The Boxing Day sea surge happened in year 2004, triggered by an earthquake which caused the sea floor to push vertically by about 10 meters, displacing hundreds of cubic kilometers of water, resulting in waves traveling at speeds of up to 800km/h heading towards the shore, generating the biggest tsunami the world has seen for at least 40 years. Thousands died in this Asian tsunami (Boxing Day Tsunami, 2009).
According to University of California, School of Medicine (2010), Autonomy is the "personal rule of the self that is free from both controlling interferences by others and from personal limitations that prevent meaningful choice."Â Although Mrs. Cheng is a cancer patient with only one month to live, nowhere is mentioned that she could be of unsound mind or suicidal as certified by a doctor so her decision to smoke is then make while in a state of sound mind. Principle of autonomy states that patients are to be allowed to make their own decision without influence or coercion by another. Clearly Mrs. Cheng's decision was to not to give up smoking. By asking Mrs. Cheng to decide not to go to the garden to smoke because of manpower constraint or any other reason which is not of patient's own is a violation of her autonomy which is definitely not ethical.
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According to Beauchamp (2008), Beneficence is a "moral obligation to act for the benefit of others, helping them to further their important and legitimate interests, often by preventing or removing possible harms". Smoking is generally bad for health, and more so for people who already have cancer. Smoking is known to increase the size and extent of cancerous cells and metastases. (Zow, Hsu, and Eng, 2004). Thus the nursing staff should advise and encourage Mrs. Cheng to stop or reduce the number of cigarette she smoke as it will worsen her condition by possibly hastening death.
Non-maleficence is defined as not to deliberately cause unnecessary harm or injury to the patient, either through acts of commission or omission, "above all, do no harm" (McCormick, 2008). By restricting Mrs. Cheng to go out to smoke, the nursing staffs are depriving Mrs. Cheng of possibly the only thing that she enjoyed in what thought to be the last one month of her life thus affecting the quality of life Mrs. Cheng has. Mrs. Cheng might then become unhappy and miserable which might gradually caused her to become depressed or even suicidal since there is also no caregiver support for her as the rest of her family died in the tsunami. Thus, the nurse should not ask Mrs. Cheng to refrain from going out to smoke as they will be doing harm to the patient and violating the ethical principle of non-maleficence.
Justice refers to what the general public deems as right and fair (Hawley, G., 1997, p.26). To deprive an elderly patient of what she would like to do in the last one month of her life is simply cruel and unjust. To utilize manpower to accompany a patient just for smoking 5 hours a day when the nurse would be able to do more for other patients in the ward is a waste of manpower as well as tax payers' money. It is also unfair to the other staffs that have to cover extra duties while this particular staff is away in the garden with Mrs. Cheng. Due to shortage of manpower and unfinished work, the staffs might have to stay back to finish their work, taking up their personal time which could be spend with their own family. Quality and duty of care to the rest of the patients might be in question if the remaining nurses in the ward have to rush to finish their work before the shift ends.
Identify ethical conflicts
Beneficence versus Non-maleficence
Often a healthcare professional's good intention might not be what is best for the patient. Though to stop smoking has its benefits to health, it seems almost futile to ask a person who only has one month of lifespan to quit smoking. For a smoking cessation program to succeed, it would take more than a month, not to mention Mrs. Cheng has to endure the unpleasant withdrawal effects and unhappiness in the last few weeks of her life of not having to smoke (Zow, Hsu, and Eng, 2004). To resolve the conflict between the two principles of ethics, one needs to weigh the risk and benefits between the two to make a decision (Pantilat, 2008).
Autonomy versus Beneficence
Always on Time
Marked to Standard
Autonomy requires the staff to respect the patient's decisions whereas beneficence requires the staff to make decision in the patient's best interest, to remove harm and to do good. These two principles conflicted as a result when what a patient wants is deemed harmful to her health and as a healthcare worker, the responsibly is to remove the harm. To resolve it, the healthcare worker should respect that the patient decision as long as it is made in a state of sound mind and continue to try to convince the patient otherwise by making sure that patient has all the information she needs to make a correct decision (Pantilat, 2008).
Consider the Law
Duty of care
A nurse owes a duty of care to a patient, where there is a nurse-patient relationship that creates that duty. (Corcoran, 2000) In this case, the staffs of the medical ward owe Mrs. Cheng a duty to see to her needs and wellbeing, ensuring safety by accompanying Mrs. Cheng to the garden being one of it. The nurse accompanying have the option of wearing a N95 mask supplied by the hospital for protection against the organic vapors from the cigarette smoke. (Mask and More, 2010)
According to Singapore Nursing Board (SNB), Code of Ethics and Professional Conduct, Value StatementÂ 7(2006), the nurses need to advocate in the best interest of the clients, by "ensuring clients' interest and needs are recognized and considered by the entire healthcare team" and also protecting the clients from any form of coercion to involuntarily agreed to accept or change their decision. In this scenario when some nurses are advocating for the other patients' quality of care, it is very important to ensure that the nurses also advocate for Mrs. Cheng's interest and needs as well so as to ensure fair treatment of all patient irregardless of race or age. (SNB Code of Ethics and Professional Conduct, Value Statement 1, 2006)
Nurses and Midwives Act
Any registered nurse or enrolled nurse found to have been guilty of misconduct or negligence shall either be imposed a fine upon, have their registration suspended or terminated. (Nurses and Midwives Act, Section 19, 2a-d) By breaching the duty of care not abiding by the SNB Code of Ethics and Professional Conducts, the nurses are likely to be guilty of misconduct or even negligence if relations are proven between the breach of duty and the injury caused (Nair, n.d.).
Consent to Medical Treatment & Palliative Act 1995
"Medical Practitioners in the practice of palliative care for patients in the terminal phase of a terminal illness are protected from civil and criminal liability by the Act if they administer treatment only to relieve pain and distress, even though an incidental effect of the treatment is to hasten death, provided they act with consent; in good faith and without negligence; and in accordance with proper professional standards of palliative care". (Consent to Medical Treatment and Palliative Act 1995, Section 7.1) In this case, Nicotine patch could be a consideration provided that patient consented to using it. It can be administered to relieve the urge to smoke thus preventing patient from suffering from the withdrawal when the staff is unavailable to bring her to the garden to smoke.
Capacity to give consent
According to the Mental Capacity Act 2008, Section 3 (2, 4), a person is assumed to have mental capacity unless proven otherwise, and should not be deemed as incapable of making a decision simply just because he or she made an unwise decision. Thus it is to assume that Mrs. Cheng is capable of making decisions for herself in terms of treatment and among other things. The palliative team should then come together with patient to discuss issues, propose suggestion(s), provide relevant information and allow the patient to make a decision for herself.
Relationship between the clinical-ethical decision and the law
In nursing, decisions made regarding patients' care and needs are always based on the ethics and standard of practice that the Nursing Board or Council upholds. The Code of Ethics and Professional Conducts, Standard of Practice and Competency Standards are all in turn, written according to the Law in terms of legislation that govern it, e.g. Nurses and Midwives Act.
Making the ethical decision
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The author believes that Mrs. Cheng should be allowed to continue to go to the outside garden to smoke in the company of a nursing staff if she chose to. This decision is justified by balancing the principles of ethics and by following the Australian Nurses and Midwifery Council (ANMC) Code of Ethics and the SNB Code of Ethics and Professional Conducts.
Nurses are to promote and uphold patient's autonomy by respecting the informed decision made by the patient concerning their own care. (SNB Code of Ethics and Professional Code of Conduct, Value Statement 2, 2006) Thus if Mrs. Cheng's decision is to continue smoking despite being informed and educated on the hazards of smoking, then the nurses should accept and respect that decision.
According to ANMC, Code of Ethics, Value Statement 2.3, nurses who are indifferent to her colleagues' plight, manipulative and bullying their colleagues are basically just disrespectful towards others and are ethically intolerable. Thus some of the staff from the ward should not use resignation to coerce the management or the rest of the nurses to agree to a decision that they are in favour of but might not be beneficial to the patient.
Document the decision
Effective documentation provides evidence to show that individualized nursing care and the patient's response to that care outcome. Proper documentation of the quality care the nurses have given ensure that they would be able to defend themselves in court if they were being subpoenaedÂ (Henderson, 2010).
The documentation would include the date and time, names of the people who are present during the discussion, topics discussed for e.g. no smoking policy, assigning additional staff on each shift, and the understanding of the patient of these topics, comments from various parties including the patients, and the final decision, the plans to follow up and schedule a time for evaluation. The documentation of the decision will be done in a clear manner and according to the organizational guidelines. (ANMC Registered Nurse Competency Standards 6.3 and 10.3) The patient's mental capacity will also be documented by the team doctor present at the discussion to ensure that patient did not agree to any decision when she is in a vulnerable state of mind (A Guide for Healthcare Professionals, n.d.).
Evaluate the decision
Evaluation must be done throughout the whole process and not just at the end of it as it is a process of gathering data and analyzing it, using the information gathered to determine whether the plan is progressing towards the objectives and planned outcomes set initially (The Importance of Evaluation, 2005). In order for the plan of care to succeed, continuous supervision, evaluation and revise of plan of care in accordance with evaluation data is needed. (ANMC Standard of Practice, Standard 8.1 & 8.2, 2008 and Standard 3 of SNB Standard of Practice, 2006).
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