Ethical Issues in Paediatric Wards

Smith, a five-day-old newborn, experienced a decrease in oxygen saturation and abdominal distension. Abdominal radiograph indicated free air in abdomen. When obtaining the consent for surgery, the parents refused the use of blood or blood products, because both of them were Jehovah’s Witness (Meadow et al., 2010). There are no absolute rights or wrongs to this case, which is based on a synthesis of this clinical scenario. The aim of this essay is to explore the ethical and cultural issues in nursing practice. Because of these problems, there are more than one solution in clinical settings to preserve human lives free form blood transfusions without violating their beliefs.

Ethics is a branch of philosophy concerned with the study of rational processes for decision-making. When the parents’ decision is not the best interest for the child, the paediatric nurse should advocate for him in order to protect his rights to receive treatment according to the Code of Ethics for Nurses in Australia (ANMC 2006). The first step for the nurse in resolving the ethical dilemma like this is to provide information to the parents honestly about the child’s diagnosis, treatments, outcomes and risks. This enable the parents to make free and informed decision (ANMC 2006; Janine & William 2010). During the discussion between the health practitioners and the parents, fully explained situation may help the family realize that the decision may not the best choice for the child. Next, health practitioners should strive to remain truly objective and avoid all personal, racial, cultural, religious or other bias when counselling or caring the child and the family. The parents’ autonomy should also be respected during the practice (ANMC 2008b). Thirdly, nurses should respect of the parents’ competence. Competence implies the parents’ level of understanding that allows them to weigh up the ethical issues posed by a clinical situation, assimilate these and reach a rational decision.

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Culturally effective paediatric health care can be defined as the delivery of care within the context of appropriate physician knowledge, understanding, and appreciation of all cultural distinctions leading to optimal health outcomes. However, there sometimes has the conflict between the parental authority and the child’s best interests. On the one hand, Australia Nursing and Midwifery Council (2008a) states that nurses should respect the culture, values, beliefs, personal wishes, and decisions of the patients and their families. Moreover, a basic principle in law is that a minor cannot consent to medical treatment until he or she was of or above the age of 14 years old in New South Wales, 16 years old in South Australia or 18 years old in other states. As a result, the parents, or the legally pointed guardians of the child have the rights to make the decision for treatment (Janine & William 2010). On the other hand, the patient must always come first, before any vested interest of any third party including health practitioners as well as the parents, guardians, extended family and society. Brody and Aronson (cited in Tabak & Zvi 2008) argue that the patient has the fundamental right to quality medical care and the best treatment. Zohar and Langham (cited in Tabak & Zvi 2008) claim that parental consent to medical treatment may negate patient autonomy. In a conflict situation as described here, when informed consent is not forthcoming, the nurse’s important role in working is to seek an alternative decision (Tabak & Zvi 2008). Where a parent or guardian refuses consent to use blood products in the emergency treatment of a child (less than 16 years of age), the local, state, territory or national legislation or guidelines in regarding consent for a medical procedure must apply (Australian and New Zealand Society of Blood Transfusion Ltd 2011). Slonim et al. (2008) states that the administration of blood products to children is a common practice in academic children’s hospitals; Complications associated with these transfused products are rare. When blood transfusions are deemed necessary for an immature minor.

Jehovah’s Witnesses believe that receiving blood from other people will damage their relationship with God. However, it is true that acute blood loss has been associated with increased mortality for decades; a blood transfusion is the best way of replacing the blood quickly (BloodSafe 2008). Due to this, several methods have been used to protect their autonomy in emergent situations where blood or blood product may be used. Office of the Public Advocate (2010) introduces the guideline of Jehovah’s Witnesses and Blood Transfusions to assist physicians and other health workers to deal with this kind of dilemma based on Guardianship and Administration Act 1986, Medical Treatment Act 1988 and Human Tissue Act 1982. In Victoria, most Jehovah’s Witnesses have a “No Blood Card”. It indicates that the person who hold this card will not receive blood or blood products in no circumstances (OPA 2010). Furthermore, there are blood transfusion alternatives, and practices that use no blood for elective or non-emergency surgery or as a result of traumatic injuries to address the medical needs of patients who did not wish to receive blood products or blood transfusions during medical care. The 2009 Association of Anaesthetists of Great Britain and Ireland guidelines recommend the method of cell salvage in cases where patients have refused to use allogeneic blood and blood products (cited in Ashworth & Roscoe 2010). Goldberg and Drummond (2008) states administration of recombinant activated factor VII (rFVIIa) is effective solution to treat Jehovah’s Witness patients with life-threatening bleeding associated with haemophilia or trauma. Schmitt el at. (2008) recommend the use of autologous peripheral blood stem cell transplantation for high-dose chemotherapy without support of allogeneic blood products.

In conclusion, clinical problems with significant ethical and cultural implications pose an ever increasing dilemma in everyday medical practice in the 21st century and rarely present a simple solution. The paediatric nurses’ role is to advocate the child’s best interest when the parents’ decision is contradictory. Individuals’ religions and cultural beliefs should be respect. In clinical settings, there are increasing options other than blood product transfusions for those who refuse blood transfusions.

Reference

Ashworth, A, & Roscoe, A 2010, ‘Safety of cardiac surgery without blood transfusion: a retrospective study in Jehovah’s Witness patients’,Anaesthesia, vol. 65, no. 7, pp. 758-759.

Australia Nursing and Midwifery Council 2006, National Competency Standards for the Registered Nurse, Australian Nursing and Midwifery Council, Dickson.

Australia Nursing and Midwifery Council 2008a, Code of Ethics for Nurses in Australia, Australian Nursing and Midwifery Council, Dickson.

Australia Nursing and Midwifery Council 2008b, Code of Professional Conduct for Nurses in Australia, Australian Nursing and Midwifery Council, Dickson.

Australian and New Zealand Society of Blood Transfusion Ltd 2011, GUIDELINES FOR THE ADMINISTRATION OF BLOOD PRODUCTS, Australian and New Zealand Society of Blood Transfusion Ltd, Australia, Sydney.

BloodSafe 2008, Children receiving a blood transfusion – a parents’ guide, BloodSafe, Australia.

Goldberg, R & Drummond, KJ 2008, ‘Recombinant activated factor VII for a warfarinised Jehovah’s Witness with an acute subdural haematoma’, Journal of Clinical Neuroscience, vol. 15, no. 10, pp. 1164-1166.

Janine, F & William, J 2010, Health care & the law, Thomson Reuters (Professional) Australia, Rozelle.

Meadow, W, Feudtner, C, Antommaria, A, Sommer, D, & Lantos, J 2010, ‘A Premature Infant With Necrotizing Enterocolitis Whose Parents Are Jehovah’s Witnesses’,Pediatrics, vol. 126, no. 1, pp. 151-155.

Office of the Public Advocate 2010, Jehovah’s Witnesses and Blood Transfusions, Office of the Public Advocate, Australia, Melbourne.

Schmitt, S., Mailaender, V., Egerer, G., Leo, A., Becker, S., Reinhardt, P., Wiesneth, M., Schrezenmeier, H., Ho, A.D., Goldschmidt, H. & Moehler, T.M. 2008, “Successful autologous peripheral blood stem cell transplantation in a Jehovah’s Witness with multiple myeloma: review of literature and recommendations for high-dose chemotherapy without support of allogeneic blood products”, International journal of hematology, vol. 87, no. 3, pp. 289-97.

Tabak, N & Zvi, MR 2008, ‘When parents refuse a sick teenager the right to give informed consent: the nurse’s role’ 2008,Australian Journal of Advanced Nursing, 25, 3, pp. 106-111.

Xiaoyan Tang

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