Law, Ethics, and Accountability for Nurses - Essay Example

Running head: Law and Ethics Law, Ethics, and Accountability for Nurses (school) Law, Ethics and Accountability for Nurses Introduction Law, ethics, and accountability for nurses are crucial aspects of the nursing practice. These aspects help guide legal and ethical practice for the benefit of the patient and for the protection of the credibility of the nursing practice. This paper shall study and evaluate three case scenarios which illustrate ethical and legal dilemmas in the practice. This paper shall analyse the legal and professional issues that arise from the different scenarios. A personal and critical analysis shall be conducted on these legal and professional issues identified. This study is being conducted in order to comprehensively explain the legal and ethical issues which nurses often encounter and the possible ways that such issues can be legally and ethically resolved. Discussion Case scenario 1 In the first scenario, a nurse decided independently to indicate in the chart of an 80 year old end-stage heart failure patient that the latter is classified as ‘not-for-resuscitation’ or NFR. The NFR order was not consulted with the patient’s doctor. Moreover, since the patient was too ill to express her consent or dissent to the order, her husband’s consent was secured. The nurse recorded in the patient’s chart that the on-call physician approved the NFR order. The physician also apparently agreed to the discontinuance of the patient’s continuous positive airway pressure (CPAP) machine. The following day, the patient died and the cause of death was not the withdrawal of the CPAP but because of a heart attack. The RN was later fired for disregarding the chart orders which indicated that the patient’s medical treatment should be continued. The relevant legal and professional issues in the above case can be broken down to: a) the RN’s independent decision on the NFR decision – without proper consultation with the patient’s physician and in violation of orders indicated in the patient’s chart; and in b) ordering the withdrawal of the treatment without proper consultation with the patient. First and foremost, NFR orders are decisions and orders which are indicated in patient’s charts by the patient’s doctor. It cannot be independently decided upon by the nurse without proper consultation with the physician. In turn, this decision is made by the physician after proper consultation with the patient (Dames Clinical Nursing Education Site, 2010). The function of a nurse in NFR orders is to carry it out and to follow the directive as indicated in the patient’s chart. In the current case, the nurse independently decided that an NFR order was appropriate in her patient’s case. In effect, she violated the legal provisions of the Medical Treatment Act of 1998 which indicates that a refusal of treatment order must be decided by the medical practitioner after proper determination of legal requisites qualifying the patient for coverage. The nurse was rightly dismissed for her actions because she did not consider the patient’s wishes. The patient already had end-stage heart disease; therefore, she already knew beforehand that she might die from her disease at any time. This eventuality would have been considered in advance by the physician and the patient and this would have prompted them to discuss the possibility of considering an NFR order (McGrath, 2008). However, such order was not indicated in the patient’s chart. Instead, the standing orders by the physician were to continue the patient’s treatment. In other words, the patient did not express to her physician any desire to have her treatment be discontinued. Based on these considerations, the nurse was in violation of the patient’s wishes. In effect, she also violated the patient’s right to self-determination (Johnstone, 2009). Regardless of the fact that the patient was already too ill to express her wishes, the nurse still did not have the right to independently decide against the patient’s continued treatment. Before her health took a turn for the worse, she did not express a desire to have her treatment discontinued. Such wishes should have been respected (Johnstone, 2009). The right to self determination is an inherent right of a patient. It is a right which basically states that a patient has the power to make the decisions about his care and treatment and to be informed of the different decisions and options available to him (Luekenotte, 2006). In this case, the patient had the right to be informed of his options and the interventions to be carried out in her behalf. She also had the right to make her choices about her care (Sidhu, Dunkley, & Egan, 2007). Before the NFR order was chosen and carried out by the nurse, the patient did not express a desire to have the treatment discontinued. She had the choice on whether to live or die, and she chose the former. Such option should have been respected by the nurse. In practicing her right to self-determination, she chose and determined that her treatment should be continued. Even if, in the end, her death was not caused by the nurse’s actions, her right to determine her life and her care was still violated by the nurse (Sidhu, Dunkley, & Egan, 2007). A nurse’s liability is not dependent on whether or not the impact or the effect of her illegal or unethical actions was negative. It was dependent on the act of violation. Beauchamp and Walters discusses that normative ethics is also based on Deontological principles which basically aver that “moral standards exist independently of utilitarian ends and the moral life should not be conceived in terms of means or ends” (as cited by Stauch, Wheat, & Tingle, 2007). The ends of this case – that of relieving the patient of her pain and suffering was a desirable end. However, the moral standards must not be conceptualized with a complete disregard for utilitarian ends (Stauch, Wheat, & Tingle, 2007). The patient’s rights to autonomy should not have been compromised in favour of a nurse’s personal desire to ensure that the patient dies with dignity. The husband’s consent was obtained in this case, however, the law requires that in relation to guardians and NFR Directives, the decision for an NFR directive must be determined as early as possible. It is a process or a decision which arises from a “process of discussion with the represented person, their relatives, and the guardian” (Office of the Public Advocate, 2004, p. 3). An NFR directive which is consulted with a guardian must be considered: with the wishes of the patient and strictly considering the authority of the guardian making the directive. It must be stated clearly and indicated for a current condition. The guardian must also be fully informed of the patient’s condition and possible choices in treatment (Office of the Public Advocate, 2004). Finally, such directive must also be made after thoroughly reviewing whether or not the patients, if competent, would seriously consider the directive (Office of the Public Advocate, 2004). In this case, although some of these elements are present in this case, the fact that the patient did not express and give her consent to the NFR order with her physician negate all other elements present. In effect, the action of the nurse is unethical and illegal. Case scenario 2 In this second case, a 20-year old University student had abdominal surgery 2 days past and while on an 8-hour IV antibiotics and receiving wound care, he told RN Y that he has called a taxi and is going home. The relevant legal and professional issues involved here include the nurse’s responsibility of ensuring the patient’s welfare and the patient’s right to autonomy or self-determination. Nurses and other medical professionals have the responsibility of ensuring that a patient in their care receives the adequate care that he is entitled to by law and by the principles of health care practice (Smeltzer, et.al.2008). The process of delivering care therefore includes the delivery of health services to the patient based on patient needs. In this case, the patient needed wound care and needed to receive the IV antibiotics to prevent infection. It is also the nurse’s responsibility to ensure the patient’s safety, especially while he is in the care of the hospital (Smeltzer, et.al., 2008). It is a patient’s right to request discharge from the hospital. It is a right in keeping with the ethical principle of autonomy and self-determination. However, this right also comes in conflict with another ethical principle – that of beneficence. The principle of beneficence is about acting for the benefit of the patient and ensuring that the actions implemented would not harm the patient and would instead, benefit him (Huber, Nelson, & Netting, 2007). It is important to resolve the above issues because they serve as basis for ethical behaviour in the practice. In the medical practice, when confronted with this issue, the nurse and other medical staff must do everything they can to convince the patient to remain in the hospital’s care (Brook, et.al., 2006). They must also explain to the patient the possible risks he is exposing himself to by insisting on the discharge. The nurse and the doctors must also determine the patient’s physical and mental capability and whether or not they consider him physically able to bring himself home and to care for himself (Hwang, et.al., 2003). They must also determine if the patient has a companion or a caregiver who can assist him in getting home and who will later assist him in his needs. The doctors can discharge patients who insist on going home and indicate in their chart that the patients were discharged “against medical advice.” Such annotation helps protect doctors and other health professionals against malpractice lawsuits (Rosdahl & Kowalski, 2007). However, such annotation is not sufficient to excuse a health professional’s behaviour in instances when the patient is not mentally and physically capacitated of discharging himself (Rosdahl & Kowalski, 2007). In instances when the patient is not healthy enough to be discharged, the health professionals can keep the patient in the hospital despite the patient’s desire to be discharged. In this case, the principle of beneficence far outweighs the patient’s right to self-determination (Saks, 2002). In Patient B’s case, he does not appear to have a companion (family or friend) who can assist him in his daily activities. There appeared to be no one else with him to assist him in his possible health needs – including wound care. Clearly, he has not finished the prescribed antibiotic treatment as well. There are already inherent risks in having him discharged against medical advice. He may not be able to care for his wound properly and he would also risk opening and infecting his wound. Since he did not finish his antibiotic treatment, he is at even greater risk of having his wound infected. The RN should immediately consult the patient’s case with the patient’s attending physician and in the meantime, try her best to prevent the patient from leaving the hospital. After the physician is informed, a thorough discussion with the patient must be undertaken and a thorough explanation of the various post-operative health risks has to be fully laid out for the patient (Rosdahl & Kowalski, 2007). Hopefully, with these explanations, the patient would be enlightened about his condition and about the folly of his desire for early discharge. If, despite the clear explanations, the patient still feels that he has to leave the hospital, he must be restrained and prevented from leaving. He is not capable of caring for himself and for his benefit and to prevent harm from befalling him, he must not be allowed to go home (Rosdahl & Kowalski, 2007). The above precautions and actions by the medical staff helps ensure that they were not negligent in their responsibilities and that they did everything in their power to carry out their duties despite the patient’s refusal for further treatment. It shows their vigilance in carrying out their duties and on a more practical scale, it would help protect them from malpractice suits. The patient may sue the hospital for assault or for involuntary confinement; however, the doctors and the medical staff can defend their actions under the principles of beneficence. Case Scenario 3 In this third scenario, the patient is mistakenly administered KCl as a bolus dose by the nurse. This later leads to cardiac arrest and the patient’s subsequent death. The case here is primarily one of malpractice. The question of the two RN’s liability in this malpractice case is a crucial legal question which also needs to be settled. First and foremost, RN Z is liable for malpractice. As a health professional, the nurse has the primary responsibility of delivering the best and the safest care to the patient (Smeltzer, et.al., 2008). She is therefore required to administer all the responsibilities she has towards her patient. In the administration of medications, authors discuss that a nurse must ensure that the 10 Rs are followed. These Rs include: right dose, right patient, right route, right site, right time, right preparation, right administration, and right drug (Jones, 2009). Without checking any of these elements, the nurse must not administer the medication to the patient. In this case, RN Z did not check that she was administering the right medication and the right dose of the patient’s medication. Her actions directly caused the patient’s death. This makes her liable for malpractice in not fulfilling her duties and responsibilities to the patient. A nurse must be vigilant and alert at all times (Jones, 2009). She must double-check all her actions and interventions before she carries them out on her patients. As shown in this case, one error cost a patient her life, and much worse, it cost two children their mother and their sole provider. In evaluating RN W’s liability, she may also be held liable for failing to accompany RN Z to the cubicle to confirm correct administration. Since, W’s responsibility seems to be supervisory, under the principle of respondeat superior she may also be held liable in much the same way as RN Z (Iyer, 2001). As a nurse manager, she may also be held liable for the actions of her subordinate. Nurse managers have to account for the actions of the employees under their supervision to ensure that such duties are being carried out in accordance with the minimum requirements of law and of the ethical practice (Iyer, 2001). The fact that the ED is busy cannot be considered an extenuating circumstance in this case because such is the nature of EDs. It is how RNs and other health professionals work well as nurses under high-pressure situations that set them apart from other health professionals and other professions. If they cannot be counted on to function well under these circumstances, then they cannot be allowed to practice as health professionals. An important ethical principle which applies to this case is the principle of non-maleficence. This principle is basically about “doing no harm” (White, 2004). From the physician’s context, this principle requires physicians to do what is considered beneficial and to avoid that which is harmful to the patient (White, 2004). This same explanation and concept of non-maleficence also applies to the nursing profession. In effect, the nurses must only do what would be beneficial for the patient and avoid that which would harm or cause his further deterioration (White, 2004). In this case, the RN’s act of malpractice caused the patient harm – worse, it caused her death. She therefore is in clear violation of the ethical principle of non-maleficence and should be help legally accountable for her actions. It is important to impose such legal and ethical principles in order to protect the nursing profession. People trust medical professionals. When they go to hospitals or other medical centres seeking medical care, they are already putting their trust in the doctors and the other members of the health care team. They trust that the medical professionals would do their duties as required by law and by the ethical principles of their profession. When incidents like these occur, such trust is somehow reduced or diminished (Westrick & Dempski, 2008). In order to restore such trust, the medical community has to impose the appropriate penalties and hold the appropriate people accountable for their negligence. Only then would such trust be restored in the health care practice (Westrick & Dempski, 2008). It is important to protect and restore such trust in order to ensure that patients would continue to seek medical attention for their diseases. It also helps ensure that nurses and other health professionals who cannot function well in emergency situations are legally held liable and are taught the hard and important lessons of the health care practice (Westrick & Dempski, 2008). Moreover, imposing liability would help improve the vigilance of nurses in their practice. Conclusion Based on the above cases, the importance of the basic ethical principles is highlighted. These principles include: beneficence, respect for autonomy or self-determination, non-maleficence, and justice. In evaluating the different ethical dilemmas presented here, it is important to have knowledge of these ethical principles. These ethical principles applied in the first case when it deemed that the nurse’s actions were illegal and unethical because they violated the principle of self-determination. The second case presented a dilemma between the patient’s right to self-determination and the principle of beneficence. In this ethical conflict, the principle of beneficence shall be given priority over the patient’s right to self-determination, especially in instances when it is apparent that the patient’s actions are detrimental and dangerous to his welfare. Finally, the third case illustrates the application of the principle of non-maleficence. The nurses are liable for malpractice for not checking the type and the dosage of the medicine before administering it to the patient. Based on the above considerations, the actions of the nurses can be resolved and better choices and options for care can be conceptualized and recommended. Works Cited Huber, R., Nelson, W., & Netting, E. (2007) Elder Advocacy: Essential Knowledge and Skills Across Settings. California: Cengage Learning Hwang, S., Gupta, R., Chien, V., & Martin, R. 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