Nursing Case Study Ethical Scenario

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Ethics is very important in nursing and the health care field in general. Health care providers’ licensure depends on the caregivers’ ethical ability to provide competent and safe care. Ethics are moral values that many people use as guidelines in their daily lives. According to Shahriari, Mohammadi, Abbaszadeh, and Bahrami (2013), “Ethics seek the best way of taking care of the patients as well as the best nursing function”. Nurses and other health care providers should always care for their patients in the most ethically way possible, however, each patient and case is different. Caregivers may face many difficult ethical situations throughout their career. It is important that caregivers resolve the dilemmas they may face without violating an ethical code.

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Patient Scenario

An 80-year-old Caucasian female was admitted to the Intensive Care Unit (ICU) with a diagnosis of pneumonia, after aspirating on macaroni and cheese at home. This patient had a chronic history of COPD and Hypertension, but no other health issues. The patient lived with her brother and his wife for a few years before this medical issue. The patient had lived on her own, until her COPD starting to have debilitating effects. The brother and his wife noticed this and took her in to live with them. They had converted their home to make things easier for her. They installed power stair chairs and hired caregivers to stay with her while they were at work or needed to step out of the home. When the patient moved in with her brother, she made him the medical and financial Power of Attorney. This patient’s infection got worse, and the intensive care physician told the family that the patient’s prognosis was not looking good. The patient’s brother and his wife made the decision to proceed with hospice care.

Once the patient was moved out of the ICU and onto the Medical/Surgical Unit, the patient seemed to get better. They were able to sit up and became very talkative. They ate almost all of their dinner and seemed to be doing well. The ICU doctor was notified and met with the brother and the brother’s wife. Collectively, a decision was made to retract the hospice care and resume treatment with aggressive antibiotics. Over the course of the next few days, the patient seemed to be declining. The patient had COPD, and seemed to be struggling to move air through their lungs. The patient seemed very uncomfortable and miserable, but the doctors and family decided to keep trying with the antibiotics. Four days had passed and both the doctors and family realized the patient was not responding to treatment. The decision was made to put the patient back on hospice care and a morphine drip was started. The patient expired a day and a half later. The brother and his wife stayed by the patient’s side the entire time, holding her and comforting her while she slipped away. It really seemed as though there was a lot of love being shared in that room during that difficult time. I cared for this patient for four days in a row; the second day she was on the Medical/Surgical floor, until she was started on the morphine drip.

My first day assigned to her, her brother called and asked for updates. His name was listed in the chart, and I was able to disclose information to him. The patient’s daughter had also called asking for updates. I was not familiar with her, and I felt as though the patient was alert enough to answer whether I could explain her condition to her daughter. The patient consented to me talking to her daughter, but I knew the brother was POA, so I briefly told her that her mother was stable at the time.

My second day with the patient was more of the same. The patient did not seem to be improving, but doctors and her brother wanted to continue with antibiotics for a few more days. The brother called again for more updates, which were provided to him. I met the patient’s brother in person on the third day I was caring for the patient. While conversing with him, he told me that the patient’s daughter did not have a good relationship with the patient and had not had anything to do with her in years. I had let the brother know that the patient’s daughter had been calling and asking for updates. I received permission from the brother to give the daughter information on the patient’s condition when she called. The brother seemed very frustrated that the daughter kept calling the hospital and was very apologetic to the nursing staff. That day, the daughter had come in to sit with her mother for a few hours. The daughter was telling me stories and acted as though there was no barrier between her and her mother. She did however, made it known that there was some ill feelings towards her uncle, the patient’s brother. I did not push the daughter to talk about this situation and really did not want to know the underlying issues. It seemed as though the daughter and uncle had two very different sides of what had happened in the family.

My fourth day was the final day I had with this patient. She had a persistent temperature all morning and was not responding to the antibiotics. The doctors met with the family, and the decision was once again made to proceed with hospice care. A morphine drip was then started. I sat down with the brother and his wife consoling them and educating them on the decision that was made and what to expect in the next few hours to days. I then asked the brother if I was able to update the patient’s daughter on the latest decision. He told me absolutely and that she should be involved in the rest of her care. As I told the daughter that her mother was going back to hospice care and was started on a morphine drip, I suggested she come she her mother as soon as she could. She said she would be in to visit in the afternoon, as she had things to do that morning. The patient’s brother and his wife stayed with the patient constantly. The daughter arrived late that afternoon and asked to speak with me privately. I understood that there was an issue in the relationship between the patients’ daughter and her uncle. While speaking with the patient’s daughter, I noticed she had no desire to visit her dying mother. All she did was bash her uncle, saying terrible things about them after he cared for the patient for several years. I told the patient’s daughter several times that she should go visit with her mother and that her uncle and his wife agreed to leave the room and give her as much time as she needed with her mother. The daughter had no interest, and stated “So I guess I am out of the will, huh?”. The daughter began pulling out pieces of paper, stating she had been working all day on these arrangements. When I saw what she had, I noticed it was end of life plans for her mother. She told me that she wanted to take care of her mother’s end of life arrangements. She knew that her uncle was the power of attorney, and when I suggested that she should speak with him, regarding his plans, she immediately shot me down. It was clear that the daughter and her uncle had two very different sides of the issues in their family.

This was my first ethical situation I had been put in, because I have only been a nurse for a little over a year. I reached out to my supervisor, who sat with her and told her there was nothing that we could do because the POA was her brother. She immediately requested copies of all advanced directives in which we could not supply her because her name was not listed on the paperwork. I told the patient’s daughter that if she wanted to know the arrangements or help plan them, she should reach out to her uncle. She seemed as though she wanted nothing to do with her uncle or his wife and was very distressed. At this point, all I was trying to do was to get the daughter to sit with her mother while she was actively dying. The daughter had no interest and became very agitated. She said that she would wait for her uncle to return to handle this situation. I knew how sensitive the situation was, and did not want to make this worse. The daughter was still there when my shift was over, so I called the patient’s brother to let him know that I was leaving for the night and that the oncoming nurse was aware of the situation and would call when the daughter left. All the patient’s brother wanted for his sister was to make sure she was never alone, and the daughter did not want to sit with her. We made sure that if there was not a family member sitting with the patient, one of the staff members was until the family returned. I was not working when the patient expired, and I do not know if there was ever a resolution between the patient’s brother and her daughter. This issue between the patient’s brother and her daughter stood in the way of family getting together during a difficult time. There were many issues in this patient’s case that could have become unethical if staff were not aware and did not intervene.

Ethical Dilemma

This particular scenario consists of a few ethical issues, however, the biggest ethical dilemma is the patient’s daughter demanding the advance directive paperwork and trying to make after death arrangements for her mother, even though she was not the Power of Attorney. The staff was put in an ethical situation because they wanted to respect the daughter, but at the same time there was nothing that could be done. The staff was able to handle this dilemma ethically by not providing the daughter the information she was requesting, even though she was making a scene throughout the hospital, and stating she needed to ask the patient’s brother about after death planning because he was the POA. The daughter was doing everything she could to get information without her uncle’s knowledge. If the staff was not knowledgeable of the situation, or did not realize that the uncle was stated as POA in the chart, private information could have gotten into the wrong hands. This patient knew she was not improving and chose the palliative care route. She knew what would be happening in the next hours to days and agreed with her POA. “Studies show that patients who are informed of their prognosis and engaged in shared decision making regarding their treatment choices are more likely to request quality-of-life care focused on symptom management or palliative care (PC) services”.

This patient had completed advance directives and POA information well before she became ill. She knew what her wishes were and knew who would follow them best after her death. Once these decisions are completed and signed, healthcare providers have to follow those guidelines to care for their patients. “Advance care planning (ACP) discussions provide the possibility of clarifying future directions and choices so that the issues can be raised, examined, and fully discussed; fears both trivial and huge can be clarified and addressed, and a more realistic and pragmatic approach can be taken to living out the final stage of life in the way that is important to that individual person”. If the patient did not have advance directive paperwork, there may have been family turmoil between the patient’s brother and her daughter. Both family members wanted different plans for the patient. The brother wanted to respect her wishes, whereas the daughter wanted to do what benefited her the most. Without advance directives, the patient would not have respectfully died based upon her wishes. Some patients do not complete advance directives because they think that their family knows their wishes and will respect them. Once their family is put into a situation where they have to choose between life and death, they may choose one against the patient’s wishes. Advance directives are meant to be the patient’s voice when a patient cannot be heard. In a study that was conducted in patients with a terminal illness, most of the wished to not be resuscitated if or when something was to happen and life saving measures were needed.

According to Garrido, Balboni, Maciejewski, Bao, & Prigerson (2015), “The associations between DNR orders and better quality of life in the week before death indicate that documenting preferences against resuscitation in medical orders may be beneficial to many patients” (835). Because this patient had advance directives and POA on file, her wishes were kept during her final moments and after death. The staff was able to respect the patient while remaining ethical. The staff followed the principles of beneficence and non-maleficence, because they followed the patient’s wishes according to the advance directives and POA. The staff also demonstrated veracity: remaining honest with both the patient’s uncle and her daughter during advance directive debacle. This dilemma could have gone against the ANA Code of Ethics, but staff was able to resolve the situation while still remaining faithful to the code of ethics, specifically provisions one and two. Provision one states “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person”. According to provision two, “The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population”.

Ethics Policy and Ethics Committee

According to Chooljian, Hallenbeck, Ezeji-Okoye, Sebesta, Iqbal, & Kuschner (2016), “Hospital ethics committees are typically charged with addressing ethical disputes, conflicts, and dilemmas that arise in the course of patient care”. At the facility I work in, if one feels something needs to be reported to the ethics committee, one must report the event to their manager. From there, the manager will contact the ethics committee; and if a meeting is required the committee with contact the ethics council. In our facility, supportive care services are the head of the committee. The employees in supportive care services are our chaplain, and palliative care employees. If there needs to be a presentation to the ethics committee, I feel as though the employee calling the meeting, manager, and patient care supervisor need to attend. I feel as though our committee is strong because the members of the committee are very educated in ethics and tackle difficult situations every day.

Resolution

The main resolution I was hoping for while working through this ethical dilemma was achieving my patient’s wishes. I wanted to keep my patient comfortable and respect her wishes while she was dying. My patient knew that her brother was trustworthy and would respect her wishes when she did not have a voice of her own; that is why she made him the POA. She did not have a good relationship with her daughter and decided that this route would be best. I was hoping that my patient’s daughter would put her ill feelings aside to be there with her mother, but unfortunately that was not the case. I understand people cope differently, but my patient’s daughter was only bashing her uncle to make her seem like the better family member to take charge of my patient’s end-of-life plans. My hope for resolution was to benefit my patient.

Throughout this patient’s stay, I became very close with her brother and his family. My end goal was to make them all as comfortable and emotionally prepared while my patient was dying. My patient’s brother did not want her to die alone, so we made sure there was always someone there if her family needed to step out for a moment. Luckily, the issue between my patient’s daughter and her uncle resolved at the supervisor level and we did not have to take it to the ethics committee. Once the daughter realized she had no power over her mother’s end-of-life plans, and she was not going to speak to her uncle, she left the hospital and had not been seen again. The supervisor was able to handle the situation delicately, while still showing authority and advocating for the patient at all times. The patient in this scenario was placed on hospice because of her condition, withdrawn, and then placed on hospice again due to her condition not improving. I believe the patient and family had a sense of hope when the doctors withdrew hospice and continued treating the patient aggressively with antibiotics. The patient had designated her brother as POA, and he made the decision to proceed with hospice when the patient was not responding to the antibiotics. When the daughter realized her mother was dying, she tried to take over care from her uncle and wanted to make end-of-life plans for her mother, even though she had not seen her for years. She wanted to know about her mother’s will and was concerned she would no longer get a portion of her mother’s finances. The supervisor was able to resolve this situation by gently explaining to the daughter that no matter what she said or how many documents she tried to obtain, she had no power over her mother at the time, because the patient had already established Advance Directives.

The ethics committee did not have to get involved, because we were able to resolve the situation to put the patient first. Had there not been Advance Directives, this situation could have been very severe. The patient had been living with her brother for several years and he knew her wishes. The daughter had not spoken to her mother in years, but was trying to make end-of-life plans. Had there not been Advance Directives, the patient may not have gotten her end-of-life wishes fulfilled. Advance Directives are very important in order to achieve desirable outcomes in difficult situations. Since I have experienced this ethical dilemma, I will always educate my patients about the importance of establishing Advance Directives.

01 April 2020

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