The Ethics of Physical Restraint in Critically Ill Patients: The of Monty an Autistic Patient - Case Study Example

The ethics of Physical Restraint in critically ill patients: The case of Monty an autistic patient Introduction Patients who are critically ill are at high risk of the developing agitation and delirium, leading to non-compliance with their treatment (Huai & Ye, 2014; Schrems, 2014). In this case, the employment of physical restraint seems to be an important and simple answer to avoiding interference of this treatment. Black and Boore (2011) indicate that a restraint is an issue that is complex, entailing psychological, physical, ethical and legal issues. One of the laws that protects for the rights of the patient is Mental Capacity Act (MCA). It has provisions on the way the patient is supposed to be handled. Physical restraint to Monty, a patient suffering from autism raises many moral, legal, and ethical questions particularly for all health care workers; therefore, this discussion addresses or Identifies the ethical and legal dilemmas that arise from the scenario. Scenario: The case relates to the story of Monty, a twenty nine year old autistic man. Due to his illness he had been put in intensive care, but was resisting the treatment that doctors considered best for his condition. At the start of the year, Monty was having breathing difficulties and was becoming increasingly withdrawn. Immediately he was transferred to intensive care unit. He was immediately put on antibiotics and after several days showed signs of improvement. With this, doctors stopped the sedation, woke him up, and removed the breathing machine. The plan was for Monty to put on a mask to support his breathing as he was still frail. In fact, doctors indicated that the mask would only be used for a short period of time, while awaiting his full recovery. However, being autistic as he was, immediately the mask is put on his face, Monty pushed it away. The nurse in charge would again struggle to return it. As the nurse persists, the patient also becomes more violent and lashes the mask away from him. Exhausted, Monty starts changing to blue state. Fearing for his life, the medical team re-sedates again and returns him on the breathing machine. Mental health capacity and confidentially According to Brayne and Carr (2010), the overriding principle particularly when dealing with the disclosure of important information of a patient, who is not in the position to make sound decisions, is ensuring that all decisions are made in his or her best interest. Ethical and legal dilemma Andersson and Chapman (2010) argue that normally, a duty of care is always important. Within a designated setting of care setting, medical practitioners owe the patient and his family a legal duty of care. In the case of Monty, the fact that the medical practitioners allowed him to dictate to doctors what needed to be done despite his poor state of health; they had violated or breached the duty of care. It is arguable that, since the medical staff was aware that Monty had a diminished feeling or sense of danger, they should have ensured his safety or should have ensured that he does not wander unattended (Iacobucci & Daly, 2013). By the fact that he removed the masks at their watch which lead to deteriorating state of health, the medical staff would be looked at as having neglected their main duty of care to Monty. In fact, it is arguable that a significant harm was sustained as a consequence or result of the neglect of the duty of care by medical practitioners. In this case, the care team for Monty presents a serious dilemma. That is; on one hand, Monty is lawfully entitled to leave the hospital and any attempt to physically restrain him may be viewed as assault; whilst on the other hand, if he is allowed to leave the hospital and comes to any health problem or harm, the medical staff may be liable or guilty of negligence. That is what happened in the case of Monty. Doctors left him to get out and even removed the breathalyzer and mask. Corvol and Moutel (2013) pont that the best choice would be to justify the restriction of the autonomy of Monty in the light of his diminished perception into the likely consequences of his actions (Bevan & Senn-Reeves, 2012). In this case, the medical care team may maintain that the intention of the physical restraint is to avert harm, and that they have been acting in the best interest of Monty. With reference to recognized literary sources, critically appraise the ethical principles and discuss how they can be applied to the case scenario Ethical principles include; autonomy, beneficence, non-malefficence and justice. Legal and ethical dilemmas arise from issues of informed consent. Life-threatening illnesses usually interfere with the process of making informed decisions, and thus the inability to approach such patients for consent. Consent actually denotes a voluntary agreement and informed consent is actually tied to the principle of autonomy (Diamond, 2005). In this case, by the fact that Monty was in intensive care, he may not have been in the position to make sound decisions about his care. His next of kin were not available either to the decision on his behalf. This, therefore, must have put doctors in a precarious situation of saving his life over and above everything. The issue, according to the case, is that medical practitioners were not able to reach get the consent, but used common sense to provide the much needed care. In addition, it must be understood that this was the only option available apart from the breathing aid in intensive care. Therefore, there were only two choices available to doctors: for Monty to accept the mask or get back to intensive care. However, the option of intensive care can only be used if the patient was actually in critical condition. Consent The Mental Capacity Act (MCA) provides that; for the patients to make an independent choice about their treatment, they must have appropriate knowledge necessary to enable them make sound decisions. Therefore, the amount of information given to the patient concerning the treatment should be considered. According to (Fernandes & Isabel, 2013)there are three standards of information disclosure determined with reference to a reasonable person, the actual patient and professional practice. With all these, the medical standards stipulate that the information should be given by reference to the state of health of the patient. So, what information should patients know before making a decision to the treatment? At a minimum, the patient should know the purpose and nature of the proposed treatment, benefits and the material risks of the treatment, any option to the treatment along with their benefits and risks, the prognosis of the disease if left untreated and the costs associated with treatment. The risks to be disclosed to the patient include; the severe and probable damage of the treatment and the probability of harm occurrence, the more feasible the damage would be considered pertinent by the patient in their benefit-risk examination of the varied treatment options (Newham, Curzio, & Carr, 2014). When looking at the case, this principle was violated as the masks and breathing machines are known to cause discomfort to patients. Such treatment options are usually undertaken under the patient’s consent. Also, Monty had not been briefed on the importance of the mask, or even the breathing machine. From the case, he was just struggling to remove the mask and had resisted the machine, because he did not understand their importance. Ethical Principles Beneficence This principle stipulates that professionals have the responsibility to take actions that benefits others. The main responsibility of physicians and other people connected directly to the health care facility is to offer service; to both patients and their families. The most essential aspect of this responsibility is the timely and competent delivery of medical care within the domains of clinical settings presented by patients, with consideration being expended to the values, needs and desires of patients. The same ethical principles apply whether the healthcare practitioner engages in managed care, fee-for-service or some other medical arrangement (Tamayo-Velázquez & Simón-Lorda, 2012). Justice Kangasniemi and Papinaho (2014) state that justice is a term that concerns the way people are treated. The treatment could be fair or worse. In deliberating on distributive Justice, the main concern emphasizes on who gets the treatment and who actually determines the medication to be administered. Justice is actually concerned with the decision based on the need, and prognosis (Diamond & Barker, 1996). Justice specifically relates to issues of equity and fairness in treatment. Autonomy The Mental Capacity Act (MCA) indicates that autonomy mainly refers to the right of independence and self-determination. In the health-care environment, it means that the medical practitioners are compelled to respect the rights of patients to make decisions concerning the patients (Ramsey & Mezey, 2009). Under this right, medical practitioners might only interfere when they have enough evidence that the patient does not have the capability to understand. Under autonomy of patients, medical practitioners have no obligation to help people to undertake damaging deliberations, nor do they have the responsibility to help people to cause damage to themselves (Park, 2012). Furthermore, the informed consent principle is entrenched in autonomy. Non-maleficence Byrd and Winkelstein (2014) non-maleficence means using an approach that inflicts the least harm to patient. The principle of non-maleficence is always an option when treatment is feasible (Andersson & Chapman, 2010). In the case of Monty, physical restraint is the best alternative to save his life; therefore, the committee does not make any mistake by putting him under restraint. In addition, the institution or use of breathing mask aligns with the non-maleficence principle. It inflicts least pain to the patient. According to Schrems (2014) providers of care must always question the likely harm and advantages of technology in situations of critically ill patients whose prognoses are actually poor. In such cases, use of technology usually inflicts additional pain and suffering and may result in unconstructive outcomes. In Monty’s case, for a disorder mostly considered to be life-threatening, the non-maleficence principle combined with the beneficence principle should guide medical practitioners in arriving at the best care plan for him. According to Corvol, Moutel and Gagnon (2013), the choice of treatment should have minimal damage to the patient and avert elongation of a treatment. The Mental Capacity Act (MCA) also indicates that it is vital to not just respect, but also support the wishes advanced by members of the family who may request continuation of different interventions, palliative and technology. Buzgová & Ivanová (2011) say that it is challenging to balance the wishes of family members and appropriate intervention. Explore the legal issues within the case scenario, referring to relevant case law / statute Conventionally, care providers have sought to rationalize the extensive employment of restraints under a range of situations. Some of these situations comprise avoiding patient relapse or preventing the patient from disrupting prescribed therapies. The key reason for employing restraints as expressed by care providers is that there is anxiety concerning potential personal exposure to legal liability and litigation, in the event that patients who are unrestrained injure themselves and litigate. Case Law Case law has some provisions that touch on physical restraint. However, to a larger extent, the laws that are specific to health care providers are highly mixed. Muthuswamy (2011) observes that the clinical evidence that many physician-caused injuries are as a result of dependence on restraints. There have been legal judgments rendered, as well as settlements negotiated based on the ordering of restraints inappropriately, failure to not just monitor, but also correct their negative impacts on the patients (Cerit & Dinç, 2013). The Mental Capacity Act (MCA) The act functions as a base upon which people can directly or indirectly make informed deliberations. Alternatively, the law also takes into consideration those who do not have the capacity and want to actually make preparations for a directive to be executed in future time, when they are not of sound health to make sound decisions (Monteverde, 2014). The MCA act clearly sets out who can make decisions, and the situation under which decisions are made. The Act and applies to every person; ‘mainly those residing in Britain’. The act provides that Every adult has the right to make their decisions and are therefore presumed to have the capacity to execute their decisions unless it is determined otherwise (Settle, 2014). Therefore, it eliminates the presumption that someone is not in the position of making a sound decision just because he or she has a particular disability or medical condition. Every person has the right to make his decision regardless of what others might think. Everyone has their beliefs, preferences and values, which may not actually be the same as what other people have. The act also provides that people must actually be supported by all means to make deliberations before reaching a conclusion that they are unable to make sound decisions. The act in fact envisages that people will always take it upon their initiatives to encourage the sick person to make sound decisions. The act indicates that anything undertaken on behalf of an incapacitated person must be in his or her best interests. Before executing the decision or an act, the person acting on behalf of an incapacitated person must act in a way that is less restrictive or that does not infringe on the freedom and rights of the incapacitated person. Ethical theories Consequentialism Consequentialist school of thought holds the assertion that the correct moral reaction is linked to the consequence or outcome of the action (Monteverde 2014). Therefore, the main objective is maximizing the greatest benefit for the majority of the affected people. Consequentialism, as an ethical theory, is very attractive as there is usually an outcome, as well as the correct moral reaction. Ivanhoe (2000) argues that the theory also has its shortcomings. It has restrictions as it can endorse actions which would be in contravention of individuals’ rights. Principlism principlism is an ethical approach that is commonly used in healthcare.  The theory of principlism emphasizes four vital ethical principles (beneficence, autonomy, justice and non-maleficence) (Grasso, 2013). This theory espouses the ethical principles earlier mentioned with practical wisdom and virtues.  According to Holm and Severinsson (2014), the theory attempts to bring together all elements of ethical theories, especially those that are compatible with most individuals, societal, as well as religious aspects.  Corvol and Moutel (2013) by entrenching virtue ethics which makes it able for professionals in the healthcare sector, as well as patients to place value on any useful principle to strike a balance as well as rationalize for making decisions. Confidentiality Buzgová and Ivanová (2011) indicates that the right to confidentiality particularly of information relating to the patient must be respected. In this case, the information relating to Monty was respected. This is because; Monty is not his real name. Basing on the provisions of the Mental Capacity Act (MCA), if it were the real name, the committee would have violated the right of confidentiality of information. Also, the committee kept most of the private dealing with the patient confidential. Conclusion In critically ill persons, especially those who need treatment that is not used regularly, ethical questions usually arise. For medical practitioners to be able to administer the medication on time, they usually demand that the sick person makes the decision to ascertain that it is what he or she needs. Since in most cases patients are not able to make sound decisions, their kinsmen are used to make it their behalf. However, this is only used if the care providers are contented that the decision made captures the wishes of the sick person. In addition, it looks as if he was in a state that would not allow communication between him and medical practitioners. This is depicted in the way he was acting. References Andersson, G., and Chapman, J., 2010. The Balance of "Beneficence" and "Non-Maleficence". Spine, 35, S2-S8. Bevan, J., and Senn-Reeves., 2012. Critical social theory approach to disclosure of genomic incidental findings. Nursing Ethics, 19(6), pp.819-828. Black, P., and Boore, J., 2011. The effect of nurse-facilitated family participation in the psychological care of the critically ill patient. Journal of Advanced Nursing, 67(5), pp. 1091-1101. Brayne, H. and H. Carr, B.A., 2010. Law for social workers. Oxford: Oxford University Press. Buzgová, R., and Ivanová, K., 2011. Violation of ethical principles in institutional care for older people. Nursing Ethics, 18(1), pp.64-78. Byrd, G., and Winkelstein, P., 2014. A comparative analysis of moral principles and behavioral norms in eight ethical codes relevant to health sciences librarianship, medical informatics, and the health professions. Journal of the Medical Library Association, 102(4),pp. 247-256. Cerit, B., and Dinç, L., 2013. Ethical decision-making and professional behaviour among nurses: A correlational study. Nursing Ethics, 20(2), pp.200-212. Corvol, A., and Moutel, G., 2013. Ethical issues in the introduction of case management for elderly people. Nursing Ethics, 20(1), pp.83-95. Corvol, A., Moutel, G. and Gagnon, D., 2013. Ethical issues in the introduction of case management for elderly people. Nursing Ethics, 20(1), pp.83-95. Daniels, N., 2008. Just health: meeting health needs fairly. Cambridge: Cambridge University Press. Diamond, B., 2005. Legal aspects of nursing. 4th ed. Essex: Pearson Education Limited. Diamond, B. and Barker, F. 1996 Mental Health Law for nurses. Oxford: Blackwell Science Ltd. Fernandes, Maria; Moreira, Isabel. 2013. Ethical issues experienced by intensive care unit nurses in everyday practice. Nursing Ethics, 20(1), pp.72-82. Garber, P., 2008. The ethical dilemma. Amherst, Mass: HRD Press. Grasso, M., 2013. Climate ethics: with a little help from moral cognitive neuroscience. Environmental Politics, 22(3), pp.377-393. Holm, L., and Severinsson, E. 2014. Reflections on the ethical dilemmas involved in promoting self-management. Nursing Ethics, 21(4), pp.402-413. Huai, J., and Ye, X. 2014. A meta-analysis of critically ill patients reveals several potential risk factors for delirium. General Hospital Psychiatry, 36(5), pp.488-496. Iacobucci, T., and Daly, B. 2013. Professional values, self-esteem, and ethical confidence of baccalaureate nursing students. Nursing Ethics, 20(4), pp.479-490. Ivanhoe, P., 2000. CHARACTER CONSEQUENTIALISM: AN EARLY CONFUCIAN CONTRIBUTION TO CONTEMPORARY ETHICAL THEORY. Journal of Religious Ethics, 19(1), pp. 55-58. Kangasniemi, M., and Papinaho, O., 2014. Nurses’ perceptions of the use of restraint in pediatric somatic car. Nursing Ethics, 21(5), pp.608-620. Monteverde, S., 2014. Undergraduate healthcare ethics education, moral resilience, and the role of ethical theories. Nursing Ethics, 21(4), pp.385-401. Monteverde, S.,2014. Undergraduate healthcare ethics education, moral resilience, and the role of ethical theories. Nursing Ethics, 21(4), pp.385-401. Muthuswamy, V., 2011. Ethical issues in genetic counselling with special reference to haemoglobinopathies. Indian Journal of Medical Research, 134(4),pp. 547-551. Newham, R., Curzio, J., and Carr, G., 014). Contemporary nursing wisdom in the UK and ethical knowing: difficulties in conceptualising the ethics of nursing. Nursing Philosophy, 15(1), pp.50-56. Park, E.-J., 2012. An integrated ethical decision-making model for nurses. Nursing Ethics, 19(1), pp.139-159. Ramsey, G., and Mezey, M., 2009. ethical Issue of Elder care. Institute of geriatric Nursing ,1-8. Schrems, B., 2014. Informed consent, vulnerability and the risks of group-specific attribution. Nursing Ethics, 21(7), p.829-843. Schrems, B., 2014. Informed consent, vulnerability and the risks of group-specific attribution. Nursing Ethics, 21(7), pp.829-843. Settle, P. D., 2014. Nurse Activism in the newborn intensive care unit: Actions in response to an ethical dilemma. Nursing Ethics, 21(2), pp.198-209. Tamayo-Velázquez, M.-I., and Simón-Lorda, P., 2012. Euthanasia and physician-assisted suicide: Knowledge, attitudes and experiences of nurses in Andalusia (Spain. Nursing Ethics, 19(5),pp. 677-691. Read More