught to apply very strict standards in the determination of patient capacity or the ability to make decisions. There is not allowance for medicated patients to sign consent forms, and frequently, it is assumed that developmentally disabled, intoxicated, and critically ill patients lack the capacity for decision making. In the emergency setting, in particular, there is a bias toward intervention and treatment if there is any doubt about patient capacity. However, none of the above conditions negates the patient's ability to make responsible healthcare decisions.
From an ethical standpoint, the patient is a capable decision maker if:.
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Given these guidelines, Patient J was clearly capable of refusing medical treatment, despite the feelings of the ED staff about the necessity of suturing the wound. But what about the third parties who may be affected by Patient J's decision to drive while intoxicated? Do the healthcare professionals have a duty to prevent him from driving?
In instances such as these, care providers must remember that their first duty is to the patient.
AMA Journal of Ethics
A decision to violate patient confidentiality or to detain the patient against his will automatically places the caregivers in a position that may require justification of actions. If the patient is clearly too intoxicated to drive, a prudent course of action would be to document that the patient was asked to stay and that he was advised that if he chose to leave, his license plate number would be given to the police. Always check the policies and procedures, guidelines, and protocols in your facility to see what resources and assistance you have in these situations.
You are a nurse on a pediatric unit. One of your patients is a girl, 15 months of age, with a diagnosis of failure to thrive. The mother has stated that the child appears emotional, cries a lot, and does not like to be held. You have been taking care of the infant for the two days since her admission, and she has smiled and laughed and held out her arms to everyone. She has eaten well. There is something about the child's reaction to the mother's boyfriend that bothers you. The child appears to draw away from him when he visits.
The mother is very young and seems to be rather immature, but appears to care for the child. This is the second hospital admission for this child. Although you were not on duty for the first admission six weeks ago, you check the records and see that the child was admitted with the same diagnosis. While you are on duty today, the child's father calls and inquires about her condition.
He lives several hundred miles away and requests that the child be hospitalized until the weekend it is Wednesday so that he can "check things out. He says he is also concerned about his ex-wife's four-year-old child from another marriage and is attempting to gain custody of that child in addition to his own child.
From what little the father said, you are aware that the divorce was very bitter and that the mother has full custody. You talk with the physician at length. He says that after the last hospitalization he requested that the community health agency call on the family. Their subsequent report to him was that the 4-year-old appeared happy and well and that the month-old appeared clean, although underweight. There was no evidence to suggest child abuse. However, the community health agency plans to continue following the children.
He says the mother has been good about keeping doctor appointments and has kept the children's immunizations up to date. The pediatrician proceeds to write an order for discharge. He says that although he also feels somewhat uneasy, continued hospitalization is not justified and the state medical aid will not pay for the additional days. When the mother and her boyfriend come to pick her up, the baby clings to you and refuses to go to the boyfriend. She is also very reluctant to go to the mother. All during the discharge you are extremely uneasy. When you see the car drive away, you feel very sad.
What should you do? Upon returning to the unit, you talk with your supervisor, who listens carefully and questions you at length.
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