Give positive feedback with a paragraph per post, use proper APA reference and citation.
Post #1 Junie: Ethical Dilemma in Nursing Practice. (Patient’s name and made-up)
As an oncology nurse, I recently faced an ethical dilemma involving a terminally ill cancer patient who wished to stop chemotherapy and transition to hospice care. The patient, Mrs. Wilson, was a 63-year-old lady with stage 4 breast cancer that had metastasized to her bones and lungs. Despite six months of chemotherapy, her cancer continued to progress. At her most recent appointment, she expressed a desire to discontinue chemotherapy and focus solely on comfort care. She stated she was exhausted by the side effects of treatment and wanted to spend her remaining time at home with her family. However, her adult children were adamantly against stopping active treatment and urged me to convince their mother to continue chemotherapy.
The key stakeholders in this case were Mrs. Wilson, her oncologist, her adult children, and me. As Mrs. Wilson’s nurse, I had an ethical duty to advocate for her expressed wishes and priorities while providing accurate information about prognosis and options (Sedini et al., 2021). However, the principle of patient autonomy conflicted with beneficence in this scenario. The right of a patient to make decisions regarding their medical care and have those decisions honored is known as the principle of autonomy. The principle of beneficence in healthcare ethics refers to the obligation of providers to act in the patient’s best interests by promoting health, preventing harm, and removing harm (Varkey, 2021). While Mrs. Wilson clearly articulated her values and preferences to stop treatment and enter hospice, her family cited a statistically small benefit of more chemotherapy.
This situation greatly impacted each stakeholder. As a nurse, I experienced moral distress in balancing my various duties. I had to sensitively balance her goals and quality of life with her family’s desire for more time together despite treatment burdens. For Mrs. Wilson, continuing chemotherapy would infringe upon her values and negatively impact her quality of life without offering significant benefits. Her adult children were devastated by their mother’s prognosis and desperately wanted more time with her. The oncologist also experienced moral distress in being unable to cure Mrs. Wilson’s cancer. We considered ethical guidelines, which helped identify the least intrusive and most advantageous resolution to a patient’s concern (Tulane University, 2023). Ultimately, through compassionate communication, we were able to align on Mrs. Wilson’s transition to hospice so she could spend her remaining days at home surrounded by loved ones. This collaborative decision honored her autonomy while also providing support for her grieving family. Though difficult, the experience reinforced the importance of ethical competency in nursing practice.
References
Sedini, C., Biotto, M., Crespi Bel’skij, L. M., Moroni Grandini, R. E., & Cesari, M. (2021). Advance care planning and advance directives: an overview of critical issues. Aging Clinical and Experimental Research, 1-6. https://link.springer.com/article/10.1007/s40520-0
Varkey, B. (2021). Principles of clinical ethics and their application to practice. Medical Principles and Practice, 30(1), 17–28.
https://karger.com/mpp/article-abstract/30/1/17/20
Tulane University. (2023, January 19). Ethics in health care: Improving patient outcomes. Publichealth.tulane.edu.
https://publichealth.tulane.edu/blog/ethics-in-hea
Post #2 Mimi:
Ethical dilemmas are extremely common in the neonatal intensive care unit (NICU) where I work. The death of a child much less a baby leave behind a lot of pain, stress, anger, and often more questions than answers. When I began my career we would rarely attend a delivery of a 27 week gestation. We would prepare ourselves and the parents for the worse case scenario. Technology has advanced astronomically that we now attend deliveries of 22 week gestation and have them survive. What happens when the baby is not only premature but also presents with comorbidities? For example, mom is 25 weeks pregnant and has a placental abruption. She begins to hemorrhage at home. She reaches the hospital and requires an emergency caesarean section (c-section). We are able to deliver the baby and provide life sustaining interventions. The baby in the delivery room is intubated. The NICU team is able to stabelize and transfer the baby safely into the NICU. Upon examination, the baby has a positive head ultrasound. The baby exhibits Grade IV intraventricular hemorrhages (IVH). Also, there is no brain activity note. Multiple MRIs and EEGs are ordered only to confirm that the baby has no brain activity. We as the healthcare team know the sequela and outcome. The baby is not compatible with life. We advised the parents, yet they want everything done including heroics to maintain the baby “alive”. The NICU team and the parents are at a standstill. According to Pant, there is not enough education to help us navigate these difficult situations. There is no in-depth training to help healthcare workers to prepare when faced with the complicated and delicate circumstance of a newborn’s death. It’s imperative to teach and coach healthcare professionals in bereavement and palliative care to provide quality support to the families we serve and care for (2022).
There are many key stakeholders. The key stakeholders are; the parents, their families, the government (Medicare and Medicaid), the hospital, the Ethics Team at the hospital, the neonatologists, nurses, respiratory therapists (RT), physical therapists (PT), and social worker (SW). This situation impacts the parents because the death of a child is traumatic and excruciatingly painful. Having to make the final decision to remove life-support on a baby is unfathomable to most. The aftermath and suffering is unmeasurable and life-long for parents. The government via Medicaid and Medicare are impacted due to the colossal price tag associated with NICU stays. Most of the NICU parents have Medicaid for their insurance. The hospital is impacted because whatever cost Medicaid and Medicare doesn’t cover the hospital is then left to cover. This is a huge financial burden. The rest of the stakeholders such as the entire interdisciplinary team is impacted because of the emotional and physical toll this takes on them.
When the parents choose a course of action that is different from what the healthcare team recommends, the situation can be particularly stressful. It is difficult to witness parents who want “everything done” for an infant that we know is not going to survive. How do we support the parents and also advocate for the best interests of our patient? This is one of the most difficult situations we find ourselves in and one that is not easily resolved. What we consider futile treatment may not be so in the eyes of the parents. Consulting the hospital ethics committee may be helpful in these situations. The ethics committee can help determine if the parents understand the situation. They can clarify for the staff what the parents want done for their infant. The hospital ethics committee may not force the parents to accept a particular course of action, but they can help both the parents and the staff understand each other’s point of view. Clear communication and improved understanding may lead to resolution of the ethical conflict (Wint, 2019).
Reference.
Pant, S. (2022). Ethical Issues around Death and Withdrawal of Life Support in Neonatal Intensive Care. Indian Journal of Pediatrics, 89(3), 274–278. https://doi.org/10.1007/s12098-021-03810-9
Witt, C. (2019). Coping with ethical dilemmas in the NICU. Advances in Neonatal Care, 7(5), 217–218. https://doi.org/10.1097/01.ANC.0000296622.71517.52
Post #3 Veronica
There are three themes of ethical dilemmas related to nursing revealed by a study of different healthcare settings, including balancing harm and care, work overload affecting quality, and navigating disagreement (Haahr et al., 2020). According to Haahr et al. (2020), navigation in disagreement or being overloaded by work leads to a way to care for lower quality and compromised nursing values and may lead to compassion fatigue. Therefore, I can relay my ethical dilemma to the navigation in disagreement. It took place just before COVID time at the ICU unit. I was taking care of a patient with a severe medical condition, of the patient with respiratory failure, who was intubated for several days, then extubated, got a tracheotomy, and was oxygen dependent. The patient’s mental status was intact, but he was receiving pain medications due to his pain from a severe medical condition. The patient’s status was a Full Code, and he had a healthcare surrogate, his daughter. There was also the patient’s wife who was visiting him, but she was depressed and was relying on their daughter’s decisions. The patient stated that he wanted his status changed to Do Not Resuscitate (DNR), and I passed it to the patient’s daughter. I was advocating for my patient’s rights to be met. Still, the patient’s daughter became very agitated and insisted that her father was post-sedation and being intubated, receiving pain medications. Under these conditions, he could not make any appropriate conscious decisions.
Following the above, I encountered an ethical dilemma between the patient and his family regarding changing his status from the Full Code to the DNR with the stakeholders: the patient, his family, and the nurse acting to meet the patient’s rights and wishes. The family was insistent that the patient made the decision to be a Full Code before the hospitalization and that it was based on his wishes, and now, being under medications, he is unable to participate in medical decisions. Furthermore, when I was assessing the patient, he was conscious, alert, and oriented, suffering from his medical condition and inability to change his code status at that time, which impacted him mentally. However, I could not withhold his pain medications and keep him unmedicated and in pain to prove his intact mental status. In this situation, the ethical dilemma was related to navigation in disagreement with the family decisions.
I informed the patient’s physician regarding the patient’s will, and he tried to talk to the family, but the dilemma was not resolved because their decision hadn’t changed. According to the Florida Department of Health (n.d.), The Do Not Resuscitate Order (DNRO) must be signed by the patient’s physician and the patient or his healthcare surrogate if the patient cannot provide informed consent; also, the form must be signed to be valid. However, in the other situation, we could involve the Ethical committee to resolve this ethical dilemma. According to Hajibabaee et al. (2016), a healthcare or hospital Ethical Committee is a body of persons confirmed by a hospital or healthcare institution to consider, debate, study, take action on, or report on ethical issues to deal with the ethical challenges that have emerged during Ethical practices. However, we could not involve the Ethical Committee because the patient had been transferred to the bigger hospital at the family’s request the following day.
References
Florida Department of Health (n.d.). 64J-2.018 Do Not Resuscitate Order (DNRO) Form and Patient Identification Device. Florida Health. https://www.flrules.org/gateway/RuleNo.asp?title=Trauma&ID=64J-2.018
