make choices. Alternatives are based on what one perceives to be precise or wrong depending on his or her upbringing, spirituality, and background. Other factors include peer group values and unique individual characteristics. Challenges in the decision making process arise when those friends or co-workers around us have a different view of morality that what we hold. No matter the extent of conviction, one feels that his or her choice is the correct one, it is wrong to impose ones views on another individual. In such a case, it is not about what is right or wrong, but what is admissible depending on the perspective of the decision maker.
No matter the individual opinions, employers have a code of conduct that they expect their employees to follow while conduct their duties. In the nursing profession, the National Association of Social Workers (NASW) code provides the guidelines. Other standards that the nurses have to adhere to are clinical ethics. Clinical ethics relate to the dilemmas that occur when intricate clinical choices have to be made. Such issues arise, especially at the beginning and end of life. The role of nurses in supporting patients and families when they encounter such a dilemma is paramount to their profession.
Self Evaluation Paper
Case I: To inform or not to inform
During the period of my internship at the Princess Margaret Hospital (PMH) in Bahamas, I have come across many cases that present an ethical dilemma for both the nurse and the physician involved. For example, a forty seven year old woman was admitted in the hospital with ingestion, vomiting, and weight loss related problems. As part of the diagnosis, the doctor ordered a barium x-ray and a gastroscopy. The diagnosis revealed that the woman was suffering from advanced gastric carcinoma. Gastric carcinoma is a very common cancer and kills about 700, 000 people each year. Based on the advanced stage of the cancer, the doctor gave the patient a prognostic estimate of six months. The surgeons recommended a palliative operation to reduce the stenosis. After a discussion with the womans husband, the doctors and the husband decided not to reveal the prognosis to the woman because she had a phobia about cancer (Barnett, 1986).
During the week that the patient was scheduled for the operation, I was working the night shift. I developed a relationship with the patient because she required a lot of physical care. She also wanted accompany for prolonged hours during the night because she hardly fell asleep. The next week after operation, I was working day shift. When I returned the patient greeted me warmly and seemed happier and more energetic that the previous week. After chatting with the patient for several minutes, she revealed the truth about her fears. She disclosed her fears that her husband and doctors are hiding something from her. She also revealed that even though the doctors were lying she knew I would tell her the truth because she had come to trust me through the many conversation and time we spent together. Having the knowledge about her fear of dying from cancer, I decided not to reveal the prognosis to her but seek permission from the doctor and family members first (Barnett, 1986). She continued insisting saying that she was not afraid to die as long as it was not cancer.
Explaining her situation to her would likely induce severe stress, however, I was available for the rest of the day and week to provide support. After interrupting our conversation, I proceeded to discuss the issue first with her sister who was within the premises. The sister rejected my offer to reveal this information to her but promised to discuss the issue with the concerned doctor. The husband rejected my offer to reveal the information to his wife. After a few days, the patient was discharged from the hospital without the knowledge of her prognosis. I was not able to continue our conversation, which left me feeling guilty and inadequate. The dilemma in this example is that though the patient is able to make her own decisions, her family and doctor decides not to reveal important information pertaining to her health. As a nurse, I have the opportunity to take care of the patient, however, I lack the authority to make decisions on what to reveal and what not to reveal to the patient regardless of his or her capacity to make her own decisions (NASW).
Relation of the case to the NASW code of ethics
The nursing profession fall under the category of the social work profession thus is guided by the NASW code of ethics. The primary mission of social workers including nurses is to enhance the wellbeing of people with particular attention to the vulnerable groups. When considering scenario such as the episode of a woman suffering from gastric carcinoma, it is clear that the events as they unfold violent several ethical standards. The first and most important responsibility for the social worker is his or her responsibility to the client. In this case, the client is the hospitalized woman. Nurses must always hold clients interest as primary and any other as secondary to them except in special cases where the interest of the client place other in harm. In the example, the client wants to know what she is suffering from and how much time she has left. This is primary and does not place anyone in harm. Failure to inform the client violates not only the NASW code of ethics, but also the trust the client places in the profession (NASW).
The failure to inform the patient about her specific health condition limits her role in the decision making process because she does not have the full information. After diagnosing the patient with cancer, the surgeon goes ahead and decides to carry out a palliative operation to reduce the stenosis. Without the full information about the disease the patient is suffering from, she consents to the operation without understanding the extent and intent of the operation. This violates the self-determination and informed consent ethical standards. The self-determination requires that the nurses promote and guide the patient in making the right decision depending on the patients goals. Informed consent requires that the nurse provide services to the patient after the patient understands the purpose, the risks, and limitation of the service. Not revealing nature of the disease the patient is suffering from limits her capacity to make an informed consent and her right to self-determination (NASW). The patient is well able to make her own decisions without a third party. A social worker has the responsibility of ensuring the interest of the patient are protected even in instances in which the patient is incapable of making decisions.
Ethical analysis of the case in relation to the code of ethics and impact on perspective and future action
The nursing profession has standards that members are expected to meet, which are referred to as professional ethics. Numerous documents explain the expected the expected governmental ethics of active nurses. Some of these include the penal code, the NASW code of ethics, and requirements issued by the Bahamas Medical Council for nurses practicing in Bahamas. Failure to follow these laws and regulation may result in disciplinary action, which may include suspension of a nursing license. A practicing nurse is expected to be familiar with the pertinent laws. Examples include appropriate attire at work, procedure for reporting errors, and maintain privacy (Park, 2009). Other policies under development in many institutions include the use of social media and the visibility of body art in the work environment.
Nurses have the option to opt out of a procedure or patient care when they feel that it is in conflict their personal morals. However, the nurse has this alternative if there is someone else to make available the care required by the patient. Certain clinical ethical issues do not have a single clear expectation of how the nurse, patient, or family should respond. The right choice usually varies on a case-by-case basis. In such cases, there are many right answers and each deserves exploration with the right amount of deliberation and contemplation. The role of the nurses in such cases is not to advise the patient or relatives what to do or present opinions for or against a certain choice. Rather, the nurse should respectfully guide the patient or family through the process of analyzing the available options. Nurses must always remember that their interaction with the patient and family is limited to the particular moment in the life of the patient when he or she is receiving care in the hospital. However, the decision made by the patient or family during these moments resonate with them after the end of the clinical episode and the rest of their lives (Barnett, 1986).
Nurses have the unique opportunity of not only giving physical care to the patients, but also psychological care required by the patient. Disclosure may be an issue in some cases, however, the involved parties must recognize that the most important thing is not withholding information from a capable patient or family member, but revealing the information in a skilled manner and having the necessary support available. There is no doubt that better management of such a scenario can prevent the distress and conflict associated. Nurses are accountable for the physical and psychological care of the patients when in the hospital. If their contributions to the continuation of relevant care are not considered, they lose the satisfaction and esteem associated with the profession. Not consulting nurses in the making of ethical decisions not only lower the moral of the nurse, but also reduce the quality of care available to patients (Park, 2009).
An important resource that the nurse has is to give the patient the relevant information pertains to the disease or condition the patient is suffering from and the available treatment or coping plans. Input by nurses demonstrates that providing relevant information to the patient, especially after surgery improves the rate of recovery and reduces discomfort. Honestly answering the patients questions also help reduce anxiety. The failure to involve the nurse when making a decision with an ethical bearing creates a problem of dual loyalty, especially when beliefs of the nurse are different from those of other in the medical team. It is the role of the nurse to ensure that the patient has adequate information to give a valid consent. This not only enables the nurse to play his or her role as the patients advocate, but also enables the nurse to play his or her professional role of ensuring the patient makes decisions based on adequate information (Park, 2009).
Case II: Ms. Browns Case
Ms. Brown was an Acquired Immune Deficiency Syndrome (AIDS) patient. The disease is in the late stages of development. As the nurse treating Ms. Brown, she told me that the pain she was experiencing was too much, that she could not bear it anymore. She also wanted her family to know that she did not wish for Cardio Pulmonary resuscitation (CPR) if she died because she wished to die in peace. Due to her psychological status related to her disease, Ms. Brown could not completely sign a DNR (Do-Not-Resuscitate) Order. Her daughter, Mercy, also refused to sign the order, claiming that she could not stand to see her mother die, that she wanted the hospital staff to do everything they could for her poor mother. Thus, the main problem in this case is that, Ms. Brown was dying of AIDS and because of her mental status; the hospital has not been able to have a DNR signed. The patients daughter declined to sign the DNR in favor of a CPR performance by the medical practitioners in case of a cardiac arrest, irrespective of her mother's wishes. Mercy even threatened to take a legal action against the hospital if the staff did not grant her wishes.
Refusing to carry out a CPR does not conflict a nurses personal values, cultural or religious upbringing. In this case, I personally believed that Ms. Browns autonomy in decision-making should be considered significantly, despite her current mental or psychological status. The initial response in this case was to hand over the issue to the hospitals Ethics Committee and then drop a line to the Risk Management, although there was a possibility of honoring the wishes of either party involved, that is, perform a CPR I favor of Ms. Browns daughter or just follow Ms. Browns wishes. The decision to involve the Ethics Committee was because such teams are multidisciplinary, and they play a significant role in training, recommendation of new policies as well as changes in the current ones, and consultation. Ethics Committees are great resources in solving ethical issues such as Ms. Browns.
Using the NASW Code of ethics, illustrate how these cases were related to those standards
The NASW offers a set of standards to direct conduct and decision-making when a nurse faces ethical issues like the ones discussed above. However, these standards do not specify the standards, principles, and values that are most imperative in such situations, or the ones that should outweigh others in situations of ethical dilemma. Logical differences occur among nurses regarding the methods in which ethical standards, principles, and values should be ordered whenever they conflict. An ethical decision in Ms. Browns situation ought to apply a well-versed judgment of an individual social worker. Such a decision should also reflect on how the problem would be judged from a close assessment process, which involves the applicability of professional ethical standards.
The interests of the patient form the primary responsibility of a social worker, where the prime responsibility of a social worker is to promote the well-being of the client. In Ms. Browns case, it is apparent that the client was not in the capacity to offer an informed consent due to her state. It was therefore an excellent move to safeguard the interests of the patient by including a third party, in this case the Ethics Committee as well as the Risk management personnel. These are reasonable steps to consider, bearing in mind that the two parties involved acted in a way that is consistent with the interests and wishes of the patient. This clearly indicates the commitment and ethical responsibility of the nurse to the patient. On the standard of responsibility to colleagues, NASW emphasizes on the importance of collaboration between a social worker with their colleagues as well as with colleagues from other professions in times of ethical dilemma. Interdisciplinary relationship is also an imperative aspect of consideration in such cases, as social workers are a part of an interdisciplinary group of individuals. The case of Ms. Brown surely necessitated the participation and contribution of this interdisciplinary team since the ultimate required decision concerning the issue affected the clients well-being. Such decisions draw on the values, experiences, and perspectives of the social work profession itself (Corley, 2002).
In addition, Ms. Browns case clearly required some consultation as it was a case of great magnitude. The Ethical Committee is one of the agencies with remarkable and necessary skills and knowledge to handle most ethical issues that practitioners face in the course of their work. The committee is charged with the responsibility of setting appropriate, culturally sensitive, and clear boundaries in which social workers ought to operate (Corley, 2002). The code of ethics also emphasizes on the importance of confidentiality on matters regarding the patients and clients that a social worker deals with. Ms. Brown had clearly demanded that her family be told of her wishes and this is why it was right to inform the daughter about her mothers wish. However, because of the conflict between the wishes of the two family members, it was not appropriate to just consider one side and ignore the other. This was a matter of great concern and it was crucial to hold consultations, discussions, and collaborations from the concerned teams in order to come up with appropriate actions that are legally binding, since the daughter had threatened a legal action against Princess Margaret Hospital. This would ensure a thorough, accurate, and precise charting of the event (Butts & Rich, 2008).
Ethical analysis of impacts of the theories learnt and the code of ethics on personal perspective, response, or future action in similar cases.
Several hypothetical frameworks steer around ethical or value dilemmas in a clinical context. Some of these theoretical frameworks are usually provided from a historical point of view, while others impose a significant impact on the way decisions are made in the present clinical setting. Virtue principles are based on the peoples beliefs regarding what is required of them to be moral. Examples of these virtues include honesty, courage, and compassion, and there exist certain values to adopting some virtues and making efforts to live up to individual ideals (American Society for Bioethics and Humanities, 2011). As a matter of fact, this can result to stress or frustration since people fall short of their personal insights of perfection. Additionally, there could be problems when people have diverse virtues that they deem most important.
Nurses face major challenges in their efforts to assist clients and their families, or to assist their colleagues when coping with value or ethical dilemmas. In this context, a hospitals Ethical Committees serve a major purpose and their interventions have been proved remarkable. Consultations on health care ethics is a collection of services that are provided either by individuals or groups in response to issues arising from families, patients, healthcare professionals, surrogates, as well as other parties involved in seeking to resolve conflict or uncertainty concerning value-laden issues that arise in the healthcare profession (Butts & Rich, 2008). The Ethics Committee plays an important role in helping when the value conflict situations emerge, providing resolutions, but not answers on what ought to be done. There are a number of ways to carry out consultations, which may depend on the intensity of the problem or the influence that the potential solution may have. One may decide to make consultations on an individual basis, from a first-rate team of research staff, or from a working group that may comprise of Ethics Committee members as well as other stakeholders. Undoubtedly, not all individuals among the select team or the ethics committee will be knowledgeable enough, or an expert in the competencies required for efficient consultation (American Society for Bioethics and Humanities, 2011). Nevertheless, a collective contribution by all members will support and ensure the effectiveness in the consultation process.
Conclusion
Both clinical and organizational ethical and value dilemmas pose challenges in the modern healthcare contexts. Accreditation standards, practice regulations, facility policies, and the laws of the land affect the decision-making process regarding ethical issues and questions within an organization. There are a number of theoretical perspectives steer the decision making and analysis for clinically-based ethical dilemmas. The National Association of Social Workers and the nurses code of ethics evidently makes out the accountability of the social worker and the nurse respectively, regarding the application of ethical standards and principles in providing care to patients. There are, however, no open answers to ethical dilemmas in the context of clinical practice. Therefore, it implies that the role of the nurse or social worker, as a part of the inter-professional healthcare team is to make out the prospectively ethics-associated situations, cooperate with colleagues from both the workplace and other interdisciplinary teams in order to address ethical dilemma issues, as well as offer a holistic support for colleagues, patients and their families.
Ethical dilemmas in nursing are daily phenomena regardless of their places of work within the Bahamas. Despite their functions in varied professional roles, nurses encounter ethical decisions that can, and does affect them as well as their families. However, there is no specific remedy to an ethical dilemma. Some examples of ethical dilemmas that nurses encounter in their places of work include pro-life versus pro-choice, quantity versus quantity, control versus freedom, deception versus telling, resource distribution, and personal versus experiential knowledge values and beliefs. The decisions that nurses ought to make in ethical dilemma situations are normally affected by a myriad of factors, which include experiences, personal beliefs, values, and principles taught at school.
References
American Society for Bioethics and Humanities. (2011). Core Competencies for Healthcare Ethics Consultation. Glenview: American Society for Bioethics and Humanities.
Barnett, J. W. (1986). Ethical Dilemmas in Nursing. Journal of medical ethics. 12 (1), 123-126, 135.
Butts, J., & Rich, K. (2008). Nursing Ethics (2nd ed.). Boston: Jones and Bartlett.
Corley, M. (2002). Nurse moral distress: a proposed theory and research agenda. Nursing Ethics, 9(6), 636-650.
Park, Mihyun,M.S.N., R.N. (2009). Ethical issues in nursing practice. Journal of Nursing Law, 13(3), 68-77.
The National Association of Social Workers (NASW) code of ethics. Retrieved from http://www.sp2.upenn.edu/docs/resources/nasw_code_of_ethics.pdf
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