Nursing is a profession regulated by the Nursing and Midwifery Council (NMC 2008). The NMC is an organisation set up by the Parliament to protect the public by ensuring that nurses and midwives provide high standards of care to their patients. These healthcare professionals are also accountable for their own actions. The body sets standards for education, practice and conduct as well as providing advice for nurses and midwives. The NMC also considers allegations of misconduct or unfitness to practice. Using the case study given, it shall be the author's aim to demonstrate the understanding of the NMC Code of Conduct suggesting ways in which it can be applied to practice. In order to comply with the NMC Code of Conduct of confidentiality, the patient to be discussed in this assignment will be referred to as Mrs X. Furthermore the author will explore the four main principles of the code relating them to issues arising out of the case study. The author will also demonstrate the understanding of ethical issues arising, analysing and discussing autonomy, non-maleficence, beneficence and justice.
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The case study refers to an 80 year old woman with a hip fracture, admitted to a hospital ward from a nursing home and urgently added to the operation list. She is bedridden, with severe heart problem and in early stages of Alzheimer's disease and appeared to be coherent and lucid as recorded. She agreed to have a hip replacement operation after the consultant explained the procedure. On her way to theatre, she changes her mind and the consultant was informed. The consultant insists on proceeding, citing a busy week ahead and commenting that these elderly confused patients don't know their own mind.
According to the NMC Code of Conduct, a healthcare professional has a duty to care and protect the interest of those in their care regardless of age, gender, culture, religious and political beliefs. Mrs X is 80 years old but the professionals still have a duty of care and must protect her interests. An interview was carried out by the medical staff and the patient appeared coherent and lucid but Mrs X has changed her mind on route to theatre. This author will critically examine the procedures that followed. The consultant explained the procedure to the patient who agreed to have the operation. Thompson et al (1994) stated that communication is one of the fundamental aspects in nursing
The consultant was informed of the patient's decision to change her mind on the operation and responds stating that 'We will have to proceed'.
As a nurse one could argue that the consultant should respect this decision as going against it would be breaching the NMC code. Mrs X's decision to change her mind on the way to theatre, not wanting to go ahead with the operation should be respected. Hope et al (2008) stated that a patient's autonomy can result in conflict, raise ethical dilemmas and may not be straight forward. Autonomy is defined as the right to choose or refuse treatment .Beauchamp and Childress (2009). The consultant could also argue that he is working in the best interest of the patient but does this override the patient's right to make her own decision? Beauchamp and Childress (2009) stated that individuals' views and rights must be respected as long as these individuals' thoughts and action do not cause harm to other people. The NMC makes a point of highlighting the point of advocating for patients. In this instance, the nurse faces the ethical dilemma of standing up to the consultant and advocating for the patient in order to uphold the code. Thompson (2003, cited in Buka, 2008) suggests that ethics is a study of how people behave, what they do, the reasons they give for their actions and the justification behind their decision. The need to maintain professional boundaries as well means that nurses have to raise their points in a manner that does not destabilise the team. Each and every member of the healthcare team must act as the patient's advocate and remind or challenge colleagues should they fail to practice according to standards, Hindle and Coates (2011). If any medical team members working with the consultant on Mrs X's case are not in agreement with his decision to proceed, they should challenge or remind him of the ethical code stipulating that the patient's decision must be respected. When healthcare professionals are faced with dilemmas, patients should always come first. Childs et al (2009) states that when considering our actions we are bound by NMC codes, standards and guidelines, for students guidelines set by their training institution by local standards and guidelines within the clinical practice area and by the law of the country. It is unprofessional and unlawful to force treatment on anyone.
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Although the consultant explained the procedure, one could argue that making information available is different from effective communication. Consent was given the first time but the patient later changed her mind. An exploration for her reason to change her mind should have taken place and at least inform the patient that the operation was going ahead and the reasons for going ahead.
The wording used by the consultant could be a concern. "We will have to proceed. We have a very busy week ahead; these elderly confused patients don't know their own mind. Carry on as usual". One could interpret that the consultant is suggesting that when people get old, they automatically become confused; which could be stereotyping amounting to discrimination which is against the law. This could be taken to suggest that the consultant is of the assumption that the elderly are confused and don't know what's good for themselves and so should have decisions made for them. Patients are supposed to be treated with dignity, respect and as individuals considering their physical, psychological and social care with decisions made in partnership with clinicians, rather than by clinicians alone according to DOH (2010).
Hendnrick (2004) defines consent as the permission given by patient voluntarily, without pressure, force or manipulation or undue influence. The NMC emphasises that healthcare professionals must seek consent from their patients otherwise they might be liable to be charged with assault or battery. The consent could either be in writing or verbal. In the event of a law suit, such documents and discussions can then be used in courts of law. Although Mrs X had given consent for the operation to proceed, health professionals should respect the withdrawal of consent. Proceeding with the planned operation against Mrs X's wish amounts to violation of her rights and the nurse has a duty to highlight this aspect.
The Mental Capacity Act (2005) was established to empower and to protect vulnerable people in making their own decisions. In particular, this was to safeguard those who lack capacity and those who have difficulties in making decisions because of illness, disability and those with mental health problems. The mental capacity act has four main principles of capacity:
A person must be assumed to have capacity unless it is proved otherwise. Mrs X should be deemed to have capacity as she was interviewed and appeared coherent and lucid.
Any act or decision taken on behalf of someone lacking capacity must be in the person's best interest. The consultant could argue he was working in the best interest of the patient. In the event that Mrs X lacks capacity, an advocate could be appointed to act on her behalf.
An unwise decision is not to be taken as a lack of capacity. Even though Mrs X changed her mind and appears to have made an unwise decision, this should not be seen as lack of capacity.
Until all practicable steps have been taken to help someone make a decision without success, they cannot be treated as lacking capacity. The consultant did not exhaust all efforts to help Mrs X in her decision making as no interaction took place after she changed her mind. The consultant took it upon himself to make the decision and dismissed Mrs X as an elderly confused patient who does not know her mind.
The Mental Capacity Act (2005) has a test for capacity which states that a person lacks capacity if at the material time he is unable to make a decision for himself in relation to the matter because of an impairment of or a disturbance in the functioning of, the mind or brain. It does not matter whether the impairment or disturbance is temporal or permanent (Brammer, 2007). A person is unable to make a decision for himself if he is unable to understand the information relevant to the decision, to retain the information, to use or to weigh up that information as part of the process of making the decision, or to continue the decision (Brammer 2007). Section 3 of the act states that if the patient can retain information relevant to the decision for a short time only, this does not necessarily mean she cannot make a decision. When Mrs X changed her mind the consultant should have respected this decision because she was capable of retaining information for a while, had thought it through and decided she did not want to proceed.
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The Mental Health Act (1983) covers the reception, care and treatment of mentally disordered persons, the management of their property and other related matters. The act empowers authorities to detain those diagnosed with a mental disorder in hospital or police custody and have their disorder assessed or treated against their wishes, known as sectioning. Mrs X was diagnosed as having early signs of Alzheimer's disease. This disease is a form of dementia, a neurologic disease characterized by loss of mental ability severe enough to interfere with normal activities of daily living. It usually occurs in old age, and is marked by a decline in cognitive functions such as remembering, reasoning, and planning. As Alzheimer's disease is a progressive illness with no recovery, it is not applicable to use the Mental Health Act (1983) because whether or not treatment is given for the disease, this will not improve the decision making capacity of Mrs X.
The General Medical Council clearly stipulates that healthcare professionals ought not to discriminate but should treat those in their care fairly based on their needs. The consultant is going against the GMC's code of conduct when he ignores the patient's wish to discontinue with the operation. The GMC emphasises that patients have the right to change their minds on decisions.(ref)
Nurses are required by the NMC Code of Conduct to express compassionate attitudes in their careers (Byrne and Byrne 1992). Nurses act as advocates for patients and as such can be described as special and unique to other health care professionals as they spend more time with the patients (Norman and Ryrie 2004). They are expected to develop a nurse-patient relationship which must be kept professional. It is also a nurse's duty in accordance with NMC to educate the patient. Mrs X should have been educated and made aware of the advantages and disadvantages of the operation.
The principle of non-maleficence is one which seeks to avoid intentional harm. Mrs X does not wish to undergo the procedure so to agree with her wish would be harmful although proceeding may harm any existing relationship between the healthcare professionals and the patient. What then happens if for instance the procedure does not go according to plan?
Operations to correct hip fractures in the elderly are common and to abstain from conducting them would result in a lot of pain and discomfort not to mention the immobility issue. It is common knowledge that bedridden elderly patients if not moved regularly will develop pressure sores (Onslow 2005). The principle that requires action which benefits the patient is known as beneficence. To effect such an action sometimes medical professionals have to ignore the wishes of the patient if they can prove the patient's incapacity to consent.
While respecting the right of Mrs X's treatment refusal, capacity test should be done to find out if she is capable of making her own decision. If Mrs X lacks capacity, then the medical staff should seek consent from the relatives or Independent advocates (Tingle and Cribb,. 2008).
The ethical difficulties are compounded by such cases as the Canadian case of Malette v Schumann. The claimant came to hospital after being involved in a road accident. The doctor went ahead to perform blood transfusion despite the nurse having found a card in her pocket stating that she was a Jehovah's Witness and never to be given a blood transfusion. Later, on recovering the claimant won $20,000 of damages (Tingle and Cribb, 2008). The doctor was charged with battery. Mrs X's wish not to proceed with the operation may be well founded and give grounds to litigation. The outcome of the operation also plays a major part in determining whether the decision to go ahead and operate is a good one or not.
On tacking this assignment l learnt that establishing the patient's consent is very vital for any action to be justifiable carried out. The consultant did manage to convince Mrs X to agree to undergo the procedure after talking her through it. He unfortunately could not accept her change of mind sighting her age as the problem. I felt that Mrs X hadn't been given enough time to ponder the idea of undergoing the procedure.
She has been admitted to the hospital ward and urgently added to the list. I thought because she was in pain, she was not thinking straight and was pressured into giving consent. Looking back l now feel the consultant wanted the hip fracture operation to proceed as soon as possible as this would in turn ensure speed recovery. Looking at her age, I would like to think that the sooner she got operated on the quicker the recovery. He had the patient's interest at heart.
At the time l felt team work and better communication would have brought about better decision. The team members should have objected or aired their feelings against the consultants wish to proceed without consent. The positive was that if Mrs X was operated on, the pain would easy and she would then be mobile, which would be good for her heart. Taking the age issue into perspective the sooner she underwent the procedure the sooner she was expected to heal. The negative was that if anything went wrong, bearing in mind Mrs X had severe heart problem, the whole team would be in trouble.
When Mrs X changed her mind about undergoing the procedure the issue should have been addressed properly since consent is fundamental in a patient's care. A meeting between the medical care professionals to look into the reason of change of plan, if need be, a mental capacity test taken as is warranted under the Medical Health Capacity Act. In nursing the interests of the patients always come first. I think communication is vital in nursing.
Communication is very important when dealing with patients in nursing. The consultant did not act as a professional when Mrs X changed her mind that she is not ready for the hip operation. I was not comfortable with his response as it sounded harsh, commanding and unprofessional when he was informed of Mrs X decision
I have learnt that team is important in nursing and healthcare professionals should always respect the rights of their patients and consent is at the centre of every action.
The author has explored the professional, legal and ethical implications of the case study provided. It has been identified that although the NMC provides guidance and regulates the nursing profession, the onus is on the practitioner to make decisions based on the guidelines. Although the nurses and doctors may be working together, it has also been noted the two professions are governed by two different bodies and therefore have different codes of ethics although some of the codes could be similar. The NMC code of conduct is often updated as the code sometimes conflicts with other policies and procedures from employment and the law. Nurses should ensure they are up to date with any changes and guidelines within this body (Beech 2007). Because of the trust accorded nurses by society (gained through recognition of nurses' expertise) and the right given the profession to regulate practice (professional autonomy) individual clinicians and the profession must be both responsible and accountable Hitchcock et al (2003). The basic ethical principles of beneficence, nonmaleficence, justice and autonomy which are among the ethical principles that influence decisions in health care ethics have been explored and applied to the case study. The Mental Capacity Act (2005) has also been discussed and identified as the main legal instrument relating to this case study. It is crucial that nurses understand how the law influences nursing practice, particularly in relation to anticipating lack of capacity Hindle and Coates (2011).