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The Case Study

Discuss about the Ethical Dilemma for Nursing Ethics.

Every nurse has to go through ethical dilemma which is a leading problem in nursing field. Often in various situations a nurse might get into confusion between two conditions which might seem morally correct for treatment of a patient in distress. Especially in case of a patient demanding for resuscitated taking the correct decision to proceed with the course of activities often becomes difficult. Various factors come into play that creates ethical issues.

In the provided case study, one can find a very pathetic case of the death of an old lady named Elsie due to cardiac arrest. The various stakeholders involved in this case are the nurse manager, the registered nurse on duty on that day when the patient died and the paramedics. The discussion of the topic would mainly consider the role of the registered nurse as well as that of the paramedics who attended her that day.

In the case there has been a massive conflict between the  dignity of the patient as well as the ethical decision that the ACD (Advanced Care Directive) authority undertook. In this case, it is seen that the dignity of the patient was entirely overlooked by the nurse on duty that day. Elsie was an extremely weak old lady who had already faced an acute myocardial infarction earlier. She never wanted to go through strenuous treatments as she believed that it could be painful and would make her uncomfortable. By the word dignity in healthcare one can certainly ascertain the various aspects that the patients possess and should be clearly respected by the nurse on duty. Caring for a nurse does not only involve guiding medical treatments and taking care of her so as to relieve her stress.

The duty of a nurse mainly includes providing respect and dignity to the patient showcasing medical knowledge that can better the health of the patient as well as make them feel cared for (Gastmans, 2013). Providing dignity therefore makes the patient feel comfortable, peaceful as well as important in the sense that she has been given value as human being. This would include fulfilling the wishes of the patient as well as carrying out the wishes that would not harm her physically and mentally. When the activity of the nurse contains actions that harm the dignity of a patient, the patient might feel depressed, humiliated and even embarrassed (McSherry, 2016). The priority should remain irrespective of the capability whether the patient is able to express or not. It happens a lot of time that a person might become tensed or vulnerable after ailment. In that case, respecting the dignity of the patient is the sole duty of the nurse. However, in case of Elsie it can be said that her dignity was not handled properly by the Registered Nurse and also the paramedics. In spite of her unwillingness to be transferred to a hospital she was not paid importance to. Moreover, she had already mentioned earlier that she should not have been resuscitated if a serious condition would arise. This request was not carried out from the part of the registered nurses and the paramedics. Such a response from the part of the nurse was a complete breach of the criteria of nursing and healthcare. Their primary activity should have been to provide utmost care to the request of the patient and perform accordingly.

Respect for Dignity in Healthcare

This case is the exact condition where perfect ethical models would help the governing nurse on duty. In certain cases ethical dilemma forms the main concern that prevents the nurse from the proper course of activity (Jhonstone, 2015). In this situation she needs to follow the ethical system models that would help her to be strong under trying situations and come out with decisions that would be beneficial for both the patient and the nurse and would keep her in a safe side.

A nurse’s main motive would be to listen and perform according to the patient but marinating her ethics at the same time for the betterment of the patient (Butts & Richs, 2012). There may be many cases, where the decisions taken by the patients or their family might not be suitable for the wellbeing of the patients and might become the reason for their death. In such a situation, the nurse should only have the authority to make the family members or the patient understand the side effects and the negative aspects of the decisions taken by them. She may suggest ways that the family should follow in order to cure their patient and make her happy and healthy. However, if the patients or their families are forcing to perform activities that would go against the health of the patient, then the nurse’s job would be to respect the decision and perform accordingly (Maurer & Smith, 2013). Herein she may face an ethical dilemma where her knowledge would clash with the task that she had to perform that would be entirely against her will. This situation would be judged and handled with care on the basis of evidence based practice and would increase her experience of dealing with such incidences in her nursing career. In case of Elsie, it is seen that the nurse faced an ethical dilemma when she faced such a critical condition where she could not decide what she had to do. Her inner-self guided her to be more caring towards the patient’s health than her dignity.


In order to not involve herself in a legal issue where the ACD form was not submitted she went with the decision that she thought might save her patient’s life from death. However, her ethical dilemma made her lose the life of the patient and made her solely responsible along with the paramedics for the occurence. The nurse and the paramedics should have considered the patient’s wishes and requests when she had already mentioned to leave her in the condition she was, as she did not want herself to be more stressed in that situation and wanted her life to end that way. Herein, the nurse’s and the paramedic’s role was therefore questioned as they tried to save the life of the patient by taking the best decision which otherwise would have proved successful if luck would have been favored. So the right of the nurses should be restricted to their own decision making and thinking for the patient’s betterment and should not impose them over the wish and demands of the patient.

Principles of Nursing Ethics

The main principles that a nursing professional should follow are Respect for Autonomy, the quality to do no harm (non- maleficience), to do good (beneficience), fairness, truthfulness and justice (Corey et al., 2014). These are the principles that a nurse should follow when she faces an urgent situation where her single decision would alter a course of activities, which will have an impact on patients. Before a nurse instructs her patient she should have to formulate her decisions so that it can match the four principals without harming the patients (Parahoo, 2014). As Elsie wanted not to be shifted to hospitals (Respect for Autonomy), the nurse for her wellbeing (beneficience) should not have arranged for ambulances (non- maleficience) and should have been truthful to her and thereby showing justice to her wish and demands.

Apart from the four principles that a nursing professional would follow strictly during the maintenance of the health of the patient, one has to always remember that nursing which is the other name of humanity might not always be as strict as following the principles. In order to simplify the statement one can say that following the four principles always does not yield a satisfactory result. In certain cases, virtue ethics are necessary to treat dilemmas that are quite sensitive and require experience to handle (Putman, 2012). Virtue ethics can be simplified as the attitudes that a nurse may exhibit in order to deal with a situation that is much emotional and might not follow a regular path of treatment. Certain cases the nurse’s reasoning capability and her knowledge of medical treatment might not find a solution that can justify a patient’s attitude and wishes of her health. These decisions might be harmful even leading to death. She should never judge the value of the patient’s existence and reason of decision based on her own experience of life and happiness (Doherty & Purtilo, 2015). She should deal with it on the basis of moral virtues of ethics such as compassion, honesty and many others to understand the exact condition of the patient’s life which is forcing her to end her life (Newham, 2015).

In Elsie’s case, it can be noted that the nurse’s end minute decisions were not at all based on virtue ethics for she failed to incorporate some of the key factors. She should have considered these key factors of virtues for proper evaluation of the patient’s decision and her state of mind where she applied the moral principles that should not have been done. The first virtue should have been taking CARE of the fact that why the patient is not wanting to survive and the emotional condition she is going through to understand the turmoil inside of her. The second would have been RESPECT and INTEGRITY that is the nurse should have respected Elsie’s decision for trying to tell her own decision in spite of having acute pain in the chest. Integrity means that she should have had entire trust on the patient for her decision and should have been integrated on the patient- nurse relationship showing her trust for the decision taken by Elsie. The third virtue should have been her COURAGE that would have helped her to take a responsible action for the demand of the patient and make up herself for the task thereby assigned to her that is leaving her in the condition she wanted to be in. The last should have been the proper reasoning of the entire episode. This should include an entire evaluation of the mental as well as the physical and mental inputs that she had to give in order to carry out the wish of the patient and understand the importance of the entire situation that Elsie was in through a proper reasoning.

Virtue Ethics in Nursing


If one judges the situation, entirely based on codes of conduct with respect to ethics in nursing profession a similar scenario can again be observed. The codes of conduct in nursing professional mainly help in guiding a nurse or a midwife in her professional life with the correct quality assistance and acts as guidance of the day-to-day activities that a nurse performs (Cannaerts et al., 2014) . It mainly covers five important aspects of the nursing practice that mainly consists of respecting the dignity of the person, professional responsibility and accountability, maintain confidentiality and trust as well as being engaged into collaborations (Davis, 2013). While the last two codes are not applicable in Elsie’s case but the first three were not maintained properly by the nurse on duty. The RN did not maintain maintenance of dignity of the patient. Moreover, she did not exhibit enough professional responsibility by not maintaining the patient’s pleas and comfort. This even affected her quality of work as she got entangled in ethical dilemma and could not take a correct decision. Therefore, the nurse failed to maintain the ethical conduct expected from her, resulting in becoming the person accountable for the entire incident.

In order to describe the entire complications that are involved in the mentioned case, first two important conflicting ideas have to be enlightened in this case. The Euthanasia Laws Act 1997 has taken the power of the states to legalize euthanasia in every corners of Australia, which mainly nullified the Rights to terminally ill Act of 1995, which had legalized euthanasia (Humanrights.gov.au, 2016). Though Euthanasia was not legalized but this act has left a hole in the decisions taken in case of passive voluntary euthanasia (Humanrights.gov.au, 2016). A person who is not demanding the nurse to assist her for death by providing medication but requesting to stop her life supports are to be listened because she is not directly participating in voluntary euthanasia (Shields et al., 2015). However, if this had been the case, she did not ask the nurse to help her provide with medications that would bring her death. If that would have been a case, then the nurse could have been penalized and a legal procedure should have been considered. However in case of Elsie , she asked the nurse and the paramedics to leave her as she was, without asking any treatment for death. This would not have caused any legal issue if the nurse would have conducted it. Again, the nurse faced ethical dilemma because her prior principal should be saving a life of a patient and provide her with utmost care. Therefore, ethical dilemmas often gets associated with issues concerning legal complications and therefore each and every aspects of ethical issues should be entirely ascertained by the nurses before taking it as a profession.

Conclusion


While deciding the course of treatment for a patient who has already informed for resuscitation is very difficult and the nurse has to be knowledgeable about the every aspect associated in such a case. She should be well informed about the dignity and the rights of all the stakeholders, the various principles and the legal complicacies so that a correct decision might be taken by them that would avoid any confusion and correct ethics. A nurse with proper education on ethics and correct evidence based practices would be calm and composed and would have the ability to take an apt decision, which would be fruitful for the nurses as well as the patient (Vezina et al., 2014).

References:

Aph.gov.au. (2016). Euthanasia - the Australian Law in an International Context – Parliament of Australia. [online] Available at: https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/rp/RP9697/97rp3 [Accessed 30 Sep. 2016].

Butts, J. B., & Rich, K. L. (2012). Nursing ethics. Jones & Bartlett Publishers.

Cannaerts, N., Gastmans, C., & de Casterlé, B. D. (2014). Contribution of ethics education to the ethical competence of nursing students Educators’ and students’ perceptions. Nursing ethics, 21(8), 861-878

Corey, G., Corey, M. S., Corey, C., & Callanan, P. (2014). Issues and Ethics in the Helping Professions with 2014 ACA Codes. Nelson Education.

Davis, M. (2013). Codes of Ethics. The International Encyclopedia of Ethics.

Doherty, R. F., & Purtilo, R. B. (2015). Ethical dimensions in the health professions. Elsevier Health Sciences.

Gastmans, C. (2013). Dignity-enhancing nursing care A foundational ethical framework. Nursing Ethics, 20(2), 142-149.

Humanrights.gov.au. (2016). Euthanasia, human rights and the law | Australian Human Rights Commission. [online] Available at: https://www.humanrights.gov.au/our-work/age-discrimination/publications/euthanasia-human-rights-and-law [Accessed 30 Sep. 2016].

Johnstone, M. J. (2015). Bioethics: a nursing perspective. Elsevier Health Sciences

Maurer, F. A., & Smith, C. M. (2013). Community/public health nursing practice: Health for families and populations. Elsevier Health Sciences

McSherry, W. (2016). Reintegrating spirituality and dignity in nursing and healthcare: a relational model of practice. Stories of Dignity within Healthcare: Research, narratives and theories.

Newham, R. A. (2015). Virtue ethics and nursing: on what grounds?. Nursing Philosophy, 16(1), 40-50.

Parahoo, K. (2014). Nursing research: principles, process and issues. Palgrave Macmillan.

Putman, D. A. (2012). A reply to ‘Scepticism about the virtue ethics approach to nursing ethics’ by Stephen Holland: the relevance of virtue in nursing ethics. Nursing Philosophy, 13(2), 142-145.

Shields, L., Hartin, P., Shields, K., & Benedict, S. (2015). Teaching the Holocaust in Nursing and Medical Education in Australia. Working Papers in the Health Sciences, 1(12

Vézina-Im, L. A., Lavoie, M., Krol, P., & Olivier-D’Avignon, M. (2014). Motivations of physicians and nurses to practice voluntary euthanasia: a systematic review. BMC palliative care, 13(1), 1.

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