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Ethics case study: Poor staffing results in brain-damaged patient
Shirley Keck, age 61, was admitted to Kansas medical center. Because of understaffing of nurses in the hospital, Shirley’s nurse did not assess her often enough and did not monitor her oxygen level. Shirley’s deteriorating condition was not noticed by the nurse because the nurse was overworked. Shirley suffered a respiratory arrest with a resulting brain injury.
Shirley went to the hospital with what she thought was a bad cold, and was admitted with a diagnosis of pneumonia. Following admission, she became increasingly feverish and short of breath, but her family’s calls for help went unanswered. In fact, her daughter was unable to find anyone when she went to the nurses’ station looking for help. The patient eventually stopped breathing, and someone finally responded to the family’s desperate and frantic calls for help. Shirley was successfully resuscitated, but sustained brain damage due to oxygen deprivation. She was left unable to walk, talk, or care for herself.
At the time of this incident, there were 41 other patients on this unit. Although the hospital’s own staffing standards called for 5 registered nurses and 2 licensed practical nurses to staff this unit, only 3 registered nurses were on duty. The plaintiff’s attorneys contended that lack of monitoring by nurses—caused by short staffing—led directly to the permanent brain damage Keck suffered. Furthermore, the attorney claimed that the hospital’s staffing plan, calculated according to hours of care per patient per day, failed to account for patient acuity, resulting in one nurse caring for as many as 20 patients at a time. The hospital claimed that the unit was safely staffed at all times. However, when the records for the unit in question were subpoenaed, they indicated that the hospital failed to meet its own staffing standards for 51 out of 59 days before this incident. Moreover, during depositions, a staffing supervisor said that administration warned about the costs of scheduling extra nurses, and a staff nurse submitted copies of documents in which the staff expressed their concern about the impact short staffing was having on patient care safety. According to the American Trial Lawyers Association, this was the first case to target corporate level staffing decisions rather than individual provider negligence.
The defendant hospital blamed the doctors caring for the Shirley Keck, and denied any allegations of understaffing in order to increase profits. It would have been very interesting to see what a jury would have done with this case; however, the hospital agreed to a $2.7 million out-of-court settlement while still denying allegations of short staffing. To put this in perspective, in 2010 the median range for out of court settlement was approximately $125,000 versus $235,000 for jury verdicts–and the hospital settled for $2.7 million in 1999. Moreover, the family refused to agree to any conditions that the settlement remain confidential so that others people might not suffer injury as a result of poor staffing. Thus, Keck’s story became nationally news, and was presented on CBS – 60 minutes, NBC nightly news , and CNN , and published in Reader’s Digest, Chicago Tribune, Wichita Eagle , and other media.
About the same time a Kansas Court was considering this case, The Wall Street Journal (September 29, 1999) published an article about another corporation that chose to risk human lives to save money. On the front page in a bylined article the paper reports the stunning punitive damages—$4.9 billion—levied against GMC. Even though it was reduced to a “mere” $1.2 billion on appeal, GMC lost the case because of the “cold calculus” of life versus money. Patricia Anderson, her four children and family friend Jo Tigner were awarded $107 million to compensate them for their pain, suffering and disfigurement. As the fire consumed the Malibu, the adults were able to escape, but the four children were trapped in the back of the car. Young Alisha Parker was the most gravely injured. Her burns were so severe that she lost the fingers of one hand and has undergone more than 70 surgeries.
Jurors awarded $4.8 billion in punitive damages after finding that GM acted out of fraud or malice. The verdict was quick and unanimous, particularly after jurors heard evidence that GM chose not to spend $8.59 per car to relocate the Malibu fuel tank because it cost less to settle lawsuits from injuries and deaths in fuel fires. One piece of evidence was a 1973 internal “value analysis” memo which calculated that deaths from such accidents cost the company $2.40 per automobile. So the executives decided not to recall and repair the cars to save roughly $6.00/vehicle. Attorneys for the plaintiffs did not ask for a specific amount, but pointed out that GM paid one of its expert witnesses $3.5 million over four years and spent about $4 billion annually on advertising.
Case commentary
Why talk about Anderson v GMC or even Keck v Wesley Medical Center ? Because staffing is still an issue. It will become more of an issue as reimbursement continues to be curtailed. Moreover, as patient ratios are increasingly mandated, and studies of the impact of nurse staffing on patient outcomes are providing a growing body of knowledge, it is not only possible but likely that now that we can know what is safe hospital leadership will be held liable if they do not maintain safe staffing levels. Indeed, in the Keck case, it is important to note that Keck never filed a suit or even a claim against the nurse assigned to her care. Making a profit at the expense of human life and well-being is and always will be an issue that is directly impacted by staffing decisions. Indeed, the attorneys in the Keck case could easily have asked how much it would have cost the hospital to staff the unit according to its own standards!
Maintaining safe care is the first ethical and legal duty of any hospital, and of all health professionals. Setting and meeting its own staffing standards is a hospital’s regulatory and moral duty. Moreover, as researchers produce the data needed to ensure safe patient care (and as these data are introduced as evidence in malpractice cases), there will be more pushback from courts as judges and juries react to a cold calculus of profits over human life. Indeed, in many instances, it may be the healthcare executives who make staffing decisions who are dragged into court instead of harassed and overwhelmed staff nurses. What do you think?
Selected references
Keck v Wesley Medical Center, no. 99 –C20307 (D. KS 1999)
Medical Malpractice Settlements, onlinelawyersource.com/medical_malpractice/settlements.html . Accessed November 5, 2011.
Anderson v. General Motors Corp., BC116926 (Super. Ct., Los Angeles).
14 Comments . Leave new
To this day, professional nursing organizations continue to refuse discussion on the silencing of nurses via management retaliation. A recent study by a PhD candidate on unjust discipline of nurses has been effectively supressed. The media, who takes its cue from these organizations, has been complicit in this cover-up. When nurses see there is no accountability for manager retaliation, they are effectively silenced from reporting staffing and other safety issues. Licensing boards seem not to enforce unprofessional conduct when it applies to management. To wit, even instances where management loses or quietly settles retaliation or discrimination lawsuits.
As you discuss culpability of nurse vs hospital leadership, it is important to note this case is 13 years old. With changes like IHI and IOM report, the standard across the country has reinforced this case creating the expectation that leaders must create non punitive environments where safety is a priority.
Betty did you read the whole article? It was not the nurses fault that the hospital over a 2 month period failed to follow their own staffing numbers. Nurses are super human but no one can be in 2-3 places at once. Placing the blame once more on the nurse…with this kind of support I would not wonder why any nurse would care… for they are being held out to dry for things they have all the responsibility for but no authority to change…perfect storm for burnout and PTSD.
Leah Curtin makes the case for corporate responsibility in health care systems as well as at GM. Hospital budgets are decisions about people (staff) and things (physical plant, amenities, parking lots, etc.)The hospital had options, made conscious choices; there must be corporate consequences beyond the customary placing of blame on the individual nurse. That distinction was made in this case. This is a lesson to be learned throughout the health care “industry.”
It is obvious Betty did not read the entire article. The nurse/patient ratio was obviously too high for THE NURSE to make a judgement or the family would have sued THE NURSE. When’s the last time you worked as staff Betty?
Even wih short staffing, ignoring the symptoms this patient displayed amounts to nothing short of nursing malpractice!
Unfortunately short-staffing has always been a problem, and seems worse today. When greed and paperwork began to win over ethical and thorough patient care, I sadly took a break from nursing, and can’t see going back anytime soon.
There is mounting evidence that poor staffing negatively affects patient care. Isn’t it about time we demanded evidence-based staffing?
Nurses are always complaining about staffing….no matter how many are on duty
For KathyRN: This is a bill to amend title XVIII of the Social Security Act to provide for patient protection by establishing safe nurse staffing levels. It has been referred to the Committee on Finance for deliberation, investigation, and revision before it goes to general debate. So far as I know, it’s still there.
Kathy, RN, this particular case happened in 1999. ‘Safe staffing’has always been a concern. In the ’80’s I worked in L&D, management started to pull us to ICU…This upset many nurses who did nothing but complain. I wrote a letter to management and said I would only do basic nursing when sent to an area out of my expertise! The pulling stopped immediately! Nurses need to CYA, management is looking for the buck.
Staffing issues remain the number 1 issue for staff nurses. Leah’s article was refreshing reviewing cases where judgement was based on hospitals taking human risks to save money instead of providing appropriate staffing. Ohio must continue to explore next steps despite legislation requiring Staffing Committees in each hospital with x number of nurses from departments throughout the hospital. Thanks you Leah for this very helpful perspective. Michele Valentino
Whatever happened to the ‘Safe NUrse Staffing legislation introduced in Congress in 2010 and 2011?
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- The Maryland Nurse Maryland February 2016 issue is now available.
Case Study in Nursing Ethics Human Rights and Human Dignity
Staff Writer
This article appears on page 4 of
The Maryland Nurse Maryland February 2016
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Patients trust that by virtue of being a patient, a nurse is providing unconditional care to them. This is especially true for incapacitated patients who are unable to self-advocate for appropriate and empathetic care. However, ethical conflicts can arise for nurses caring for incapacitated patients because these patients cannot make their wishes known or participate in their own care. Nurses find themselves in positions to make decisions for patients that often challenge the ability of the nurse to maintain patient dignity while protecting the patient from harm. One example of this is the decision to use sedation as restraint for incapacitated patients with agitation. While this makes sense clinically, it can challenge the ethical framework of nursing care. This case study illustrates the importance of knowing how to apply the Code of Ethics for Nurses to these difficult situations.
As professional nurses, we make decisions that may affect the very human “being” of the patients for whom we provide care. Being human is inherent; it just “is.” The Code of Ethics for Nurses begins by informing nurses that human dignity is inherent also. “All persons should be treated with respect simply because they are persons” (ANA American Nurses Association, 2015, p. 45).
Provision 1 states, “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person” (ANA American Nurses Association, 2015, p. 1).
Provision 1 establishes the fundamental premise for the ethical delivery of all nursing care and is based on human rights, the fundamental freedoms that all persons are entitled to because they are human (ANA American Nurses Association, 2015, p. 45). Delivering ethical nursing care in a complex health care environment is not always clear. Situations occur that result in ethical conflict when it is difficult to determine or perform the right course of action. Nurses must be aware of the significance of human rights in order to provide ethical nursing care and advocate for the rights of patients in these situations. The risk of ethical conflict exists when patients cannot make their own decisions or assert their rights. They are vulnerable to violations of these rights (Center for Ethics and Human Rights, 2010). A study that explored nurse leaders’ identification of risk factors that lead to complex ethical situations included patients with altered capacity as a contributing risk factor to nurses’ ethical conflicts (Pavlish, Brown-Saltzman, So, Heers, & Iorillo, 2015).
The purpose of this article is to examine an example of a complex situation that involves the use of sedation as a restraint in an incapacitated patient, identify the ethical conflicts, and show how the code of nurses guides the nurse in everyday practice. The case is a compilation of events and patients experienced over years of nursing in diverse environments. Many nurses can relate to similar situations in their practice.
Case Study Mrs. Smith is an incapacitated patient admitted to the hospital with confusion and weakness. Her diagnosis is pneumonia, complicated by end stage cirrhosis and an elevated ammonia level. During the previous shift, Mrs. Smith became physically aggressive, confused, and uncooperative. She fell but had no injury. Staff was not able to console or manage her behavior and obtained orders to sedate her. After multiple doses of sedation, Mrs. Smith is resting but heavily sedated. Now some nurses’ advocate for continued sedation throughout the night for behavioral control. Others advocate for continued sedation to prevent another fall. What is the dilemma? The Code of Ethics asserts the need to balance patient dignity with sedation.
Conflict with Provision 1 “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person” (ANA American Nurses Association, 2015, p. 1).
According to the ANA position statement on restraints, “Restraining or secluding patients either directly or indirectly is viewed as contrary to the fundamental goals and ethical traditions of the nursing profession, which upholds the autonomy and inherent dignity of each patient or resident” (Center for Ethics and Human Rights, 2012).
It is important to understand that sedation is a chemical restraint when it used to restrict or manage the patient’s behavior or to restrict their freedom of movement, and when it is not a standard medication or dose for care of the patient’s condition. Chemical or (physical restraints) can lead to incontinence, pressure ulcers, pneumonia, muscle weakness, and other health issues (Center for Ethics and Human Rights, 2012). This is not in the patient’s best interest and will lead to other health declines over time.
Conflict with Provision 2 “The nurses primary commitment is to the patient, whether an individual, family, group, community, or population” (ANA American Nurses Association, 2015, p. 5).
Administering sedation as a restraint to control behavior is in conflict with nurses’ ethical responsibility of beneficence and nonmaleficence to the patient. In its position statement on restraints, the ANA recognizes that nurses may face pressure from peers to use restraints (Center for Ethics and Human Rights, 2012). However, these intentions may not be in the interest of the patient. The nurse’s primary focus is the patient. Provision 2 states this and reflects upon Provision 1 as it explains that each plan of care must reflect the fundamental commitment of nursing to the uniqueness, worth, and dignity of the patient (ANA American Nurses Association, 2015).
How the Code Directs Nursing Care Nurses assume a great amount of responsibility when providing care to incapacitated patients. There can be conflict between doing what is right and good for the patient while avoiding harm. It is not appropriate to administer sedation for convenience.
However, should nurses sedate a patient to prevent another fall? In this case, study falls prevention interventions are in place as per policy, except for an option of assigning one to one observation to this patient because staff is not available. The conflict is now between the responsibility to keep the patient safe or using a practice such as sedation that is not safe. How should a nurse make the decision and know they have done the right thing? Follow the guidance provided in Code of Ethics for Nurses Provision 2, begin to think of the care plan for the patient who is confused, agitated, and at risk for falls.
Implementation of Ethical Nursing Care Recognizing uncertainty in a course of action is the first step in providing ethical nursing care. Imagine yourself as the nurse caring for Mrs. Smith. Begin by following the nursing process. Your nursing assessment finds her asleep, vital signs are with in parameters, and she has loud snoring respirations. She arouses to gentle shaking and answers simple questions. She is agitated during the assessment but cannot keep her eyes open. She intermittently follows commands with heavy limbs. She remains sedated, and you wonder about the prolonged effects of all the medications she received because of her extensive medical problems. You review her records and see that she was articulate and oriented a few days ago, and wonder how much the elevated serum ammonia level affects her behavior. You also note that her dose of lactulose was increased, and that she did not receive it earlier due to her behavior, but she does take it now.
Mrs. Smith does not exhibit the same behavior that she did earlier. You are not sure that she needs sedation. A sitter would be beneficial, but none is available. If you sedate her and she cannot take her medication, the condition will worsen and the incapacitation will increase. As her nurse, you feel the appropriate goal is to keep her safe from falls, harm, and her symptoms. This demonstrates respect for patient dignity and human rights by exhibiting a caring ethic. Nurses’ ethical responsibilities are to promote health, prevent illness, restore health and alleviate suffering (Center for Ethics and Human Rights, 2010). The Code of Ethics for Nurses guides nurses in this situation by instilling the nurse with the fundamental elements of respect for the human being under care.
The ANA position statement on restraints provides valuable guidance in making an ethical decision in this situation and tells nurses what to do. 1. All behavior has meaning. 2. Patient needs are best met when behavior is understood. 3. A systemic approach of assessment, intervention, and evaluation is the best means to respond to behavior (Center for Ethics and Human Rights, 2012, p. 9).
During the shift, Mrs. Smith intermittently tries to get out of bed and causes the bed alarms to sound. However, she is still unable to keep her eyes open and still seems sedated. Now the reason for her agitation is that she needs to void and attempts to get to the bedside commode, has abdominal discomfort related to the lactulose, and is simply trying to reposition herself in bed and secure her blankets and pillows. These are all needs that nurses should address. The nursing process does not identify a diagnosis that supports sedation for this patient. You now can plan and implement care according to the unique needs of Mrs. Smith. She is still agitated but sleeps for long periods between episodes. Each time she awakens, she is more appropriate. By morning, the disruptions are less frequent, she is more awake, and she is able to converse. This is a more desirable outcome.
Conflict Provision 4 “The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and provide optimal care” (ANA American Nurses Association, 2015, p. 15).
This provision directs nurses to take action and accountability for situations that prevent or interfere with delivery of ethical care for a patient. In this case, refer to Provision 4.3, “Nurses must bring forth for review difficult issues related to patient and/or institutional constraints upon ethical practice for discussion and review” (ANA American Nurses Association, 2015, p. 16). The implications of this case are apparent when reviewed in an ethical context. In this case, because of staffing issues, a one on one sitter was not available. This caused some nurses to consider sedation as a likely treatment to manage behavior and prevent falls. The institution does have a responsibility to support an environment and provide resources that are conducive to the delivery of ethical nursing care. Nurses have an ethical obligation to inform nurse leaders of these implications and offer ethically informed suggestions to improve care. Nurse leaders also have an obligation to promote ethical care by influencing changes to make this happen. The Nursing Code of Ethics provides the ways and means by which to learn from and improve nursing care.
Conclusion The Nursing Code of Ethics Provision 1 provides unwavering position in this case study. The use of sedation for the purpose of restraint or behavior management is not ethical and does not respect the inherent dignity of the person receiving nursing care. Provision 2 provides guidance because it directs nurses’ primary focus to the patient. It is not appropriate to use sedation for nurse convenience. Provision 4 guides nurses in taking action to change practice in difficult situations in which ethical conflicts occur. In this case, continued sedation would prohibit this vulnerable patient’s ability to express basic human needs, accept care and treatment, and may cause negative health outcomes. The nursing profession has a responsibility to uphold an unwavering trust that an incapacitated patient receives dignified nursing care that is his or hers by inherent rights. Through knowing and applying the Code of Ethics, nurses are better prepared to provide patient-centered care and uphold social trust in the nursing profession.
References ANA American Nurses Association. (2015). Code of Ethics for Nurses with Interpretitive Statements. Silverspring, Maryland: nursebooks.org. Retrieved October 18, 2015 from www.nursingworld.org. Center for Ethics and Human Rights. (2010, June 14). ANA Position Statement: The Nurses Role in Ethics and Human Rights: Protecting and Promoting Individual Worth, Dignity and Human Rights in Practice Settings. Retrieved October 18, 2015, from nursingworld.org: http://nursingworld.org/MainMenuCategories/EthicsStandards/Ethics-Position-Statements Center for Ethics and Human Rights. (2012, March 12). ANA Position Statement: Reduction of Patient Restraint and Seclusion in Health Care Settings. Retrieved October 18, 2015, from nursingworld.org: http://nursingworld.org/MainMenuCategories/EthicsStandards/Ethics-Position-Statements Pavlish, C., Brown-Saltzman, K., So, L., Heers, A., & Iorillo, N. (2015). Avenues of Action in Ethically Complex Situations: A Critical Incident Study. JONA: The Journal of Nursing Administration, 45(6), 311-318.
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Ethical Decision Making
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#37074: Ethical Decision Making
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Nurse P is a staff nurse in the coronary care unit of a large medical center. One morning he is informed that a patient from the recovery room will soon be admitted to the coronary care unit and assigned to him. The patient, a white man, 67 years of age, with known history of myocardial infarction, also has cancer of the prostate. The initial hospital admission was for a transurethral resection, which had been aborted in the operating room when the patient developed cardiac changes following spinal anesthesia. The patient had been transported to the recovery room with the diagnosis of possible myocardial infarction and was to be transferred to the coronary care unit for management and evaluation.
Nurse P heads to the recovery room with a bed to pick up the patient. When he arrives, the patient is being coded. He had apparently gone into ventricular tachycardia/ventricular fibrillation in the recovery room and had required countershock, cardiopulmonary resuscitation (CPR), intubation, lidocaine, and vasopressors to maintain his blood pressure. A Swan-Ganz catheter was put in place. Recovery rhythm was sinus bradycardia to sinus tachycardia with occasional pauses. The patient was acidotic, in pulmonary edema by chest x-ray with an alveolar oxygen partial pressure (PaO 2 ) of 50–60 mm Hg, a fraction of inspired oxygen (FIO 2 ) of 100%.
During the events of the code, an attending cardiologist (Dr. D) passed by, observed the code, and made the following statement to the recovery room staff and coronary care unit resident: "Say, that's Mr. S. I know him from his last hospitalization of 1 month ago when I was attending in coronary care unit. I believe he has a living will." While the patient is stabilized, Dr. D calls the patient's relative, who happens to work in another part of the medical center. The relative also expresses the belief that Mr. S has a living will and does not want to receive extraordinary support measures. Dr. D relays this information to the other physicians, and there is general agreement that conservative measures to ensure support are indicated while the living will is located.
The coronary care unit resident and Nurse P transport Mr. S to the coronary care unit. When admitted, the patient's systolic blood pressure is 70 mm Hg while on dobutamine 8 mcg/kg and dopamine 26 mcg/kg. The patient occasionally responds to verbal commands, opens his eyes, grips Nurse P's hands, and responds to pain in the upper extremities (his lower extremities are still under the effects of the spinal anesthesia). Cardiac monitoring shows that the patient is still having sinus tachycardia.
At this point, the coronary care unit resident and an intern approach Nurse P and inform him that they believe that the present treatment of the patient is cruel. Upon locating old medical records, they learned that the patient had been designated "do not resuscitate" (DNR) on his last admission, and the patient is supposed to have a living will, although it has still not yet been located. They order Nurse P to slowly turn off the intravenous (IV) drip of dopamine and dobutamine. Nurse P is faced with an ethical dilemma.
Rationale and Comments
The treatment modalities in Mr. S's treatment plan were basic: IV therapy, medication, and oxygen support. Some people might say the hospital team missed its chance when it failed to act decisively when it might have omitted the resuscitation of this patient. The IV, medication, and oxygen support may have been seen as obligatory for the patient and as supportive care.
Two reasons for this position might be offered. First, it might be argued that aggressive resuscitation is extraordinary, whereas an IV drip is ordinary. Another question might be whether the patient saw the IV as serving a purpose any more than the CPR served. Second, the difference between the CPR omission and stopping the IV drip is that one is an omission and the other would be a withdrawal. This raises the question of whether there is a difference between the two. Maintaining such a distinction might incline caregivers to be reluctant to start treatments such as an IV drip. Defenders of the view that there is no legitimate moral difference, believe that it is better to start a treatment when there is doubt about the correctness of the course and then withdraw if the time comes when it is clear that the patient would not have wanted the treatment to continue.
Here, however, Nurse P is being told by a resident and intern to turn off the IV drip on the basis of an unconfirmed belief that the patient has a living will and the fact that he reportedly had been designated for nonresuscitation on his last hospital admission. Nurse P must face the question of whether that is sufficient reason to stop the treatment even with the apparent approval of Mr. S's relative.
It is likely that the next of kin's judgment would be sufficient in the case where the patient's wishes cannot be determined, but that does not seem to lead to a clear answer here. First, we are not sure if the relative is Mr. S's next of kin. Moreover, even if it is, it seems possible that Mr. S has expressed his own wishes, and those wishes would surely take precedence. While the assumption is that he has a living will, no one seems to know exactly what it says. Some living wills are written for the purpose of insisting that treatment continue. The other possibility is that the living will could have been changed or voided by the patient between hospitalizations. Therefore, any action based on assumptions is taking considerable liberty. Also, any previous DNR order during another hospitalization would not be in effect for the present hospitalization. Again, there is the danger of paternal decision making by physicians and others for the patient [33] .
More prudent action here must be considered in the light of the PSDA. Because a living will is thought to exist and a relative was found, no withdrawal in the treatment of Mr. S should occur. The following would be a reasonable and prudent decision making process on behalf of the patient, Mr. S: (1) the living will document should be obtained (there should have been a copy from the last hospitalization, or perhaps in the possession of other family members or with the primary care physician's office); (2) relatives should be notified, and those, by law and policy of the hospital, could consent for continuation or removal of treatment modalities in the absence of an advance directive; and (3) consideration of the patient's wishes and witnessed comments and conversations in the past regarding healthcare decisions to be made for him under specific circumstances should be ascertained, in the absence of an advance directive.
Every situation that presents itself may be different, but ethical decision making based on a framework of ethical theories can provide the nurse with useful means for resolving ethical dilemmas in patient care.
What happens when, for example, patients are unable to make decisions for any reason? A blending of theoretical ethical systems and principles and a practical framework on which the healthcare professional can help patients and their families make healthcare choices is our next area for discussion.
Patient M, a woman, 34 years of age, is in critical condition and is scheduled for emergency surgery following a severe motor vehicle accident. You have been informed that her two children have been killed in the crash. She is almost hysterical and is asking you repeatedly about the condition of her children as you prepare her for emergency surgery. Do you tell the mother the truth about her children at this time or wait until after the surgery?
The ethical principles involved are beneficence and veracity (i.e., doing what is in your patient's best interest and telling the truth) and to a certain extent non-maleficence. This is an emotional issue, as most ethical dilemmas are, so be careful not to get into the "what if" trap (e.g., "What if Patient M were not in a critical condition, but was still facing surgery," or, "What if this woman was a close friend or family member?"). Remain as objective as possible when gathering facts and assessing the information and do not let emotions cause altered behavior.
Other considerations are personal values. Telling the truth is a concept that varies substantially between individuals. Personal views on absolute versus situational ethical reasoning will also affect the decision-making process and, perhaps, the definition of and decision-making use of the veracity principle. It is also very important to remember that there are other healthcare professionals to assist in the dilemma and help make a collaborative decision.
The other major consideration is knowing your hospital's policies in regard to deciding ethical issues. The groundwork 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. It may be helpful for your use and can be adapted to fit your institution.
CASE STUDY 1: AN INTOXICATED PATIENT
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 10-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.O.L.E. as their framework, note that the authors identify the same decision-making issues as the framework and algorithm examples discussed in this course.
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? 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.e., those who may be traveling at the same time as the patient and who may be endangered from a safety standpoint)?
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:
The patient can understand information relevant to the decision at hand.
The patient can interact and communicate with caregivers about the decision.
The patient can weigh the possible alternatives.
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. 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.
CASE STUDY 2: A SUSPECTED CASE OF CHILD ABUSE
(From the book Leadership Roles and Management Functions in Nursing: Theory and Application , in a chapter entitled "Ethical Issues" [45] .)
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 tells you that he feels the child is mistreated. 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 15-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. Finally, she says, "It seems as if you have nothing concrete to act upon and are only experiencing feelings. I think you would be risking a lot of trouble for yourself and the hospital if you acted rashly at this time. Accusing people with no evidence and making them go through a traumatic experience is something I would hesitate to do."
You leave the supervisor's office still troubled. She did not tell you that you must do nothing, but you feel she would disapprove of further action on your part. The doctor also felt strongly that there was no reason to do more than was already being done. The child will be followed by community health nurses. Perhaps the disgruntled ex-husband was just trying to make trouble for his ex-wife and her new boyfriend. You would certainly not want anyone to have reported you or created problems regarding your own children. You remember how often your 5-year-old bruised himself when he was that age. He often looked like an abused child. You go about your duties and try to shake off your feeling.
If the pediatrician had not yet alerted the community health nurses or another child welfare agency, this option might have been taken by the nurse. She had reasonable suspicion given the child's reaction, underweight condition and ex-husband's concern. A call would not have been inappropriate. However, this action had already been taken. The child had no other signs that she was an abused child or that she was in danger of being abused. The nurse in this situation was going on strong feelings, but little evidence.
CASE STUDY 3: THE STUDENT NURSE PERFORMING UNSAFE PRACTICE
From the Journal of Nursing Administration , we find a case to study regarding the public and professional responsibility of hospitals [46] . Hospitals throughout the country are held in high esteem within their communities for public service. They earn the public's trust by providing safe, good quality patient care. Many community hospitals serve as teaching sites for students' practicum programs, as did the hospital in this case study. Health facilities also have an obligation to share the responsibility for the quality of the nursing program by providing practice sites and nursing role models. In the case presented, the hospital should have been more proactive in addressing the quality of this practice issue.
MW is a senior nursing student at a local university. The university's nursing program requires a 200-hour practicum be completed six weeks before graduation. MW chose the intensive care unit (ICU) at a community hospital for her practicum site. MW contracted with one of the ICU staff nurses to serve as her preceptor for the six-week time period. The nurse preceptor is responsible for assisting MW to meet the course objectives. MW, the nurse preceptor, and the nursing instructor met before the practicum to discuss course objectives and expectations.
During the six weeks, MW was assigned to work the same schedule as the nurse preceptor, which was the night shift. Within the first week, the nurse preceptor reported to the ICU nurse manager that MW had displayed some inappropriate behaviors. These behaviors included inappropriate dress for work, an arrogant attitude toward the staff nurses, and considerable discussion about the amount of money MW would make as a nurse. The nurse manager and nurse preceptor discussed these issues with MW, and the behaviors improved somewhat.
By the end of the second week, the nurse preceptor reported another disturbing incident to the nurse manager. During the previous shift, MW and the nurse preceptor cared for a peritoneal dialysis patient. The nurse had explained the dialysis process to MW, and MW assisted with some of the procedure. After one of the dialysis exchanges, MW was instructed to empty and measure the dialysate output. Under the nurse preceptor's supervision, MW completed this procedure. MW and the nurse preceptor concurred that the amount of fluid removed from the patient was 1,400 cc. MW was given the responsibility of recording the amount on the dialysis flow record.
At the end of the shift, when intake and output was being calculated, the nurse preceptor noticed that the amount of dialysate fluid recorded by MW was 1,000 cc. When questioned about the discrepancy, MW responded that the recorded 1,000 cc amount was similar to the amounts recorded by other nurses. The nurse preceptor explained that the dialysate had been changed for the purpose of removing more fluid; thus, a greater amount of dialysate output was desired and expected from this dialysis exchange. MW stated that she did not want her recorded amount to be dramatically different from other recorded amounts. The nurse preceptor reinforced the reasoning behind the dialysis orders and that the actual amount removed is what needed to be recorded. When MW did not correct the dialysis flow record, the nurse preceptor recorded the actual dialysate output.
The nurse manager documented the incident and contacted the nursing instructor. The nurse manager informed the nursing instructor that MW's practicum in the ICU was terminated, and she would not be allowed to return to the ICU. The nurse manager requested that the incident be reviewed by the university's nursing program before MW continued the program.
The nursing instructor discussed the incident with MW. Later, the nursing instructor told the ICU nurse manager: "The incident does not appear to be serious. MW is completing her practicum requirement at another hospital and is doing great. She will be graduating with her class." Following this conversation, the ICU nurse manager discussed the incident with the hospital's director of nursing and sent a letter to the dean of nursing at the university documenting her concerns about MW's performance. The nurse manager never received a response to this letter. MW went on to another ICU clinical site to continue her practicum. When the nurse manager at the new facility was alerted to the previous incident, she monitored MW closely. She and the charge nurse of the ICU unit found similar inaccuracies in documentation. Further, documentation was made for vital signs by MW. However, she was observed during one shift to have not taken a blood pressure cuff or thermometer into any of her patient rooms. When the charge nurse took her own vital signs on the patients, none matched the documentation of MW.
When approached, MW indicated that "vital signs don't change much in four hours and probably don't need to be monitored that often." When questioned about the vital signs she had recorded, MW stated, "I don't want my charting to stand out and be different. None of my patients have been harmed, so I don't see what the problem is." MW was terminated from this practicum site as well and told she could not apply for a position there after graduation.
The ethical decision-making model outlined in this course can be helpful.
First, name the dilemma. The nurse is violating several ethical principles in this situation: beneficence, the duty to do good; non-maleficence, the duty to cause no harm; veracity, the duty to tell the truth; and respect for persons, the duty to honor the responsibilities of her position and to care for patients without bias, in this case, without regard for how she imagines she will be perceived.
Second, sort the issues. MW is displaying both unethical and illegal behaviors. She is falsifying patient information and potentially endangering her patients while disregarding her responsibilities. The nurse has shown that she values fitting-in over gathering accurate patient information.
Third, solve the problem. Ethical considerations and recommendations would include the reporting by the hospital to the school of nursing. The hospital should formally address concerns to the division director, dean of the school of nursing, and/or the governing board and request a written follow-up on the findings and actions of the investigation. The hospital should also investigate its State Nursing Practice Act and regulations relative to the governance of a student nurse's role. The hospital should obtain an understanding of the responsibility and accountability of the nursing faculty as well as the hospital's and staff nurse's role in this incident. The hospital should then seek and follow the advice of the State Board of Nurse Examiners. Specific actions to withhold the student's prospective licensure should not be sought unless required by the State Nursing Practice Act.
Fourth, take action. The hospital has an ethical responsibility to review the case in whatever forum its policy specifies. In many organizations, the hospital nursing leadership group is the forum. After the problem has been identified and reviewed with the individual, a probationary period should be given for the student's performance to improve. In this case, MW was counseled by the nurse preceptor in the first ICU practicum site. The school should have used the second practicum site as the probationary review. This was not done. Only the clinical nurses were aware of MW's move to another unit, and they began to evaluate her performance there. The school should have been a part of the process. Because this practice standard violation involved a student, a member of the school's faculty was included in the review. During the practice review process, the name of the individual must be disclosed and a determination made whether the practice violation is serious enough to warrant the student's suspension from clinical practice pending a complete investigation. Whatever the outcome, the contractual agreement between the hospital and the school should be reviewed to clarify guidelines. The decision makers must choose which course of action they feel best meets the particular situation and implement. Given the circumstances in this instance, termination of employment was deemed to be the most appropriate course of action.
Fifth, evaluate and reflect on the action. Time must be taken in re-evaluating with all parties involved how the decision-making process was handled. One question to be asked by the reviewers is: "Given what we know now, would we make the same decision today that we made then?" In this particular case scenario, and in any similar to it, as professionals, nurses have an obligation to act truthfully and to protect the patients (veracity and beneficence). Nurse leaders have an obligation to investigate practice concern and take the appropriate steps to correct practice problems of any nursing employee or student. This decision is absolutely justifiable.
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20 common examples of ethical dilemmas in nursing + how to deal with them, what is an ethical dilemma in nursing, 5 main reasons why nurses face with ethical dilemmas in nursing.
1. Patients or their loved ones must make life or death decisions 2. The patient refuses treatment 3. Nursing assignments may contradict cultural or religious beliefs 4. Nursing peers demonstrate incompetence 5. Inadequate staffing
How To Identify Ethical Dilemmas In Nursing?
What are the common examples of ethical dilemmas in nursing, example #1: pro-life vs. pro-choice, ethical dilemma:, how to deal with this ethical dilemma:, example #2: protecting the adolescent’s right to privacy, example #3: empirical knowledge vs. religious beliefs, example #4: parent refuses to vaccinate child, example #5: personal and professional boundaries related to social media, example #6: nurse is instructed to have patient with low literacy level to sign consent for treatment, example #7: end-of-life decision-making, example #8: inadequate resources to provide care, example #9: former patients - to date or not to date, example #10: informed consent, example #11: inadequate staffing, example #12: spirituality vs. science, example #13: patient addicted to prescription pain medication, example #14: duty and compassion do not align with facility safety protocols, example #15: patient does not have an advanced directive, example #16: incompetence among nursing peers, example #17: disclosing the seriousness of medical conditions, example #18: questioning physician orders, example #19: asked to work in a department without training, example #20: beneficence vs. autonomy, 4 consequences of avoiding ethical dilemmas in nursing, 1. nurses can quickly experience burnout., 2. avoiding ethical dilemmas in nursing can lead to legal issues., 3. nurses who avoid ethical dilemmas could lose their jobs., 4. loss of licensure:, my final thoughts.
CASE STUDIES IN NURSING ETHICS (3RD ED.) : Nursing Education Perspectives
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CASE STUDIES IN NURSING ETHICS (3RD ED.)
Editor(s): Maloni, Judith A.
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reviewed by Elizabeth G. Johnson, RN, DSN, associate professor, University of Southern Indiana, Evansville
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International Journal of Nursing Sciences
Original article the patient suicide attempt – an ethical dilemma case study, case description.
Nurses face more and more ethical dilemmas during their practice nowadays, especially when they are taking care of the patient at end of life stage. The case study demonstrates an ethical dilemma when nursing staff are taking care of an end stage aggressive prostate cancer patient Mr Green who expressed the suicide thoughts to one of the nurses and ask that nurse keep secret for him in Brisbane, QLD, Australia.
Ethical dilemma identification
The ethical dilemma is identified as “if the nursing staff should tell other health care team members about patient's suicide attempt without patient's consent”.
To better solving this case and making the best moral decision, the ethical theory, the ethical principles and the Australian nurses' code of ethics values statement, the associated literature relative with this case are analyzed before the decision making.
Ethical decision making
After consider all of the above factors, in this case, the best ethical decision for the patient is that the nurse share the information of Mr Green's suicide attempt with other health care professionals.
In Mr Green's case, the nurse chose to share the information of Mr Green's suicide attempt with other health care professionals. The nursing team followed the self-harm and suicide protocol of the hospital strictly, they maintained the effective communication with Mr Green, identified the factors which cause patient's suicide attempt, provided the appropriate nursing intervention to deal will these risk factors and collaborated with other health care professionals to prefect the further care. The patient transferred to a palliative care service with no sign of suicide attempt and other self-harm behaviors and passed away peacefully 76 days after discharged with his relatives and pastors accompany.
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