The aim of this essay is to explore the ethical principles, mainly looking at the principle of autonomy; Ethical principles are used for staff to meet the requirements of others to an appropriate standard of social and professional behaviour, General Medical Council. (2009). The purpose and status of this guidance. Available: http://www.gmc-uk.org/education/undergraduate/professional_behaviour.asp#The_purpose_and_status_of_this_guidance. Last accessed 16 December 2009). For this assignment the student will explore an ethical problem that they have been faced with on the ward. The ethical problem involves a stroke patient refusing a peg feed, and wishes to have their normal diet. Keeping in line with the Nursing and Midwifery Council (2008) the student will maintain the confidentiality of the patient who will be referred to as Mr P.
The ethical dilemma that the student has encountered is with a patient that is refusing a peg feed, after he had his swallowing reflexes affected after having a stroke. "A person that rules themselves, is free from the interference of others and free from personal limitations that can obstruct individuals choice." R Gillon (1986). here for respect of a patient's autonomy is the most basic rule of ethics. The effects of the stroke left him with speech impediments along with significant swallowing difficulties, resulting in this having an effect on his diet.
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McLaren (1998) suggests that stroke patients often experience swallowing difficulties. Correspondingly as well, patients who have been affected by a stroke can have their ability to eat affected Williams & Wilkins, (2007). Impairments range in a variety of different effects from a stroke. In Mr P's case this was evident that he did have this problem and that Mr P. needed to have an assessment done by the speech and language therapist (SALT).
Mr P. had his speech impaired along with other effects resulting from the stroke, so needed to have a swallowing assessment done, which was performed by a SALT, patients who have been effected by the stroke have different ways of coping. (http://www.manchester.gov.uk/egov_downloads/report02_25_.pdf.)
After the assessment had be done and had clarified that Mr P. need to have a peg tube to be put in place for the time being so Mr P. would get his adequate diet. But Mr. P. refused insertion of the peg feed because of the way it needed to go in through his stomach, so was making gestures towards the solid food on the tables which was his normal diet by mouth. As Mr P. had his swallowing mechanism affected it was decide for his best interest that he should have a peg feed.
Mr P did refused the peg feeding tube as he felt he could still have a normal diet of solid food, he showed that he did not want the peg tube food by his gestures towards other patients food, at food times. After the refusal a mental capacity test was needed for Mr P. to see if the refusal was made from sound mind. The 2005 Act addresses this perceived imbalance by setting
out a statutory framework for determining decision
making capacity and introducing a checklist of factors for
determining a person's best interests (Mental Capacity Act
2005, sections 2,3 and 4).
Complications may occur if Mr P. was to continue with his normal diet by month, because of his swallowing reflex he could end up chocking with his dysphasia. (NIDCD, 1998)
With Mr P. refusing the feeding tube it caused an ethical problem requiring a meeting between the multi disciplinary team, patients and Health Care staff to help maintain a high quality of health care for the patient), house officer and a nurse's. This is so that they can discuss and to resolve the issue of this problem with the best interests of Mr P. A. Atwal., M. Jones . (2007). The nurse and the house officer knew that Mr P was dysphasic and at risk for aspiration, and they knew that it could lead on to serious complications such as choking and possibly would not survive with a normal diet. The house officer and the nurses recommend the continuation of a feeding tube as it was the best for the benefit and safety of the Mr P. Through hard work and explain the situation to Mr P. and family. It was then decide from Mr P. with conisation from his family that he would try the feeding tube, with the trail of soft food on to normal food in the long run.
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With this ethical dilemma affecting Mr P. it is a struggle between patient autonomy and the principle of beneficence and non-malfeasance. S Fry, M J Johnston (2008).
The student will now explore the ethical principles and theories that link to the case of Mr. P. The ethical problem is the decision for him to have refused a feeding tube.
There are four main ethical principles that are important to nurses to use on the wards and these can be integrated for Mr P. and are used in everyday use. These are autonomy (the right to make choices), beneficence (to do good), non-malfeasance (to do no harm) and justice (fair treatment). (Beauchamp & Childress 2001). To have Respect for patients' autonomy it requires us, not to deceive patients, for example, not to lie or tell white lies about their diagnosed of their illness unless they clearly wish not to be told. Hunt (1994)
The principle of autonomy is the individuals have to be permitted personal liberty to determine their own actions to (Beauchamp & Childress 2001). This means to respect an individual as self-controlled choosers (Johnstone 1999a). With in health care respecting people's autonomy requires us to consult people and obtain their agreement before we do medical procedures on them as in the case with Mr P., hence the obligation to obtain informed consent from patients before we do any medical procedures to help them.
With in autonomy patients make there own chooses basis on thoughts of their own mind. To respect persons as autonomous their chooses as an individual must be acknowledge that they make their own choices which come from personal values and beliefs with no interference from others. Fry & Johnstone (2003)
The decision from Mr. P. not to have the peg feed, but to have his normal diet is an expression of his own autonomy. He his choosing what he wants for himself and therefore is to be respected for his autonomous diecon. As it is was not safe for Mr P. this is why non-malfeasance would come into this situation. Autonomy is a big part of the values in life. There is no such thing as complete autonomy, only maximized autonomy. This involves a person/patient being autonomous in all situation they are in. It is important for nurses to remember that patients have a right to their own bodies and lives and are free from interference.
Non-maleficence means to 'do no harm' and is considered to be an dominant principle for everyone who undertakes the care of a patient (Munson 2004).
A nurse has a duty to act in the best interest of the patient and prevent them from causing harm to themselves or others. This could be achieved through acting as an advocate to patient's needs and thoughts. If a patient frequently finds it difficult to fully express their needs and fears (cited in Burnard and Chapman 2000). Mr. P. was aware of the imprecations and with the Medical staff explains how they would slowly move onto his normal diet, but for now for his safety he will need the peg feed inserted. Before he gave consent his family (acting as the advocates) and nurse explained the procedure with the peg feed.
According to Staunton and Chiarella (2004), justice is the idea of treating people equally and giving them what they deserve. It means that all people, regardless of wealth, status or religion, that the patients are entitled to fair access to service.
Beneficence addresses actions of 'mercy, kindness, and charity.' It means to promote the welfare of other people (Beauchamp & Childress 2001). Sometimes there are limits to the good nurses can do, but nurses are directed in the Code of Ethics for Nurses with Interpretive Statements to always place there patient's interests and well-being as their primary interest. Doing good toward and facilitating the well-being of one's patient is an integral part of being a moral nurse. (Cited in Butts & Rich 2008).
Ethical principles fall under ethical theories they represent the ideas on which guiding principles are based up on. They attempt to be coherent and systematic.
The utilitarian theories follow reasoning that can suggest that an act is morally good or bad based on its outcome. Fry & Johnstone, (2002) Under this way of looking at the situation it can brings the most good to the numbers of people, it is known to be a good or morally correct act. This method is know as a consequence based approach to moral reasoning and is often used to make decisions on how health care is delivered. Fry & Johnstone, (2002)
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The deontological theories highlight the rightness of an action based on the ideas that some principles must be upheld.
When trying to come up with the most moral action to take it is not the nature of the outcome that will be judged it is the action itself that is judged right or wrong. It is deemed as an action that is ethically correct(Hawley, 1997c). (ethics in clinical practice, georgina Hawley,harlow,2007)
Teleology or consequentialism is known as "right" in terms of good produced as consequence of an action. It a calculation of the results from performing various tasks relevant to a situation and to choose one that will maximise the ratio of benefit over harm. (candee and puka 1984)
(Ethics in nursing 2nd ed, verena teschudin, 1992, oxford)
These theories bring an entirely new outlook to the process of moral reasoning for ethical issues in nursing practise. Actions are not judged on the outcome, but rather to a view of the caring and responsibility will be used to determine what might be a morally correct as an act. A morally good act is the one that shows caring and concern for other people and what might be important to them. Hunt, (1994)
Ethical codes are there for everybody in life and with in the hospital wards, there are boundaries to the roles most of the codes can be used with in. The expectation of what an ethical code can do changes depending on how ethical code in general is understood. The difficulties encountered when ethical values are applied reactively to an objective world can be avoided by seeing them as a more integral part of our understanding. It is concluded that an ethical code can establish important values and describe a common ethical background for health care but is of limited use with solving new ethical problems.
The NMC Code of Conduct (NMC, 2005) set out professional codes preparation for practice (NMC, 2005) explained that autonomous practitioners are exercise increasing clinical discretion and accept greater professional responsibility by making their own decisions.
ww.nursingtimes.net/nursing-practice-clinical-research/part-51-accountability-autonomy-and-standards/200972.article, these where the the codes of conduct that was in use before the NMC came into existence in 2002, replacing the UKCC (United Kingdom Central Council for Nursing and Midwifery).
According to the NMC, autonomy implies that that one should respect patients' and clients' choices concerning their own lives. Here it becomes imperative for nurses and other health care professionals to respect the values, thoughts and actions of patients and not let their own values or morals influence treatment decisions.
In conclusion the student understands the difficulty ethical problems that can have on a patient and staff. The decision making falls down to the patient in a lot of the situation that arise. The causes of the problem can question the decision making of the nurse to whether they believe it to be morally correct. As a professional the nurse has to maintain the respect for patients' views and continue to practice in a adequate way without prejudice to anyone. The patients going into hospital surroundings expect their rights to be upheld and be involved in the process of their care.
The student will carry on their future of learning to contain with ethics and will be better equipped to deal with a situation if one was to occur in the future while on the wards.
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