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Mr. White is a 70 year old male patient who has been pretty healthy throughout his whole life besides some issues with pneumonia in the past few years. He was driving along the road last Monday where he hit a patch of black ice, swerved off the road, and crashed into a tree. He lost consciousness and suffered minor abrasions to his arms, legs, and face. When he regained consciousness, he stated he felt very cold, numb, and fatigued as several paramedics hovered over him placing a collar around his neck and a spinal board underneath him. He was very confused and was told to not move as they oriented him to person, place, and time. He was taken to the emergency room where he was placed him on oxygen via face mask and D5 ½ normal saline 100ml/hr. He was transferred to the ICU after lung complications and a tracheotomy was inserted to open his airway and allow for oxygen exchange. Each day his family has been at the hospital supporting him and praying he will recover from this severe accident.
The nurse caring for him was reviewing his medical records and saw that he is a do not resuscitate patient and that he does not want to receive any life sustaining treatments that will prolong his life. The patient has been awake, alert, and oriented and confirmed competent two days ago, which enables him to make decisions for himself. His daughter, Mrs. Black, told the nurse that she doesn't know what she would do without her dad because he is the rock that holds their family together. The rest of the family replied that these are his wishes and we will have to accept what he has requested, even though it saddens us to think we may lose him soon.
During a routine test a few days ago the physician noticed that his labs were not within normal limit and ordered stat tests to determine the problem. The chest x-ray ordered confirmed he had pneumonia, but also revealed he was suffering from metastatic lung cancer. The physician informed the nurse of the cancer and stated that Mr. White is still very weak and fighting for his life. We will inform him and his family when he is more stable and able to be strong enough to take the news.
Identify the Problem
The nurse is informed of the confirmation that the patient indeed is suffering from cancer secondary to his car accident and pneumonia. Does she advocate for the patient's right to autonomy in delivering the news to him and his family or does she follow the doctor's orders and withhold the news since the physician believes that telling him will only worsen his condition and result in a loss of hope for all involved? The nurse believes that withholding information is going against the patient's rights to make his own decisions. The nurse wants to do what is best for the patient and believes that keeping this information from the patient is being dishonest and is not what any practical nurse would do in this situation. However, she is unsure of the best approach in addressing the issue.
Gather Relevant Facts
A sound doctor-patient relationship is an essential component when carrying out decisions based on a patient's care for treatment. Studies have shown a correlation between the quality (communication) of physician-patient relationship and better (healthcare) outcomes (Stewart, 1995). The doctor and the patient need to have a strong relationship with the patient that includes sound communication, fidelity, knowledge based learning, beneficence, and Nonmaleficence.
There are four different styles to a doctor-patient relationship which include consumeristic, default, paternalistic, and mutuality relationships. The mutualistic approach is considered the optimal relationship to have when both the patient and the doctor bring both of their ideas and resources to the table and make a commitment to work with one another to solve disagreements in a respectful way. Paternalism involves physician focused care because the decision is based on what the physician believes is best for the patient and not necessarily what the patient wants. In the scenario, the physician believed that it would be in Mr. White's best interest to hold off telling him the news of his cancer until he was healthier and stronger, but this might not have been what Mr. White would have decided (Roter and Hall, 2006).
At the beginning of the 1960's, medical procedures were beginning to address the ethical issues with paternalism by a patient's right to autonomy and informed consent. Issues with paternalism began to arise due to an increase in consumerism, the women's movement, and laws passed that allowed for the rights of patients in their health care. The patients wanted to be more involved in their care in knowing about their health, quality of life, survival, and mortality rates of their condition. As a result, a physician's violation in duty to the patient caused an increase in lawsuits. Healthcare workers began to be faced with a difficult decision in determining what pertinent information the patient needed to know about their condition (Wear, 1993; Charles, Whelan, Gafni, 1999).
Legal and more paternalism were in conflict from the example used with Mr. White. Legal paternalism base decisions around following laws and regulations created by federal, state, or local level while moral paternalism base decisions using ethical principles. The physician was going against legal paternalism because truth-telling is now considered a legal matter and the competent patient is to be informed of all matters related to their health, except if the patient is deemed incompetent. The physician was trying to practice moral paternalism because he believed that withholding the information from the Mr. White was beneficial in a sense that he would not be strong enough to handle the news of his cancer and cause his condition to worsen or not improve (McCarthy and Schafermeyer, 2004).
The debate today about paternalism is whether it is acceptable for doctors to make choices about patient's treatments in their health care when they may believe that the patient may possibly refuse the decision if they were correctly informed. Is it justifiable for doctors to go about the treatment since they feel the long term benefits to the patient would be provided and at some point the patient would concur that the actions of the doctor were suitable? Certain situations makes it challenging to know exactly what is best for the patient, and it is hard to know when a physician is carrying out an intervention that is in the patient's best interest or their own interest. Mills is a strong believer of autonomy and fights for patient's rights. He believes that each individual has the ability to identify what makes them happy and that independent exercise of aspirations is a large part of their happiness. Kant also supports patient's rights and believes that every human has a responsibility to communicate their autonomy. (McKinstry, 1992).
The Patient Bills of Rights of 1973 included the physician's responsibility to inform the patient on all matters related to their condition enabling the patient to make decisions based on this knowledge. The Bill was carried out to decrease the occurrence of malpractice by reducing the dissatisfaction of patients that meet the criteria for more liability from their providers (Faden and Beauchamp, 1986). The law entails that medical information presented to the patient be in plain language that can be voluntarily comprehended and adequate in quantity. A doctor who is unsuccessful in attaining informed consent may suffer criminal offense charges.
In 1998, the Consumer Bill of Rights and Responsibility Act was carried out by President Clinton to help consumers get involved in their own health care by increasing consumer confidence in the health care system, to give support in identifying the reasoning for a sound healthcare provider and a sound provider-patient relationship, and to help the consumer realize the important role they carry related to their rights and responsibilities of their heath care and recovery. The guidelines included several rights of the patient to create the best quality health outcome. (Shalala,1999).
Patients are competent to give informed consent unless examined and evaluated to have mental deficits and incapacity. Informed consent must follow several steps in order to be valid which includes informing the patient on the diagnosis, the suggested intervention, major benefits, risks, the consequences or prognosis if an intervention is not carried out, and any significant options along with their risks and benefits. Informed consent will need to hold true and be carried out in all cases except when the patient is susceptible to serious harm or death if the intervention is not carried out immediately, the patient voluntarily gives up their right, and if disclosure would cause serious physical or psychological harm to the patient or another person (Wear, 1993). At UPMC hospitals such as Magee and Presbyterian hospitals patients have certain rights and responsibilities that they are given such as the right to respected and quality care from staff, the right for information in medical records to be kept confidential, the right to pain control and management, the right to know diagnosis, prevention, and treatment options and alternatives given in simple language, the right to informed consent before any procedures, the right to refuse any medications, treatments, procedures, and several more . This allows the patient to decide what information they would want to know and to carry out care based on their wishes (UPMC, 2010).
Identify Methods of Ethical Justification
A person who practices consequentialism believes that a morally right act is one that produces a good outcome. The doctor was practicing a consequentialitic approach in that he believed that not telling the patient that he had cancer until he was stronger would cause a better outcome for the patient in the long run. He believed that Mr. White would give up all hope and stop fighting to survive if he was informed of the news. In deontological theory, an act is right or wrong based on fulfilling a moral duty and cannot be justified by their effects. Even though the physician was trying to do the right thing by not telling the patient that he had cancer because he believed that this would help save his life, the act was against the rules and duty of the physician to inform the patient on information related to his health (Gert et al., 1997).
Several principles come into play in the scenario such as beneficence, nonmaleficence, fidelity, and autonomy. The nurse will have to advocate for the patient that keeping this information from him and is family is not doing good. It may in fact cause more harm to the patient since he is unaware of his cancer. The patient may be able to determine treatments that could delay the spread of cancer, which could allow him more time to spend with his family. The competent patient has the right to autonomy in deciding what information he would want to know about his health and the doctor should not be the one to make this decision. The physician is keeping essential information from Mr. White that may result in a break in their commitment and destroy the patient's trust in his healthcare provider (Cassells and Gaul, 1998).
Clarify Relevant Values, Rights, Duties, of Patient, Self, and Significant Persons
The patient has the right to informed consent if he is seen as competent to make decisions based on his healthcare. It is the physician's duty as well as the nurse to respect the patient and inform him of all matters concerning his healthcare and making sure the patient demonstrates understanding. If Mr. White was deemed incompetent he may have appointed a family member as a substituted surrogate decision maker to make decisions in his health care based on the patient's values, beliefs, and wishes. If Mr. White did not appoint someone to be a surrogate then the best interest principle would come to play and decisions on the patient's healthcare would be determined by what is the best interest for any reasonable patient in this situation. The family will need explanations on the patient's status and what the future will look like for him. The family may be the ones taking care of him and they will need sound education on how to care for the patient.
Identify If There Is an Ethical Dilemma
The nurse faces an ethical dilemma because the alternatives are between two equally insufficient solutions which display incompatible testimonies. Does the nurse take away the patient's right to autonomy in keeping Mr. White's new diagnoses of lung cancer from the him because the physician believed it was in the his best interest or should the nurse take the issue to higher authority to advocate and make every effort to protect the health, safety, and rights of the patient (Cassells and Gaul, 1998).
Identify Guidelines from Nursing and Professional Codes of Ethics
The American Nurses Association code of ethics for nurses was created to help guide nurses behavior when an ethical dilemma would occur. The requirements in the code advocate the nurse's commitment to their patient's autonomy, while still keeping in the safety of the patient (American Nurses Association, 2001).
Provision 1 states that the nurse needs to practice with compassion and respect each patient regardless of their beliefs, ethnicity, class, age, etc. The patient was a 70 year old African American who was a practicing Southern Baptist and retired bus driver. The Caucasian, Catholic nurse had to make sure she didn't treat Mr. White differently because of his skin color, the religion he practiced, or his age (American Nurses Association, 2001).
Provision 2 states that the nurse's devotion is to the patient and anyone associated with the patient such as family and friends. The nurse has the ability to advocate for the patient in communicating their wishes to the doctor in carrying out treatment pertaining to his care. The nurse will need to communicate with the patient and determine what information the patient will want specific friends and family to know. The nurse with her high level of skill and knowledge can help educate his family on his condition and care (American Nurses Association, 2001).
Provision 3 states the nurse will need to do all she can to protect the patient from any harm or unsafe events. The nurse would make sure the patient's requests were followed through while maintaining his safety, health, and prevention from any harm. If she believed that the patient was not well informed of his disease and all treatment plans possible to help delay the progression of the disease, then she would need to address this issue (American Nurses Association, 2001).
Identify and Use Relevant Interdisciplinary Resources
First, the nurse should go to the doctor and see if they can work something out to determine the patient's rights. If the doctor doesn't agree with the nurse then the nurse should then talk to the nurse supervisor and move up the latter until the highest person is able to confront the issue. If this does not work, the nurse can also get in touch with the people who deal with ethical concerns/ dilemmas. The nurse can also talk to lawyers and get legal matters in place for the patient's rights to informed consent to be granted. The nurse can also get a psychiatrist involved who would speak on behalf of the patient to confirm that the patient is competent. The nurse may want to get social workers and counselors to help the patient and family finds ways to cope with grief and also determine the best care for the patient's prognosis of his such as a skilled facility, home health, or hospice care.
Identify and Prioritize Alternative Actions/Options
The nurse can speak directly to the patient and his family about the information that has been withheld. This should not be carried out since this is not solving the conflict between the nurse and the physician and it is going behind the physician's back. The nurse can make the decision of not informing the patient or family of the news. She could convince herself that the doctor knows what is best for the patient and bringing up the issue would only cause chaos. This is also going against the code of ethics of a nurse in her lack of being a patient advocate (ANA, 2001).
The nurse could talk with the physician about the issue she has with the patient's right to autonomy and try to work out their differences. Communication is essential for the nurse and the physician to have a sound relationship and work together to resolve issues. If the doctor believes this is something Mr. White does not need to know right now, then the nurse will have to take the issue to higher authority which was addressed above (nurse supervisor, the ethics committee, social workers, court system and reference hospital policy, legal, and ethical principles on the matter).
The nurse can be there for moral support and help build a trusting relationship with the Mr. White when told of the new diagnosis of cancer and the betrayal from his doctor. The patient may feel hurt, confused, angry, and may have lost trust in the health care providers. The nurse can also talk to the family about the matter as well and offer all the alternative treatments that can be carried out to help the patient decide what is best for Mr. White. This can be carried out but only after the patient's rights are addressed.
Select a Morally Justified Action/Option from Alternatives Identified
The nurse will have to make a decision as to what she feels any reasonable nurse would do in this situation and carry out the patient's wishes accordingly. She will need to advocate for his rights in decision making and converse with the physician. If this doesn't get resolved then take it to higher authority. The nurse needs to address the patient's wishes and needs and then the families. If Mr. White determines that he does not want to carry out any treatments, then his wishes need to be addressed. If he decides he wants to start treatments immediately for his cancer, then these wishes would need to be followed through.
The nurse talked with the physician about the issue, but the problem was never resolved. As a result, nurse took the matter into her own hands and talked with the nurse supervisor who confronted her boss and the case was then taken to court. The judge along with the help of the jury determined the patient must know all information related to his health care and he was properly informed of his cancer. Mr. White understood that his cancer was terminal and that he decided that he only wanted palliative means of care. He wanted to remain comfortable and spend the rest of his time with the people he loved dearly. The family agreed on his decision because they knew this was what he wanted. He was able to make decisions based on his care and was content at being in control one thing in his life. He was given quality care by his nurse and he remained comfortable throughout his illness. Mr. White passed away peacefully 3 months later at home surrounded by his family.