Nursing Dilemma Situations - Term Paper Example

Case Study on Ethical Dilemma in Nursing Nurses play an important role in the health promotion of an individual due to their direct contact and proximity with the patients. The 3 basic roles of a nurse are that of a practitioner, leader and researcher. As a practitioner, the nurse attends to all the medical needs of the patient and as a leader she takes decisions which relate to, influence and facilitate the actions of others with an aim to achieve a particular goal. As a researcher, the nurse aims to implement studies to determine the actual effects of nursing care and to work towards further improvement in nursing care (Nettina, 2006). In order to impart these duties in the most appropriate manner, nurses must not only possess sound knowledge of the subject, they must also be aware of ethical laws and legislations and how to handle ethical dilemmas. This is because, through their career, nurses encounter many situations which are tangled in ethical complexities. As Hall (1992; cited in Silva and Ludwick, 1992) rightly put it "the ethics incorporated into good nursing practice are more important than knowledge of the law; practicing ethically saves the effort of trying to know all the laws." Clinical ethics literature pertaining to nursing profession identifies four important values and principles, namely, respect to autonomy of the patient and to act with nonmaleficence, beneficence and justice (Nettina, 2006). Awareness of these principles helps in solving issues with ethical dilemmas. In this article, resolution of an ethical dilemma pertaining to an elderly cancer patient in palliative care will elaborated based on ethical laws and nursing code of ethics, in the context of review of concerned literature. Problem 53 year old Mrs. Cheng is admitted to palliative care ward with history of bowel cancer and liver metastasis. The old lady is the last surviving member of her family and her expected lifespan is one month. Mrs Cheng is a chain smoker and she sees no meaning in giving-up this enjoyable thing in the last phase of her life. She smokes about 25 cigarettes a day. Since she cannot smoke inside the hospital, she is taken outside the ward in a wheelchair and each time this consumes 12 minutes of the care-taking nurse time. Nurses taking care of Mrs. Cheng object to the fact that she needs to smoke because it is not only bad for health, but it also disrupts care of other patients due to increased consumption of time on the part of nurse. However, Mrs. Cheng wants to continue to smoke and this had led to a situation of ethical dilemma. In this essay, a solution to this problem will be discussed with reference to rules and regulations that guide the practice of nursing Four principles of nursing practice The main moral issue in Mrs. Cheng is smoking in palliative situation despite distortion of time management and care of other patients. Mrs. Cheng needs smoking for solace and enjoyment and she cannot be stopped from doing that because she is in end-of-life situation. At the same time she cannot be allowed to smoke in the ward because of hospital policy of 'non-smoking in wards'. Thus allowing her to smoke means that she needs to be taken out which is very time consuming for the nurses. Nursing care is basically based on four ethical principles, namely, beneficience, nonmaleficence, respect to autonomy of the patient and justice. The principle of beneficence comes across in everyday nursing practice. The term beneficence actually connotes acts of merciness, charity and kindness which are suggestive of love, humanity, altruism and promotion of good to others (Stanford Encyclopedia of Philosophy, 2008). This broad notion is a principle or rule when it comes to medical profession. Nurses have a moral obligation to act in ways which benefit others. Thus, the nurses must consider what benefits Mrs. Cheng and not what benefits them. Also, the patient deserves "autonomy". Thus Mrs. Cheng has the right to smoke. In a stage when there is day-to-day deterioration and it appears that death can happen any time, holistic patient comfort and care must be ensured by managing symptoms, giving minimal drugs, upholding her wishes, alleviating anxiety and fear and addressing her religious and spiritual needs (National Cancer Control Programme, 2005). When political correctness demands that we embrace change with enthusiasm there is a strongly held view that nursing, along with many other professions, struggles with a theory gap practice (Rolfe et al, 2001). The nurse has a duty to promote what is best for the patient, ensure that the patient's needs are met and protect the patient's rights (Nettina, 2006). Each country or state has its own rules and regulations as far as legal considerations in the provision of palliative is concerned. The nurse must be aware of these and implement them in their daily practice. Mrs. Cheng has the right to be from any physical restraint imposed on her like 'no smoking'. According to the principle of non-maleficence, allowing Mrs. Cheng to smoke in the wards may harm other inmates because of passive smoking and not allowing her to smoke may decrease solace to her. Thus Mrs. Cheng must be allowed to smoke outside the wards. Justice to Mrs. Cheng can be provided by upholding her only wish of smoking. Thus, based on these cardinal principles of nursing Mrs. Cheng must be allowed to smoke and that too outside the wards. Identification of ethical conflicts Mrs. Cheng is in end-of-life situation due to colon cancer. Patients with this condition develop many symptoms which cause great discomfort and despair not only to the patient but also their dear ones. The only solace to such patients would be to provide a comprehensive care which takes care of the physical, psychological, emotional, spiritual and religious needs of the patients so that they lead a peaceful life until their death. Such a care is known as palliative care. The aim of palliative care must be to relieve the patient of suffering, promote function of the patient, deliver help to meet the daily living needs of the patient, provide psychosocial support to the patient and also the family of the patient and clarify goals of care and associated treatments (WHO, 2009). Since Cheng has no relatives or friends, her only solace in life is smoking which she has been enjoying for many years. In this end-of-life situation, smoking becomes a necessity because cessation of smoking causes significant withdrawal effects like irritability, frustration, anxiety, restlessness, inability to concentrate, anger, depression, disrupted sleep impatience (Surgeon General Report, 1990) and light headedness (Munafo, 2002). The very purpose of admission to palliative care is defeated if Mrs. Cheng develops these symptoms which deteriorate quality of life. However, smoking in her case is time consuming for nurses. Thus, there is an ethical dilemma as to whether Mrs. Cheng must be allowed to smoke or not. Considering the Law According to the Australian Nursing and Midwifery Council Code of Conduct for Nurses, "nurses respect the dignity, culture, ethnicity, values and beliefs of people receiving care and treatment, and of their colleagues." Thus, "nurses promote and protect the interests of people receiving treatment and care. This includes taking appropriate action to ensure the safety and quality of their care is not compromised because of harmful prejudicial attitudes about race, culture, ethnicity, gender, sexuality, age, religion, spirituality, political, social or health status, lifestyle or other human factors." Also, "in making professional judgements in relation to a person’s interests and rights, nurses do not contravene the law or breach the human rights of any person." From these principles of Nursing Code of Conduct, it is evident that the main intention of the nurses taking care of Mrs. Cheng must be to respect her decision of smoking and allow her to smoke, keeping in mind her interest to smoke and uphold her wish to do so. Since passive smoking has risks of health hazards, smoking must be done away from the wards. The relationship between a nurse and a patient is of therapeutic nature and based on the provision of care, guidance and assistance of the patient (Neal, 2007). It is shaped mainly by four concepts namely, trust, power, intimacy and respect (Neal, 2007). Trust is a critical concept in the nurse-patient relationship because, the patient is in a vulnerable position and the patient places trust in the nurse as soon as he or she enters the health care setting. As such, illness makes an individual vulnerable and this is exaggerated in the presence of unfamiliar surrounding, relationships and situations. In the example presented, Mrs. Cheng is in a vulnerable situation and she put trust in the palliative care unit. Trust in this relationship is largely based on the assumption of the fact that the nurses are skilled and knowledgeable and will excise these aspects in dealing with the patient. Trust in a nurse-patient relationship improves care and reduces stress. According to Mok and Chiu (2004), "Trust, the achievement of the goals of patients and nurses, caring and reciprocity are important elements of nurse–patient relationships in palliative care." Nurses stay with the patients through their journey of illness to death. Thus, it is easy for them to connect to patients and establish a relationship with them. Only by establishing such a relationship will the nurses be able to deliver the best possible care and meet the levels of satisfaction of the patient. According to ANMC (2008), "nurses develop and maintain appropriate and current quality nursing advice, support and care for each person requiring and receiving care and their partners, families and other members of their nominated social network. This responsibility also applies to colleagues of nurses." Another important concept is power and this is not equal in the nurse-patient relationship (Neal, 2007). The patient is in a vulnerable position and the nurse is skilled and privileged with information and specialist knowledge. It is because of these qualities that it becomes paramount for the nurses to perform duty with the interests of well-being of the patient. It is often not easy to use professional power easily by the nurses. This is because, nurses have varying traits and values. At the same time, different patients demand needs in a different way. Thus a nurse must ascertain the needs of the patient and respond in a manner that is sensitive and acceptable. Nurses must respect Mrs. Cheng and her decisions about health care, keeping in mind that there are many restrictions. Respect can be developed by recognizing the worth of the patient. They must however not support illegal practices (Neal, 2007). Smoking outside the ward premises is not illegal. It is very important to maintain dignity in end-of-life situation like that of Mrs. Cheng. Upholding of dignity of the patient can be done by upholding the wishes of the patient. According to the Code of Ethics for Nurses in Australia, "nurses value a culture of safety in nursing and health care" and "value a socially, economically and ecologically sustainable environment promoting health and well being." Thus, nurses "actively preserve the dignity of people through practised kindness and by recognising the vulnerability and powerlessness of people in their care." Ethical decision-making Through application of laws as discussed above, Mrs. Cheng has the right to smoke and smoking seems to be the only source of solace in the end-of-life situation. Thus nurses have a moral obligation to uphold the wish of the patient and preserve dignity rather than consider consummation of their time. Actions of care, appropriate attitudes and trustworthiness not only establish a connectedness with patient, but also help in the improvement of physical and emotional state and help them go through the journey of death with peace. According to the National Competency Standards for the Registered Nurse by ANMC (2008), "a registered nurse must "comply with relevant legislation and common law" and "fulfils duty of care." Thus, the nurse must "identify and explain effects of legislation in the area of health" and "recognises the responsibility to prevent harm." To facilitate time management, nurses can delegate the task of taking the patient out of the wards to a ward boy or nursing assistant, so that care of other patients is not affected and at the same time the wish of the patient is upheld. This is known of delegation of task. Also specific timings can be allocated for smoking and the patient can be involved in taking such decisions. The Code of Ethics directs that "nurses value informed decision making." Thus, "nurses value the legal and moral right of people, including children, to participate whenever possible in decision making concerning their nursing and health care and treatment, and assist them to determine their care on the basis of informed decision making." These principles need to be applied in the perspective of respect for life, acceptance of the fact that death is inevitable, provision of treatments which take care of the ongoing suffering, striving to preserve life only as long as life is not a burden and beyond that only asserting life, and also individual needs and that of the society (National Cancer Control Programme, 2005). Conclusion Nursing dilemma situations are very common in nursing practice. Most of the times, application of principles of nursing ethics help resolve the situation. Thus it is important for every nurse to be aware of nursing laws and ethics so that they can be guided by them in case of dilemmas. References Australian Nursing and Midwifery Council. (2008). Code of Conduct. Retrieved on 20th May, 2010 from http://www.anmc.org.au/userfiles/file/New%20Code%20of%20Professional%20Conduct%20for%20Nurses%20August%202008%281%29.pdf Australian Nursing and Midwifery Council. (2006). National Competency Standards for the Registered Nurse. Retrieved on 20th May, 2010 from http://www.anmc.org.au/userfiles/file/competency_standards/Competency_standards_RN.pdf Australian Nursing and Midwifery Council. (2008). Code of Ethics for Nurses in Australia. Retrieved on 20th May, 2010 from http://www.nursingboardtas.org.au/domino/nbt/nbtweb.nsf/v-lu-all/Practice+Standards~ANMC~ANMC+Code+of+Ethics+for+Nurses+August+2008+/$FILE/Code%20of%20Ethics%20for%20Nurses%20August%202008.pdf?OpenElement Health Benefits of Smoking Cessation: A Report of the Surgeon General. (1990). 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