Professional Ethical-Legal Issues - Essay Example

Professional/ Ethical-legal issues Introduction Ethical dilemmas are part of nursing practice ever since the dawn of the profession; nurses have struggled to make the right and ethical decision as well as choices. When Florence Nightingale wrote Notes on Nursing, she discoursed on various ethical issues such as; communication, privacy and the nature of patient need. Similarly, contemporary nursing ethics expects nurses to uphold this and many other nursing principles. Notwithstanding, practicing with integrity has become difficult because of myriad complex nursing choices and pressures that confront nurses during practice (Nightingale, 1992; Ulrich & Zeitzer, 2009). The common ethical dilemma that nurses faces is control versus autonomy, which arises when patients reject nursing care. This poses problems because it contradicts the basic nursing tenet “to do no harm”. When a patient is denied treatment for whatever reason, it is likely that harm will befall them, which means that a nurse will technically have betrayed his/her ethical values (Beauchamp & Childress, 2001). On the other hand, a nurse is under commitment to respect the patient desires; consequently, there appears to be no way for him/her to take action without compromising. Case Study Mrs. Clayton (Not her real name), 65 years of age has been living alone for the last two years, and although her health has deteriorated gradually over the period, she has been reluctant to see a doctor. Her husband passed away one year ago and since then, she has neglected both her health and hygiene. Her daughter and son In-law have tried to convince her to move in with them, but she adamantly refused. Efforts to have her hire a live in house help or nurse have been rebuffed and although she is evidently unwell, she refuses to be assistance attempts. I met her during my internship when I was assigned to work with the adult care-nursing department. She had agreed to see some medical personnel but on condition, her daughter would be present and they would not try to force anything on her. Upon entering her apartment, we noticed evidence of neglect, since dirty clothes, cups and plates were all over the apartment. There was a strong smell or urine and stale food while at the same time she was unkempt with shaggy wild hair, stained clothes and a distinct body odour. She was walking with a limp and kept coughing, sometimes having fits that left her doubled up gasping for breath. Upon examination, she was suffering from a chest infection not to mention possible bacterial and other problems that could have resulted from her neglected state. She appeared malnourished and although it was evident from the dirty dishes that she occasionally took time to cook, her overflowing dustbin suggested she did not at times manage to eat what she prepared. Furthermore, we initially suspected she may also have mental problems, but this was not apparent. She answered our questions coherently enough, but kept bursting into tears when the subject of her late husband was mentioned. The senior nurse offered to give her a physical examination to determine the extent of her chest condition, but she declined. We tried to convince here that we could help and make her more comfortable; nonetheless, she insisted it is was her life and she could do whatever she wanted. It is often difficult for both nurses and physicians to deal with patients who deviate from the norm and opt to ignore their need for care (Kacen, 2005). Clearly, given the ethical conundrum, these cases places physicians in, they are not always supportive (Frenkel, 2013). Despite knowing that they should respect their rights, this does not make it any easier for nurses who have to observe patients suffer even though they can be cured or at least made more comfortable (Verhoef et al., 2008). Typically, patients are characterised into two categories those that can be healed or treated and those beyond medical assistance. When someone in the former category and refuses treatments, nurses are likely to view them as difficult or noncompliance (Madjar et al., 2007). Evidence suggests that health care professionals feel uncomfortable dealing with clients who refuse to accept care, which often can strain the communication between the two parties. This makes it worse since communication often determines if a patient will change their stand or not. A study on women suffering from cancer and opted to reject conventional treatment found that, had they felt the attending medical staff showed concern for their fears, they might have made them more receptive to treatment advances (Citrin et al. 2012). However, when faced with reluctant or stubborn patient, it is easy to lose patience and use manipulative methods to coerce them into agreeing with the “right” cause of actions (Levin, Mermelstein & Rigberg, 1999). This method is not likely to be effective since patients tend to be more open to advice and suggestions after they have been provided with information, and time to adjust to the diagnosis (Elliott, 1992). The experience in this case study puts into context the nature of nursing dilemmas. As health specialists, nurses are accountable for accomplishing health care objectives among which are to promote wellbeing, cure illness and to ease suffering. To this end, there are several ethical doctrines guiding the process; however, these sometimes are in competition and it is difficult for the nurse to decide which should take precedence. Among the key principles in nursing is ethical beneficence, which is the professional duty of the nurse to ensure they provide the patient with benefit (Beauchamp, 2007). However, while the superiority of this principle is not in question, it is rarely clear which potential cause of action is the most beneficial. In the above case study, Mrs. Clayton is undoubtedly in poor physical condition and in urgent need of nursing assistance. However, does this outweigh her desire for independence, she was after all correct in asserting that it was a free country. By virtue of the fact that she is lucid and has a capacity to make reflective decisions, Mrs. Clayton has a right to make her choices even if experts disagree. Therefore, she can freely reject treatment; on the other hand, the nurses involved have a duty to avoid causing harm and it is evident that leaving her in her condition will result in that. The principle of non-maleficence makes it clear that a nurse should ensure harm does not come to the patient, but evidently, in this case respecting the patient’s wishes will be in contradiction to it. According to Carl Elliot, the clinician must be willing to reflect on what action will be of most benefit to the patient and to do this, they must factor in this like the patients desire, beliefs and retrospective life experience (Elliot, 1992). Taking cognisance of these, the decision might be clearer and likely to be accepted by the patient. Nevertheless, while admitting that principles may be used as a means of gaining clarity about a situation, it is important to understand their underlying limitations. They should not be used to rationalise a Laissez-faire approach to nursing especially in situations where open communication can result in a more acceptable course of action. In general, autonomy and decision-making are accepted because humans are capable of thinking through proposed courses of action and they can anticipate not only results but also their impacts. In as much as one may have the right to self-determination, they may lack the capacity to make decisions, especially when they have insufficient information on a particular problem (Appelbaum, 2007). Case Analysis Pamela and Eric (2008) propose three possible scenarios regarding the ability of a patient to make a decision on matters of their health. The first applies when a patient is evidently of sound mental state and can make a decision that either correlate with the clinicians, or that is not likely to cause them harm (Standing, 2010). In the second scenario, it is not clear if a patient has the capacity to make a decision concerning their health and when they do, it may not coincide with their best interest (Hyland, 2002). The third category is one whereby it is self-evident that a patient cannot make a sound decision and, in this case, a member of the family is charged with doing so on their behalf. The first and the last cases do not always result in dilemmas; however, the challenge lies in the second. It is not easy to tell if the clinicians should follow the patient’s judgment or involve a relative since the line between being capable or incapable of making a decision can at times be very vague. Mrs. Clayton engenders the second scenario; her case demonstrates the delicate balance clinicians have to negotiate between protecting the patient from harm or respect their wishes especially when they are not sure about their state of mental health (Bickley & Szilagyi, 2012). We were aware that we could easily determine she was not of sound mind and let her daughter make the decision of providing her with medical care. This would likely involve restraining the patient since she had expressed her desire, not to be a recipient of any care whatsoever. When a patient is unquestionably in control of all their decision-making faculties but declines nursing care, the clinician is bound to look for ways of assisting them in ways they find acceptable. Nonetheless, even when the patient does not appear to be fully in control, any action taken should be according to their wishes unless there is evidence that serious harm would ensue (Noddings, 2013). However, the patients capacity for making decisions should be evaluated periodically rather than on a one-time basis. In some cases, an individual may be thought out to be of unsound mind as opposed to permanently so. In such cases, they have the option of granting someone the power of attorney so they can make such decisions for them. On the other hand, where there is no advance directive, the family will have to produce someone to act in this capacity should the situation demand. In the above case study, despite the fact that there is not sufficient information regarding her refusal to be assisted she is aware that interventions can possibly lessen her pain but she opts to disregard them nevertheless. It is self-evident that in her case, forcing her to a hospital and consequently denying her autonomy might be very distressing for her. It might call for her to be committed to an institution and ultimately undermine her trust. I believe the best option would be to reach gradually out to her by establishing her motives for refusing to be treated. Since she has shown a willingness to answer questions, she can be engaged in a discussion about her health and how her care-refusal affects her family members. Through counselling, she may come to accept treatment or at least hand over the power of attorney to her daughter. Her position left us in a dilemma since we all agreed we could not force her into a hospital without but abandoning her to her own devices was also out of the question. I considered pursuing the option of open communication since as aforementioned as she appeared willing to converse with us quite freely. I requested her to narrate about her grandchildren whom she clearly missed, and she seemed happy to talk about them. In this context, I was able to introduce the ideas of us helping her improve her condition so she could at least visit them. Her daughter told her they also wanted to see her and she would be happy to bring them over. This way we managed to help her think about her health in terms of other people aside from herself. By her own admission, she was not afraid to die, but she seemed touched by the idea that she could be denying her grandchildren her company. She finally acquiesced to an examination and agreed to have a social worker visit her and assist whenever she could. She was however still reluctant to hire a nurse and insisted she wanted to live alone. She had said that she passed out occasionally especially when she got out of bed too fast and we tried to convince her that to avoid such risks, she should have someone to live with. I talked to her about my family, my job and myself, and she seemed genuinely interested and after that and was more willing to share her feelings. She stated that living with someone else in the house would feel like betraying her late husband and although she knew it must sound irrational, it was how she felt anyway. Although we never got her to agree with us entirely, she allowed her daughter to hire someone to be cleaning after her but he or she would only come twice a week. She also agreed to get medical attention for her chest problem although she remained adamant about, not going to a hospital but staying in her house. We easily reached a compromise where her daughter would send her family doctor to see her and make a complete diagnosis the next day. While this particular case was relatively successful, I am aware that things do not always work out like that and sometimes patients can be very unreasonable in the eyes of nurses. To some extent, the fact that we used her grandchildren may come out as manipulative given that as her daughter later told us the children in question did not really know much about their grandmother. However, she saw no harm in exaggerating since it gave her a platform on which to reach out to her mother and in any case; they would be happy to see her nevertheless. I am aware that a nurse or another medical practitioner has no right to make decisions for patients or force them to accept assistance; however, they can provide information. Nurses, given their unique social interaction with patients are in a position to talk to them about both personal and medical issues and how they can affect their health and wellbeing. In the self-care theory of nursing Dorothea Orem stressed on the importance of a patient being self-reliant and able to care for themselves (Orem, 2001). Given that was Mrs. Claytons position, I believe giving her motivation to improve herself with the help of medical professionals would greatly improve her condition. Conclusion By helping her find a basis on which to ground recovery process, we assisted her in both the physical and interpersonal areas, which are all crucial to her well-being. In the end, when faced with ethical dilemmas, nurses in most cases have to choose between their judgment and that of the patient and their relatives. In most cases, the dilemma is escalated when the nurse knows that the patient is making a decision that will ultimately cause them harm but they are forced to respect it. Nonetheless, they can influence the patient to accept care by being more patient with them by listening to their concerns and fears so they can understand their mind set and assume their position. This way, nurses will be better placed to advise and convince patients to accept care without having to take drastic or manipulative action. References Appelbaum, P.S., 2007. Assessment of patients competence to consent to treatment. New England Journal of Medicine, 357 (18), 1834-1840. Beauchamp, T.L., & Childress, J.F., 2001 . Principles of biomedical ethics. Oxford: Oxford university press. Beauchamp, T.L., 2007. The ‘four principles’ approach to health care ethics. 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Verhoef, M.J., Rose, M.S., White, M., & Balneaves, L.G. 2008. Declining conventional cancer treatment and using complementary and alternative medicine: a problem or a challenge?. Current Oncology, 15(2), s101. Read More