NURSING QUESTION Case Scenario: A 70-year old patient has experienced a devastat
ID: 121930 • Letter: N
Question
NURSING QUESTION
Case Scenario:
A 70-year old patient has experienced a devastating stroke and is comatose in the intensive care unit on a ventilator. A family meeting was held. The hospital physician explained the irreversible damage to the brain, and discussed end of life care and wihdrawal of life support. Family members acknowledge understanding and return to the patient's room. As the RN was preparing to enter the room, she overheard a family member say, "Mom always said she didn't want to be attached to a bundh of machines." Another family member replies, "Don't tell anyone she signed forms on the last admission, I don't think we should take her off life support."
Referring to the 2015 American Nurses Association (ANA) Code of Ethics:
1. Describe (2) ethical principles in conflict for the RN in this scneario.
2. What should the RN do in this scenario?
3. Provide a rationale that goes beyond your personal opinion based on the ANA Code of Ethics
Thank you.
Explanation / Answer
Provision 2.2 of the ANA Code of Ethics states "any perceived or actual conflict of interest should be disclosed to all relevant parties and, if indicated, nurses should withdraw, without prejudice, from further participation." The conflict of interest in this case is the family wishes for the patient, to be kept on life support, and the patient's alleged signed forms, indicating the patient would not want this quality of life.
It might be better for the nurse to not directly address the family and what they stated right there any then. He or she could talk to a doctor or another member of the family meeting. It might be appropriate to see in his medical records, if the nurse is allowed to, if the DNR was documented, as it seems the patient signed the document "on the last admission." The fact that two family members agreed and chimed into the notion that the patient would not want to be on life support implies that it was probably well known in the family that this goes against his wishes. Conflict in the family is probably already tense, so addressing this issue with another healthcare provider first might be more beneficial.
Provisions that might be beneficial to look into for more support:
1.1: discusses human dignity
1.4: the right to self determination, if the patient signed a form earlier, then clearly the patient used their rights as a patient to decide if they wanted further patient care, such as resuscitation efforts. It may not be what the family or even the RN agrees to, but the respect the RN must give to the patient is necessary to give the utmost of care. This respect also means speaking up after hearing statements that violate the patient's rights and decisions.
Provision 3 discusses advocacy and so the RN has to be the voice of the patient and speak up for them. He or she has to be at the patient's service. To advocate for this patient would be to tell other healthcare providers about what was stated. This is not necessarily "questionable practice" but rather if the RN were to not report such statements, that the care of the RN could then be considered questionable itself since no one would be aware of such a major conflict of interest among the family and patient wishes.
Provision 5.1 discusses duties to self and others. The RN has a duty of "perseverance of wholeness of character and integrity." Ignoring statements heard by the family would severely impact this nurse's integrity. What if another healthcare provider overheard as well and noticed that RN did not state anything? This RN could lose his or her integrity which is not the healthcare provider anyone should strive to be.
Provision 5.4 discusses more about integrity itself and states "When the integrity of nurses is compromised by patterns of institutional behaviour or professional practice, thereby eroding the ethical environment and resulting in moral distress, nurses have the obligation to express their concern of conscientiousness objection individually or collectively to the appropriate authority or committee." The RN in this case will know who to approach and discuss this finding with. Discovering the statements the family has made clearly has caused some "moral distress" and so in order to maintain the nurse's integrity, it is necessary to act upon this in some productive way.
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