Nurses are constantly confronting various ethical issues in their everyday clinical practice. An ethical dilemma is complex situation emerging from the conflict between moral obligations in which complying with one would result in contravening another (College of Nurses of Ontario [CNO], 2009). Nurses using CNO’s ethical conducts and decision-making framework will help in directing their ethical course of action. This framework involves the use of moral component such as claim, evidence, warrant, basis, rebuttal and ethical decision to guide in resolving the conflict (Arnold & Boggs, 2011). Thus, the aim of this paper is to use ethical decision-making framework step by step in exploring an ethical issue by analyzing a pediatric case study to make significant decisions.
Claim is the first moral component of the framework. It emphasizes on various dilemmas arising from the case study such as pediatric advance directive, consent to treatment by being competent minor and decision-making capacity. The ethical dilemma arises from this case study is whether to choose wishes of adolescent patient considering his treatment or should the wishes of his parents outweigh his request. The case study describes Kyle 14 years old male who has stake in outcome of the decision, and suffering from lymphocytic leukemia cancer. The case study involves Kyle as patient with physicians and his parents to determine the care in best interest of patient. The involved Physicians in care stated Kyle’s health is deteriorating and not responding to the chemotherapy treatment. Hence, the value of Kyle’s parents is to continue with the chemotherapy treatment in hope to work and prolong his life. However, Kyle having different point of view, refused to take any heroic measure and asked for DNR order to be placed in his chart. This way, his parents’ value would be violated if nurse chooses to accept the decision of Kyle. According to article by Tabak and zvi (2008), patient being mature minor competent has right to refuse treatment and is allowed to choose decisions regarding all the aspects of his treatment. Hence, nurse is caught in conflict between parents and Kyle. Thus, Kyle being in client center care, whichever decision nurse chooses from patient and parents will impact the Kyle’s care.
The evidence is next moral component of the framework. According to the scenario, physician sharing information with patient about the health status shows their mutual trust in relationship. This relationship indicates Kyle’s right to know as being cognitively capable to understand pros and cons of the treatment and participate in the discussion. According to Tabak and zvi (2009), the norm of informed consent is that patient has right to know truthful information about his health status from health care professionals to make informed decisions. From the case study another evidence indicates, Kyle being cognitively mature adolescent with a chronic illness (at the age of 5), knowledge to make informed decisions (DNR) and, experienced with treatments (several dose of chemotherapy). According to the article by Tabak and Zvi (2008), if the adolescent being minor is coping with long term and life threatening situation then patient is cognitively aware of the nature of the illness and has right to give consent. With this fact, his parents are seizing over his autonomy by denying his choices or capacity to make decisions. According to the article by Rogers, Alex, Macdoland, Gallant and Austin (2009), states that allowing children to express and offering choices escalates their quality of life and dignity. In this case, parents emotional grief for child may prevent them understanding child’s moral value or quality of life. It seems parents’ attachment with child making them not to understand child’s perception of suffering from medications and wishes to extend his life even if it has to do with holding on to the hope of future medication to work (Macgrawth & Phillip, 2008). As a result, parents are going against standards and not performing critical thinking. The evidences found in the case study are true, relevant to make decision, but lacks in sufficiency due to having inadequate in-depth reasoning behind klye’s decisions.
Warrant is another part of the framework. It requires using professional standard of care, and legal precedents and policies. If I were a nurse confronting ethical dilemma conflict between patient and parents’ decision over treatment, I would critically examine choices using professional standards. First thing I will take child’s age into consideration for informed consent. As stated in pediatric Cancer Society (CPS) (2008), in Ontario there is no age of consent. However, there is “mature minor right” where patient not being adult in age, but cognitively able are allowed to consider the treatment choices and alternatives based on the evaluation of consequences. This explains Kyle being only 14 years old is able to give consent of refusing treatment, which is on his best interest along with knowing his nature of treatment. As well as, according to CPS (2008), “when benefit of the treatment overweighs burden it should be respected”. Similarly, Kyle’s choosing to preserve his quality of life overweighs the option of treatment associated with pain and suffering which should be respected. Moreover, according to CNA (2008) code of ethics, under promoting and respecting informed decision-making, nurses have right to advocate for the patient if his/her rights are being influences by other’s decisions. In this case, by abiding this code, I would recognize the kyle’s right and support his capability to withdraw or withhold the consent for treatment regardless of his parents’ request. Furthermore, according the CNO’s (2009) practice standard ethics client’s well-being and client choice are relevant ethical values for nurse when parents and patient’s view are differentiated in what is beneficial. I as a nurse without judging would evaluate, respect and determine the rationale for the chosen option by parents and patient in terms of benefit vs. risk to assist in making decision. By abiding professional standards and policies will help me as a nurse to have evidence based rationale to deliver ethical clinical care to Kyle.
Basis is the next component in the framework involves ethical principles. In this scenario, autonomy, beneficence, and veracity are ethical principles used as guide to analyze ethical issue (Arnold & Boggs, 2011). Autonomy refers to patient’s right to make informed decision about his/her medical care without having anyone’s influence on it. In this case, parents’ desired decision takes over Kyle’s autonomy by contradicting his decision-making capacity (being minor) regarding his treatment and DNR options. Hence, allowing Kyle’ to make informed decision by allowing him to express his preference, concerns, and wishes would respect his autonomy and will preserve his dignity (Whitty-Rogers et al., 2009). Another principle, beneficence requires to prevent harm to others. In this scenario, kyle’s going through chemotherapy treatment shows no improvement (beneficences), yet him going through this process for prolong life will increase his pain and suffering. From parental perception, treatment helping to prolong lifetime indicates harm in hope of beneficences. For parents, treatment adding to survival period over side effects would appear as convenient option to accept (Mcgrath & Phillip, 2008). Last ethical principle veracity refers to responsibility of telling truth. In this case scenario physician or HCP has provided truthful information to patient and family regarding health status and effectiveness of treatment. Hence, there is no other information hidden from patient to help making informed decision. Hence, it is significance for nurse to continue using this principle to support and oppose argument made by each person to solve the conflict.
In addition, rebuttal is another component of framework. It focuses on costs and benefits of each choices. The benefit of the choice made by Kyle will alleviate his suffering by refusing the unresponsive treatment and DNR, which will increase his quality of life. It will strengthen the trust in nurse-patient relationship. On the other hand the risk associated with Kyle’s choice shortens the quantity of life due to having no treatment and DNR actions to rescue his life. Another harm associated is that it would hinder the relationship between parents-patient and nurse-family due to opposing their request. Furthermore, the benefits associated with parental choices of continuing treatment will prolong their and Kyle’s time of togetherness. As well as, risk associated with parent’s choice will escalate the pain and suffering of patient by reducing the quality of life. This violates the ethical principle of choosing non-maleficence for the hope of beneficence and reducing patient’s autonomy and dignity. As denying parents preference can hinder trusting nurse-patient relationship. Especially when trust, respect and honesty are essential to meet the health care needs of patient and in facilitating end of life care decision making (RNAO, 2006). Although, alternatives could be arranging meeting with parents and patient will help to understand each other’s perception, as well as allowing to accommodate/negotiate any choices to reach mutual decision. This way parents might be able to see the suffering and pain that treatment brings for child in order to prolong time. Also, Kyle would be able to understand emotional side of parents where his life is more valuable and beneficial over side effect of the treatment. As a result, palliative care could be an alternative option in progressive illness to ease quality of life with quantity of life. Palliative care can benefit in relieving the suffering in holistic way of patient’s life. For example, chemotherapy being used can have medications to relieve side effects of nausea to minimize the suffering (Mcgrath & phillip, 2008). As well as, choosing to continue with the unresponsive chemotherapy treatment (side effects) with palliative care may limit the patient’s quality of life.
At last, a nurse being reasonably prudent and ethical should apply moral principles in decision-making. The primary object of the nurse would be to identify ethical issue. The ethical issue in this case study is adolescent’s treatment decision conflicts with parent’s decision in determining authority for decision-making. Then nurse will evaluate the evident data to obtain all the relevant and sufficient information. Moreover, nurse should have understanding of CNA, CNO’s code of ethics, and RNAO BPGs to have knowledge regarding law, legal action and to have evidence-based rationale in guiding the decision-making process. Nurse would evaluate the claim by recognizing moral reasoning in each person’s perspective. According to CNA (2008) values, under client wellbeing and choices, nurse should respect family and patient’s opinion. Nurse should make parents acknowledge about the adolescent’s right in making decision. If patient is mature minor and competent to make informed decision then nurse should advocate for patient even if its opposes parental request. Last but not least, nurse should weigh risk and benefits of each person’s choices in terms of possible long terms and short-term consequences. Hence, nurse can offer alternative options by collaborating with other HCP if necessary to balance and develop mutual goal between HCP, patient and parents.
In conclusion, to achieve resolution in ethical dilemma involves critical thinking. This paper has analyzed an ethical dilemma in determining whether is it Kyle or parents, who has authority to take decision regarding treatment. It evaluated others factors such as pediatric age consent, and being cognitively competent to understand the consequences that could influence the decision-making. Paper also included three nursing journal to support the evidence, professional standards, and ethical principles to direct decision-making. At last, being ethical nurse, to determine decision in patient’s best interest, possible consequences from the choices were outweighed in terms of risk and benefits. Thus, the use of decision making framework facilitated in deciding what is morally and ethically acceptable in patient’s best interest while facing ethical dilemma.
Kyle is a 14 year old male diagnosed with acute lymphocytic leukemia at age 5. He has endured multiple relapses requiring several rounds of chemotherapy with short periods of remission. He has been readmitted to the paediatric oncology unit after metastases to his lungs and brain have been found. During a family meeting to discuss treatment options, Kyle’s attending physician explains that the cancer is rapidly progressing and unresponsive to treatment. Kyle feels that he has endured enough and does not want any further heroic measures and has asked that a DNR (do not resuscitate order) be placed in his chart. Kyle’s parents do not agree with this course of action and are holding onto to hope that more treatment may prolong his life.
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