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NURBN1001 Legal And Ethical Decision Making In Person Centred Care

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  • Course Code: NURBN1001
  • University: Federation University
  • Country: Australia

Question:

Learning Outcomes:

1 – Explore the ethical, legal and professional frameworks that underpin professional nursing in Australia.

2 – Discuss the application of these frameworks in relation to scope of practice and professional nursing practice.

3 - Identify the legal and ethical roles and responsibilities of professional nurses, including responses to critical incidents and vulnerable populations.

Task description

Essay Topic

Critically identify and discuss the relevant legal and ethical considerations in relation to the case study.

Focus on the following areas:

  • The Australian Charter of Health Care Rights;
  • Consent, confidentiality and privacy;
  • Duty of care / breach of duty of care;
  • Elements required for an action of medical negligence;
  • The four (4) main bioethical principles, according to Beauchamp and Childress, Atkins et al (2017) and how each of these apply to this case study.

Detailed Instructions:

  1. Read the clinical scenario and identify the pertinent legal and ethical considerations from a nursing perspective.

  2. Write a response to the essay topic using essay structure with an introduction, body paragraphs - that include the key points listed above - and conclusion.

Case Study:

Doris, a 79 year old female who lived with her 88 year old husband, Peter, was brought into hospital via ambulance following a fall at their home. Prior to the fall, she was active and mobile, caring for both herself and Peter at home independently.

Following assessment in the Emergency Department, x-rays revealed that Doris had fractured her right hip and required surgery to repair the fracture. Doris was confused and agitated, did not know where she was or what had happened to her. She was admitted to the orthopaedic ward and Peter was with Doris when the orthopaedic surgeon came to see Doris. The doctor did not explain the proposed procedure and Peter was asked to sign the blank consent form for Doris as her next of kin.

The nurse caring for Doris spent time talking with both Doris and Peter. During the conversation, Peter identified that he had problems with his memory too and sometimes got lost when driving home from the shops and couldn’t find his way home. On one occasion a neighbour found him sitting in the car and drove him home. He also said he sometimes forgot how to turn on the washing machine and had forgotten to turn off the stove a couple of times. Peter said that he hadn’t told his General Practitioner as he didn’t want to bother him.

The nurse had concerns about Peters’ ability to understand the proposed operative procedure and to legally provide consent for Doris and contacted the surgeon. The surgeon replied that as the consent form had been signed that was sufficient and the surgery would proceed. The nurse discussed her concerns with her Nurse Unit Manager who told her to document them in Doris’s medical chart.

Before Doris went to the operating theatre, Peter and Doris’s neighbour, Bert, came to visit Doris. Bert stated to the nurse that he had lived next to Doris and Peter for over 25 years and for the past two years had dropped in every day to see how they were. He said that he regularly helped them with their shopping, paid their bills and that they considered him their unofficial son. Bert said that he would be happy to sign a consent form if needed. The nurse went off duty and did not take any further action regarding the consent form for Doris's procedure.

The orthopaedic surgeon decided to take the afternoon off duty to play golf and delegated Doris's operation to a junior doctor to perform alone. Due to his inexperience, the junior doctor significantly injured Doris's hip and she suffered continual pain and decreased mobility following the procedure.

 

Answer:

Introduction:

With the rapid ageing, sudden fall and associated injuries are common amongst the older adults and it has increased rapid ageing. Approximately 30% of older adults aged 65 year or more than 65 years experiencing at least one fall due to cognitive impairment, slippery floors and immobility (Ang, Brien & Wilson, 2019).. Consequently, they experience a fracture, long hospital stays and increased health care expenditure Flaatten et al. (2017), argued that it is often common instance where older individuals failed to receive adequate care due to negligence, lack of communication and lack of involvement with the consumer from the physician’s ends. Consequently,low patient satisfaction,high psychological distress, clinical errors, breaching of the ethical principle. It is duty of care of the health care providers to provide safe and responsive care to the patients by acknowledging the decision of the patients, communicating with them and ensuring compliance with bioethical principles.  The case scenario presented ethical and legal issue experienced by a 79-year-old female, Doris who subjected to fall and admitted to the hospital. This paper aims to discuss the Australian Charter of Health Care Rights; Consent , breach of duty of care; action for medical negligence and four bioethical principles in the following paragraphs.

 

Discussion:

The case study highlighted the potential breach of the Australian Charter of Healthcare Rights. It recognises that the exclusive rights of the individuals receiving care and individuals providing care ((Www.safetyandquality.gov.au, 2020). Australian Charter of Healthcare Rights use three guiding principles such as everyone has rights to access health care, rights to have the highest standard of health and rights to receive care that acknowledges cultural differences (Www.safetyandquality.gov.au, 2020).  In this context, it is the legal responsibility of the professionals to provide access to the adequate health care services, respect the dignity of the patient, involve in the communication and encourage patient participation and respect privacy of the patient.   In this current context, when Doris admitted to the hospital due to hip fracture, she was confused and unaware of her surroundings. The doctor did not explain procure before initiating surgery, indicating that lack of communicating and scope for participation breached the second guiding principle (high standard of physical and mental health) (Www.safetyandquality.gov.au, 2020). Moreover, Peter was asked to sign in a blank consent paper which indicated a lack of involvement of the patient in the decision making and hinder the rights to comment on the medical care.   The case study also represents legal issues associate lack of proper delegation of the physician which breached the Australian Charter of Healthcare Rights.  The physician ensured the adequate consent procedure and delegated the surgery to an inexperienced junior doctor who significantly injured hip and subjected to continual pain along with decreased mortality, indicating that breaching safety of the patient (Delaney, 2018). To conclude it can be said that the case study represented the potential breach of the Australian Charter of Healthcare Rights such as participation, safety, communication and comment on care.

 


The case study highlighted the potential breach of the legislation of informed consent and lack of compliance with the requirement of informed consent. According to Rogers et al. (2020),  informed consent is a legal document that indicated voluntary decision making of patients regarding treatment procedure. The common criteria for valid consent in Australia include voluntarily by the patient, the patient must be lawfully competent, the patient must be aware of the process before providing consent and patient must be aware of the material risk associated with the procedure (Www2.health.vic.gov.au, 2020). These criteria must comply with Mental Health Act 2014 which stated that competent individuals over 18 years with the capability for providing informed consent must take decisions on behalf of themselves and must receive adequate time to make a decision (Www2.health.vic.gov.au, 2020). They must receive with adequate information regarding the procedure and they must have adequate cognitive ability to understand the consequences of the medical treatment which would be assessed by professionals. Sharpe et al. (2016), suggested that patients often have limited knowledge regarding suitable medical procedure and consequences of the treatment that subjected patients to high psychological distress such as anxiety, depression. It is the legal accountability of the specialists to communicate with the patient, provide adequate information of process and obtain informed consent after ensuring that the patient and family members are aware of the consequences of the treatment (Www2.health.vic.gov.au, 2020). Taking a deep insight of the situation, the doctor did not explain procure before initiating surgery rather, peter was asked to sign in a blank consent paper which indicated lack of compliance with criteria of informed consent. The physician did not provide any information regarding the procedure and material harm, did not assess the capacity of the patient for voluntary informed consent when the patient was 76 and her husband was 88 (Ryan & Callaghan, 2017). Their neighbour visited them and suggested that he would be happy to sign a consent form if needed. The nurse was aware of the mental state of peter after communicating with him. However, the nurse went off duty, did not inform Bert regarding the clinical procedure and did not take any further action regarding the consent form for Doris's procedure. Therefore, not provided information regarding care process and lack of initiating therapeutic communication and lack of assessment of the mental capacity of the patient for providing informed consent indicated that physician and nurse both breached criteria of valid consent and Mental Health Act 2014.  

 


The case study highlighted the potential breach of duty of care by physician and nursing professionals which subjected patient to significant harm. Water et al. (2017), suggested that duty of care is a legal, professional and ethical responsibility of health care professionals, especially nurses to provide quality care that protects the safety of the patients and do not exercise practices the practices that can subject patient to the potential harm. Usually, a physician owes a duty of care to the patient and according to the basic criteria of duty of care, the physician must provide adequate knowledge of care to the patient and must be obliged to provide care that promotes the safety of the patient (Grace et al., 2018). The breaching of duty of care would be identified when physicians unable to comply with safe care and exercise practices that subjected patients to the harm and patient dies. Goudkamp (2017), suggested that any action considered as the breaching of duty of care when the patient under care is injured due to the action of another person and action causing the injury was unreasonable and insignificant.  In this context, the breaching of the duty of care results in medical negligence.  The medical negligence is an action that happens when providers deviated from standards of care which result in injury to the patient (Nowotny et al., 2019). In this context, when the physician does not attend the patient admitted an emergency, the patient expires and become a victim of the consequences due to the action that could be avoided with the appropriate duty of care, the physician can be held liable for the medical negligence (Ion, Olivier & Darbyshire, 2019). In other words, to consider an act as the medical negligence, the common four main elements of the medical negligence such as 1) professional duty to provide safe and responsible care to the patient 2) breaching of such professional duty 3) injury caused due to breaching of care and 4) consequences result in damages to the patient (Goudkamp, 2017). The orthopaedic surgeon decided to take the afternoon off duty to play golf and delegated the process of surgery to a junior doctor to perform alone. In this context, the duty of care of orthopaedic surgeon to conduct surgery of Doris in the presence of her husband and her neighbour.  However, the orthopaedic surgeon breached the duty of care by not being accountable for his care rather provided to the responsibility of the junior doctors (Goudkamp, 2017). Therefore due to his inexperience, the junior doctor significantly injured Doris's hip and she suffered continual pain and decreased mobility following the procedure. In this context, providing responsibility to the junior and inexperienced doctor is considered as medical negligence of the orthopaedic surgeon (Ion, Olivier & Darbyshire, 2019).    In this context, the potential damages are pain experienced by the patient, reduced mortality of the patient and reduced patient satisfaction.   These harms could be prevented if the orthopaedic surgeon could take the responsibility of care by conducting surgery rather than providing responsibility to the patient (Goudkamp, 2017).   Therefore, to conclude it can be said the case study highlighted significant instances of breaching of duty of care and damages by the orthopaedic surgeon.

 


The case study highlighted that the care provided the physicians breached four bioethical principles of Beauchamp and Childress. Ingham-Broomfield (2017), suggested that the four principles of bioethics according to Beauchamp and Childress such as autonomy, beneficence,  non-maleficence and justice have gained increased attention in the field of medical ethics, and they are considered as the fundamental basis for providing safe and responsive ethical care to the patient. The autonomy is defined as the capacity and freedom to self-governance. In other words, it is the need for individuals to perceive their choices (Y?ld?z, 2019).  Beneficence is defined as the act of charity, the mercy of health care professionals must promote the greater good of the individuals and the act of care must be for the best interest of patients.  Similar to the bioethical principle non-maleficence suggested that professional must provide care to the patients that promote safety and ensure no harm (Gurney et al., 2017). The justice means unbiased and fair where professionals are required to provide care to each irrespective of age, gender, race and ethnicity (Y?ld?z, 2019). To provide safe and responsive care to the patients' professionals shape their clinical practices according to this bioethical principle.  Taking a deep insight into the situation, the doctor did not explain proposed to procure before initiating surgery rather instructed her husband to sign a blank consent form (Ingham-Broomfield, 2017).  This instance highlighted that professionals breached bioethical principle autonomy as the patient did not receive opportunities to take express her choice regarding the care process and she was unaware of the procedure (Y?ld?z, 2019). Since she did not receive any information regarding care, it also breached the bioethical principle beneficence. The instances of breaching beneficence were represented by case scenario where physician assured that adequate consent was obtained and orthopaedic surgeon delegated Doris's operation to a junior doctor to perform alone. The delegation of surgery to inexperienced professionals results in significant hip injury and she suffered continual pain and decreased mobility following the procedure (Ingham-Broomfield, 2017). The consequences of the delegation of care subjected the patient to potential harm and failed to comply with the best interest of the patient. Therefore, this action not only breached bioethical principle beneficence but also breached non-maleficence (Ingham-Broomfield, 2017). Overall, the patient did not receive safe and responsive care in the clinical setting rather subjected harm, indicating a potential breach of ethical principle justice.

Conclusion:

To conclude it can be said that health professionals must provide quality care to the patients by acknowledging the decision of the patients, communicating with them and ensuring compliance with bioethical principles. The breaching of the ethical and legal principles of care results in low satisfaction, damages and lack of adherence to clinical treatment. The case scenario presented ethical and legal issue experienced by a 79-year-old female, Doris who admitted to the hospital where professionals obtained consent in a blank paper. The lack of communication and providing education indicated a potential breach of the Australian Charter of Healthcare Rights such as safety, communication and comment on care. According to the mental health act 2014, the valid consent criteria are voluntarily by the patient, the patient must be lawfully competent, the patient must be aware of the process before providing consent. None of the above criteria met by the professionals. These actions indicated breaching of duty of care and can be considered as medical negligence. The medical negligence was highlighted when the orthopaedic surgeon delegated the surgery to inexperienced junior nurse.  These actions breached four ethical principles such as autonomy, beneficence, non-maleficence and justice.  Therefore, it can be recommended that professionals must provide safe and responsible care by communicating with the patient and prioritizing the need.

 

References:

Ang, S. G. M., O’Brien, A. P., & Wilson, A. (2019). Understanding carers’ fall concern and their management of fall risk among older people at home. BMC geriatrics, 19(1), 144. https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-019-1162-7

Delaney, L. J. (2018). Patient-centred care as an approach to improving health care in Australia. Collegian, 25(1), 119-123. https://doi.org/10.1016/j.colegn.2017.02.005

Flaatten, H., De Lange, D. W., Artigas, A., Bin, D., Moreno, R., Christensen, S., ... & Soares, M. (2017). The status of intensive care medicine research and a future agenda for very old patients in the ICU. Intensive care medicine, 43(9), 1319-1328. DOI 10.1007/s00134-017-4718-z

Goudkamp, J. (2017). Breach of Duty: A Disappearing Element of the Action in Negligence?. The Cambridge Law Journal, 76(3), 480-483. DOI: 10.1017/S0008197317000721

Grace, S., Bradbury, J., Avila, C., & Du Chesne, A. (2018). ‘The healthcare system is not designed around my needs’: How healthcare consumers self-integrate conventional and complementary healthcare services. Complementary therapies in clinical practice, 32, 151-156. https://doi.org/10.1016/j.ctcp.2018.06.009

Gurney, D., Gillespie, G. L., McMahon, M. P., & Kolbuk, M. E. (2017). Nursing Code of Ethics: Provisions and Interpretative Statements for Emergency Nurses. Journal of Emergency Nursing, 43(6), 497-503. https://www.jenonline.org/article/S0099-1767(17)30487-7/abstract

Ingham-Broomfield, R. (2017). A nurses' guide to ethical considerations and the process for ethical approval of nursing research. Australian Journal of Advanced Nursing, The, 35(1), 40. /doi/abs/10.1177/096973301350904

Ion, R., Olivier, S., & Darbyshire, P. (2019). Failure to report poor care as a breach of moral and professional expectation. Nursing inquiry, 26(3), e12299. DOI: 10.1111/nin.12299

Nowotny, B. M., Loh, E., Lorenz, K., & Wallace, E. M. (2019). Sharing the pain: lessons from missed opportunities for healthcare improvement from patient complaints and litigation in the Australian health system. Australian Health Review, 43(4), 382-391. 3,https://doi.org/10.1071/AH17266

Rogers, M., Ahmed, A., Madoc-Jones, I., Gibbons, A., Jones, K., & Wilding, M. (2020). Interrogating the prevention approach of the Housing (Wales) Act 2014 for people with mental health needs who are homeless. Social Policy and Society, 19(1), 109-120. https://usir.salford.ac.uk/id/eprint/56188/3/Rogers%20Homelessness%20and%20MH%20FINAL.pdf

Ryan, C. J., & Callaghan, S. (2017). The impact on clinical practice of the 2015 reforms to the New South Wales Mental Health Act. Australasian Psychiatry, 25(1), 43-47. https://doi.org/10.1177/1039856216663738

Sharpe, R., Völlm, B., Akhtar, A., Puri, R., & Bickle, A. (2016). Transfers from prison to hospital under Sections 47 and 48 of the Mental Health Act between 2011 and 2014. The Journal of Forensic Psychiatry & Psychology, 27(4), 459-475. https://doi.org/10.1080/14789949.2016.1172660

Water, T., Rasmussen, S., Neufeld, M., Gerrard, D., & Ford, K. (2017). Nursing's duty of care: From legal obligation to moral commitment. Nursing Praxis in New Zealand, 33(3). https://web.a.ebscohost.com/abstract?direct=true&profile=ehost&scope=site&authtype=crawler&jrnl=01127438&AN=133009014&h=Wgm66n7vfrkgeFBXNZunAB8wDGuF6bAMG8V0BJRpAak%2fW%2bY7DC3RKGPJWCVDmzTS2VP0bkqhpF82FJbM7kCJhA%3d%3d&crl=c&resultNs=AdminWebAuth&resultLocal=ErrCrlNotAuth&crlhashurl=login.aspx%3fdirect%3dtrue%26profile%3dehost%26scope%3dsite%26authtype%3dcrawler%26jrnl%3d01127438%26AN%3d133009014

Www.safetyandquality.gov.au (2020). The Australian Charter of Healthcare Rights -Retrieved 30 March 2020, from https://www.safetyandquality.gov.au/sites/default/files/migrated/Charter-PDf.pdf

Www2.health.vic.gov.au (2020). Informed consent-Retrieved 30 March 2020, from https://www2.health.vic.gov.au/mental-health/practice-and-service-quality/mental-health-act-2014-handbook/recovery-and-supported-decision-making/informed-consent

Y?ld?z, E. (2019). Ethics in nursing: A systematic review of the framework of evidence perspective. Nursing ethics, 26(4), 1128-1148. https://doi.org/10.1177/0969733017734412

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