Ethical Dilemma in Nursing - Case Study Example

MHN263504 To critically analyse the processes by which societal, legal, ethical and policy issues shape mental health service a demented elderly INTRODUCTION: The ethical dilemma revolves around a gentleman Mr Brown. He suffering from dementia, been transferred informally to the elderly mental health unit from the accident and emergency department for attempting suicide and is now intending to take his own life by refusing to eat because he does not want to become a burden on his family. Mr Brown is shifted from one ward to other and that must have affected him emotionally. In a demented person recognition and memory undergo changes. As a result demented elderly deny a decision taken by themselves and accuse relatives ,children of manipulation It was apparent that nurses had difficulties choosing between feeding without consent, and the possibility of death due to lack of nutrition. Nurses are human beings with their own values and emotions. While working with demented elderly they prefer traditional religious ethics, even if this meant using force, and placed the sanctity of life above the autonomy of the patient. The case to be discussed in ethical, moral and legal sense. Here Mr. Brown requires treatment of a nasogastric feeding tube for his nutritional needs to prevent his mental and physical health deterioration and him experiencing a painful end. However the nursing intervention could possibly be seen as a contradiction of his personal rights yet would enable him to stay alive (Rumbold 1993). The nurse has to address a dilemma of ethics and moral duty to this difficult issue where there is much pressure from people in society for vulnerable people with deteriorating illness that questions what are the correct and incorrect actions to take in the light of a patient consenting to treatment or refusing and having a right to die with dignity. Tube feeding in demented elderly: Since Mr Brown refuses to take any food at all with hands, but at the same time time he has reasonable mental and physical abilities the tube feeding may in fact prove to be of some help. However, before deciding to put a patient on tube feeding the necessity of it should be viewed in the light of literature available. It should be weighed well whether such a thing is necessary immediately or that the elderly may be given time for better option as followed below in the physiology of reduced eating in cases of dementia. Surrogate decision makers for demented patients who opt for feeding through a nasogastric tube usually do so because they hope to extend life and prevent aspiration pneumonia. They also do so because they wish to prevent suffering or because their values, particularly religious beliefs, dictate that life should be sustained. (Ouslander et al. 1993). Feeding tubes do not prevent aspiration in patients with dementia. It may however enhance the suffering. A gastrostomy tube is placed in a patient to provide nutrition and hydration. Theoretically, tube feeding can provide adequate nutrition in a patient with dementia however, in reality this is often not the case. The problems with diarrhea, clogging of the tubes and the tendency of patients with dementia to pull out the tubes happen and thus the nutritional status often does not improve with the use of feeding tubes (Mitchell & Lawson 1999). It has been remarkably difficult to demonstrate any difference in longevity between patients with feeding tubes and those without tubes. A carefully performed study of the outcomes of nursing home patients with advanced dementia and eating disorders found that the patients who were fed through a gastrostomy tube and those who continued to be fed by hand had the same survival rates. (Rethinking2000). There is also a physiological side of tube feeding as presented by Hoffer (2006a). He stated that there is sufficient evidence that non-demented, elderly malnourished people do benefit from nutritional supplements. But severely demented patients may not benefit from tube feeding for two main reasons, firstly, there is little or no potential for physical or neurological recovery, and secondly they are not starving. People who reach the advanced stage of dementia when food intake is reduced or almost stopped have a low metabolic rate. Their resting metabolic rate is low because muscle wasting has shrunk their lean body mass and their brains are atrophic; their metabolic rate above basal is low because they are physically inactive. Finally, they have a history of weight loss, which the body adapts to by reducing its metabolic rate and retaining dietary protein more efficiently. This adapted state can persist indefinitely (Hoffer 2006b). Severely demented people may be thin and eat less food than seems appropriate to their doctors, nurses, and surrogate decision makers; but in many if not all cases they are not progressively starving. They are in a state of physiological homoeostasis as shown by low metabolic rate, low energy consumption and constant body weight. A contradictory study by Abayomi & Hackett (2004) is based on psychological reasons rather than metabolic aspects. They think that nurses generally overlook malnutrition in psychotic patient and link it with not eating enough due to depression. Safety and assistance to demented elderly: In the elderly, food is one of the major sources of possible pleasure and it is the challenge for health providers to try and give this enjoyment to their patients for as long as possible. Many times it is depression that demented elderly refuse food. They also are unable to swallow. The nurse need to pay attention whether it is refusal of food or inability to eat. To avoid depression the demented elderly should be kept in safe and pleasant environment.Elderly with disabilities are more likely to require assistance with intimate personal care so there needs to be sufficient staff of appropriate gender for these care tasks. Disinhibition and inappropriate sexual behaviour are common features of dementia so units for such patients need both space for people to move about but also sufficient rooms to allow privacy. There will be complete phasing out of mixed sex wards to provide safety and prevent abuse of mentally disables patient (DOH 2000) Ethical principles and theories to resolve the dilemma in the case Informed consent : It is usually considered that people with mental disability can not make legally valid decisions about their health care. Such a strict approach is not taken into consideration in English law. It is the ability of person in making decision in the context of a particular situation or decision making task. A mentally disabled person is also able to make proper decision in some situations while not able to do so in other situations. With this foundation the white paper valuing people (DoH 2001a ) aims to address the invisibility of people with intellectual disabilities in the NHS and endorse their right to access equitable mainstream healthcare. What the concept of informed consent According to Reeves and Orford (2002) Consent may be given in three ways: expressly, implied or hypothetically. Express consent is in writing it though may include a nod of head or verbal yes. Such as preoperative consent. The implied consent is in general practice e. g. the patient offering his arm for vaccination. While living will is the example of hypothetical consent. The verbal consent is legally valid but in the court it is easier to produce a written consent. Patients usually fall in three categories: first are those who prefers to remain in dark and accept a suggested treatment. The second group requires all information about the treatments and then makes his choice while the third group does get all the information yet wants health professional to decide. Even if the patient is submissive or passive, he should be informed about treatments. In Mr Brown's case the nurse has to acknowledge that though he is suffering from dementia and wants to end his life under depression. But at the same time he is sensitive to the feeling that his behaviour is causing troubles to others. His case is to be considered in the light of DoH (2005) Mental capacity act which protects mentally disabled people, enhance their capacity to take decision or to be part of decision making process as per their mental abilities. The five principles of the act emphasise that it is necessary to establish beyond doubts that a person cannot take decision which should be concluded only after providing him all practicable help to decide. Merely one bad decision (Trying to commit suicide in this case) can not brand a person unable to take decision. Any action for his treatment should be taken in his best interest. Finally the act states that any decision on health care should be taken so effectively that it does not restrict persons rights and freedom of action. According to the act Mr Brown can not be labeled as unable to take valid decision just because of his dementia and attempted suicide since he reasons for that. It is a feeling similar to normal individuals when their conduct troubles people. Thus his mental abilities are not cognitively deteriorated though the present condition is of depression. Hence the nurse has to decide whether Mr Browns decision is competent in the context. When faced with a moral dilemma where there are two alternative choices, neither of which seems a satisfactory solution to the problem, a decision has to be made based on one's own moral principles and what each person believes to be right. The standard of professional conduct desired for accountability and practice as given in code (NMC 2004) to be taken as base for such conditions. The code places responsibility on each practitioner to constantly develop his/her knowledge, skill and competence. Each practitioner must limit personal deficit in knowledge and take steps to remedy these. The code of conduct also clarifies responsibility and accountability. A nurse is responsible and accountable to the patient, the profession ,the law and the employer. However Tadd (1994) argues that nurses should be given authority to take an ethical decision to be accountable to that but this aspect is ignored in the code (ethics). Thus the burden of decision making in Mr Brown's case should not entirely be on the nurse he/she should be given adequate help by the surrogate decision makers and the patient's physician. The work of Beauchamp and Childress (2001) has had a great impact on ethics in health care. They present four principles, derived from common morality and medical tradition, These principles are: Autonomy in health care implies that person is free to make his/her choice without interference or limitations by others. Autonomy is giving a patient full information and understanding of the issue and respecting his decision. However in Mr. Brown's case his competency to decide is to be ascertained before respecting his autonomy. As the competence is context or task specific. Does his decision to end his life is a competent decision and for such a decision should we respect his autonomy Beneficence: Beauchamp and Childress (2001) present two principles of beneficence. These are positive beneficence,which is to provide benefits, and utility which is to balance benefits and drawbacks. As opposed to nonmaleficence, beneficence requires action. Beneficence is described as the core of care, expressing the goal, rationale, and justification of medicine (Beauchamp and Childress 2001). Non-maleficence: Nonmaleficence is described as "an obligation not to inflict harm on others" (Beauchamp and Childress 2001, p. 113). It also includes avoiding risking harm. It is mostly about not doing things, like non-treatment, and is a principle present in discussions on such issues as whether to withhold life sustaining treatment for terminally ill patients and on physician-assisted suicide. Justice On many occasions conflicts occur, like when a caregiver wants a patient to have a certain treatment and the patient does not want it, which is a conflict between beneficence or nurses' commitment to care and respect for autonomy. To resolve a conflict judicious comparison is required. Deontological Vs consequential theories: Deontological theory asserts that each person's binding duty is to society, and one has obligations that have to be fulfilled regardless of their outcome. Kant (1973) emphasized that human beings should be treated as end in themselves and not the means to achieve that end. He says that being human is greatest worth and should be given respect. Consequentialism emphasises that the rightness or wrongness of an act depends on the consequences of that act, and all people are considered equal. Thus nonmaleficence and beneficence are mainly drawn from ethics of consequence, while respect for autonomy and justice are associated with deontological thinking (Beauchamps and Childress 2001). The correct and incorrect actions to take in the light of a patient consenting to treatment or refusing and having a right to die with dignity (Corrignon 2003). In Mr Brown's case the dilemms is that the nursing intervention could possibly be seen as a contradiction of his personal rights yet would enable him to stay alive. Thus though the deontological theory applies fully in the case however as the outcome is also morally and ethically suitable so the consequentialism is also not absent. Legal issues The legal theory of informed consent represents various aspects of tort law that protect individuals from harm to person, property, and reputation. Tort law allows compensation for injury, deters corrupt conduct, and punishes those who are involved in wrongful behavior (Booth, 2002). Bolam v Friern (1957) indicated that absence of negligence in the duty of care should clearly establish that the treatment is done by skilled practitioner according to the standards prevailing at that time. The suit has made a basis for the 'Bolam test' for future claims of negligence in health care. At that time the code of conduct did not have informed consent practices so the doctors were not found guilty of not telling patient about the risks of elecro-convulsive treatment but as informed consent is necessary today before treatment it should be practiced. On a final point the Human Rights protects individual freedom. This is the sum of the rights and freedoms protected within the Convention. When fully applied they ensure that each individual has the right to determine how to live their own lives, free from unwarranted interference from the state.. The mental health act 1983 permit her to use nasogastric tube to provide nutrition which does not require consent of the patient under the act. However this Human Rights Act 1998, which is to be considered in all cases in UK, challenges the MHA 1983. The case involving Ian Brady, one of the infamous 'Moors Murderers', at the Court of Appeal in March 2000 may be referred here to clarify. It provides an up-to-date extensive overview of established case law in this complex area of mental health law. Being detained, Brady was treated with force-feeding via a naso-gastric tube (Curtice 2002). One fundamental aspect of this right must be the ability to choose the medical treatment which is imposed upon one's body. The right to refuse unwanted treatment manifests itself in numerous Convention rights. The key Articles are 3 and 8 which, taken together, will ensure that treatment is consensual or, if the patient is genuinely incapable of consent, therapeutically necessary (Wicks 2001). The professional requirement clearly binds health care personnel to record the details of an event immediately after it has taken place. The nurse should do so involving the patient. The properly kept record enables good care of patient and it is also an authentic document in cases of legal claims (NMC 2005). The supports for nurses in decision making: Bakalis & Watson (2005) noted that decision making by nurses is associated with their experience in nursing and their nursing area. For e.g. critical care nurses make frequently decision in emergency situations and regarding changing medication than surgery nurses. Saunders (1995) acknowledged that there is close partnership between nurse and her patient. But nurses do not practice autonomy fully since they feel threatened that patient may have stronger role in decision making, or they may be asked too many questions. Nurses also prefer to do their work without interruption and a passive patient is more suitable to them. Nurses respect the idea that patient should put their trust in medical staff. The psychological and moral condition of a nurse may make her hesitant in allowing a patient to die by starvation (DoH 1999) Aim at lifelong learning and continuing professional development Nurses, midwives and health visitors must play a full part in developing and implementing national service frameworks and clinical governance. They may be given new roles and more responsibility to increase their compatibility to act in critical situations that puts one in dilemma. The professional code of conduct(NMC 2004) gives guidance and advice regarding professional duty. It emphasises moral responsibility rather than giving statutory directions. A discussion of professional ethics has been made above. The MHA 1983 clearly emphasise that merely diagnosis of a mental disease does not necessarily mean that person's ability to decision making is also affected. A patient can give valid consent if he/she understands what the treatment is and why it is needed, what are the benefits and risks associated with the treatment, the consequences of not taking the treatment. In case the patient does not have mental capacity to decide then his/her relatives or carer decide but ultimate decision is to be taken by the doctor. The act clearly guide the choice in case of Mr Brown though he is not incapacitated to take decision as he is reasonably sound mentally but at the same time his decision in the particular context is not right The question here is whether some one is suffering from depression currently and so wants to die can be competent to control the situation and should his refusal to eat and drink be respected The nurse need to consult his carer and finally act in consultation with the doctor. At the same time the elaborated version of MHA 1983 ,The mental health act 2005 states the patient should be given all possible help to decide. Since Mr Brown's ward has been changed after his suicide attempt, he may be in a state of settling to his new surroundings. So giving him his favourite food, in his favourite utensils, may be more of finger food should be allowed to decide him. The food is great enjoyment for elderly and may cure depression sooner than anything else. There is no indication that Mr Brown has drawn up a living will for advanced refusal of treatment for his deteriorating health so going against law does not occur here. (Dimand 2004). Staden and Kruger (2003) emphasise that mental disorder unable to give informed consent should prove clinically and specifically to the intervention for which consent is sought. To simplify their meaning that just because a person is psychotic it should not be taken as unable to decide. Some mental disorders prevent patients from understanding the nature and purposes of a medical intervention, or prevent patients from choosing decisively, or prevent patients from communicating their consent. Examples are dementia and learning disability of sufficient severity. It is an important point here since Mr Brown does not seem to have dementia of severity. Incapacity is judged in terms of lack of understanding and communication. In case of Mr Brown it is impaired judgement since he understand the treatment (nutrition) and can communicate as well but still does not want it so as to relieve the troubles of his relatives. However, in the case of a patient who cannot accept that an intervention is warranted or necessary due to a mental disability, such a patient's choice is not autonomous because it is determined by the mental disorder (Staden & Kruger 2003). Conclusion: Thus in the light of above discussion, it is clear that the nurse needs to take an ethical decision . The support from code of professional conduct and law comes to her though. The former clearly gives her authority to act in the best interest of the patient. Since Mr Brown is fairly healthy and his mental abilities are not deteriorated badly however in the context of discontinuing eating to end life is not a competent decision by him so to disregard it would not be a breach of his autonomy. The principle of autonomy does not apply in the present context, as there is no living will or advance refusal either. It would be a good step, if possible, to allow him to develop liking for food by giving him his favourite food under familiar conditions so that he takes food by hand instead of through the tube. There are certainly some precautions required during tube feeding and also some debated issues whether tube feeding is of any benefit to demented elderly but probably Mr. Brown is not a severely demented case and as in other elderly it has been proved useful so it would be in his case. Cranston (2002) advice nurses to consider evidence based practice and use a multidisciplinary approach. The previous experiences do give good hints to take appropriate decision in cases of dilemma. In fact ,with the details covered so far it would be useful for the nurse to consider steps to arrive a final decision. Rest (1994) has defined ethical principles viz. moral sensitivity, moral judgment, moral motivation, and moral character. Moral sensitivity is ability to interpret the situation as containing a moral dilemma, Second, reasoning has to take place, which results in a moral judgment. The third step is the establishment of moral intention, i.e. the intention to comply with the moral judgment. Finally, the ethical behavior can be performed. The application of principle of beneficence based on deontological theory is certainly in the best interest as well as correct morally and ethically for Mr Brown's case. So if all methods of feeding have failed, he should be tube fed without any ethical dilemma. References Abayomi J, & Hackett A (2004) Assessment Of Malnutrition In Mental Health Clients: Nurses' Judgement vs. A Nutritional Risk Tool, Issues And Innovations In Nursing Practice, Journal Of Advanced Nursing, 45, (4) 430-437 Bakalis, N. A. & Watson, R. (2005) 'Nurses Decision-Making in Clinical Practice', Nursing Standard, vol: 19, No: 23, pgs 33-39 Beauchamp T & Childress J (2001) Principles of Biomedical Ethics 5th edn. New York: Oxford University Press. Bolam v Friern Hospital Management Committee [1957] 2 All E.R. 118 BOOTH, S. (2002) 'A philosophical analysis of informed consen'. Nursing Standard. 16 (39) pp 43-46. CABLE, S. (2003) 'Informed Consent'. Nursing Standard. 18 (12) pp 47-53. Corrigan, O. (2003) 'Empty Ethics: the Problem with Informed Consent', Sociology of Health & Illness, vol: 25, No:3, pgs 768-792 Cranston, M. (2002) 'Clinical Effectiveness and Evidence -Based Practice', Nursing Standard, vol: 16, No: 24, pgs 39-43 Curtice M. J. R. (2002) 'Force-Feeding: Implications for the Mental Health Act 1983 and Human Rights Act 1998', Journal of Mental Health, vol: 11, No: 3, pgs 235-242 Department of Health (1999), Making A Difference, Strengthening the Nursing, Midwifery and Health Visiting Contribution to Health and Health Care, London, HMSO Department of Health (2000) Safety Privacy and Dignity In Mental Health Units, London, HMSO DEPARTMENT OF HEALTH (2001a) Good practice in consent implementation guide: Consent to examination or treatment. London: Department of Health. DEPARTMENT OF HEALTH (2005) The Mental Capacity Act. London: Department of Health. Hoffer, J2006a.Tube feeding in advanced dementia: the metabolic perspective. BMJ;333:1214-1215 (9 December Dimond B (2004) The refusal of treatment: living wills and the current law in the UK. British Journal of Nursing 13 (18):1104-1106 Hoffer LJ. 2006b, 'Metabolic consequences of starvation'. In: Shils ME, Shike M, Ross AC, Caballero B, Cousins RJ, eds. Modern nutrition in health and disease. 10th ed. Philadelphia: Lippincott Williams & Wilkins, 2006b:730-48. Kant, I. (1973) Cited in Rumbold, G. (1999) Ethics in Nursing Practice. 3rd edn. Bailliere Tindall, London Mental Health Act (1983) London: HMSO NURSING AND MIDWIFERY COUNCIL (2004) Code of Professional Conduct: Standards for Conduct, Performance and Ethics. London: NMC. Nursing and Midwifery Council (2005) Guidelines for records and record keeping. London: NMC. Ouslander JG, Tymchuk AJ, Krynski MD. Decisions about enteral tube feeding among the elderly. J Am Geriatr Soc 1993;41:70-77. Reeves M & Orford J (2002) Fundamental Aspects of Legal, Ethical and Professional issues in Nursing. Wiltshire: Quay Books Rethinking the Role of Tube Feeding in Patients with Advanced Dementia, 2000, NEJM,Volume 342:206-210 Rumbold G (1993) Ethics in Nursing Practice. London: Bailliere Tindall. Saunders P (1995) Encouraging patients to take part in their own care. Nursing Times 91(5), 42-43. Staden C & Kruger C (2003) Incapacity to give informed consent owing to mental disorder. Journal Medical Ethics 29: 41-43 Tadd V (1994) Professional codes: an exercise in tokenism Nursing Ethics 1(1), 15-23. Mitchell SL, Lawson FM. Decision-making for long-term tube-feeding in cognitively impaired elderly people. CMAJ 1999;160:1705-1709. Wicks E, (2001), The Right To Refuse Medical Treatment Under The European Convention on Human Rights, Medical Law Review 9(17) Read More