ETHICAL DILEMMA THAT RELATES TO FAMILY INVOLVEMENT

ETHICAL DILEMMA THAT RELATES TO FAMILY INVOLVEMENT

by Ricky Ocampo RN

Introduction

            A nurse is faced with many decisions while executing his or her work responsibilities (Milstead, 2016). Some of these decisions may cause an ethical dilemma since the nurse may be confused with the moral choice to make. Ethical dilemmas can cause moral distress since the decisions that the nurse has to make may conflict with his or her morals (Nickitas et al. 2014). As a nurse at the Kaiser Permanente recovery unit, I have been faced with various ethical dilemmas that caused a moral distress. One such ethical dilemma was a situation where the patient’s family requested that I should not tell the patient his condition since they felt that the patient was not well enough to handle the news.

 The patient was conscious and was of sound mind according to my assessment. The family, however, claimed that the he is not good at receiving bad news and his poor stress coping mechanism could jeopardize his treatment and health care decisions. Such an ethical dilemma needs a proper knowledge of the nursing laws and principles as well as the patient’s rights to ensure good decision-making. State and federal statutes as well as prior rulings on legal cases that involved the ethical dilemma are also to be considered while making a decision. This ethical dilemma can violate ethical principles and laws, and there are ways of solving moral distress caused by the difficulty.

Codes of Conduct that Apply to the Ethical Dilemma

Decision-making in the case where family feels that the patient is not able to handle information about his medical condition is hard. On one hand, the patient deserves to have full knowledge of his medical condition to participate in any health decisions. On the contrary, the patient’s family might have a valid reason to fear the patient’s reaction based on their experiences and interactions. They are also close to the patient and have his best interest at heart. The decision should also protect the nurse and the hospital from any malpractice suit from the family and the patient. Various things including various professional guides and policies direct nurses’ decision-making. The nurses code of ethics that apply to this decision include provision 2 which states that a nurse’s primary commitment is to the patient, whether an individual, population, community, group or family. Therefore, the decision to be made needs to be focused on the patient’s needs and wellbeing. 

Another code of ethics that apply to this scenario is provision 3 that states that a nurse protects advocates and promotes the rights, safety, and health of the patient. This means that the nurse has to ensure that the decision does not infringe upon the patient’s rights. The nurse should also ensure that the patient’s rights are balanced with his safety and health. Provision 9 can also apply in this case. It states that the nursing profession, collectively through its professional organizations, must integrate nursing values, the principle of social justice, and maintain the integrity into health policy. Therefore, the nurse should ensure that the decision made is based on professional ethic laws and the rules that govern healthcare. The nurse should also remain unbiased while coming up with the solution of the problem. The nurses’ code of conduct mostly addresses the patient and nurse relationship and does not mention the rights of the patient’s family in regards to withholding patient information. To make a practical decision, there is need of analysis of other laws that govern the right to medical information. 

Ethical Principle and Law that could be Violated

One ethical principle that could be violated in the decision on the disclosing of information as per the request of the patient’s family is the principle of autonomy (Costello, 2010). This refers to the patient’s right to determine a course of action in regards to his or her health. The nurse, the doctor, or any other staff member should not interfere with the patient’s right to a decision. This principle is governed by the Patient Self-Determination Act, which was passed in 1990 by the Congress (Taylor, 2014). The act also outlines how the patient can appoint a right of an attorney to another person to make the tough decisions if the patient is not able.

The only time the patient’s family is allowed to make action under this principle is when the patient is unconscious and incapable of making a comprehensive judgment. The members of the family, however, need to be accorded the right to an attorney for them to make these decisions. Civil action can be pursued by the patient if they feel that the nurses did not respect their autonomy. They can sue the nurses or the hospital responsible for the malpractice. If someone else has the right to attorney, then they can make the decision instead of the family.

One law that can be violated by the decision is the right to informed consent. Accurate information on the health condition of the patient should be presented to him so that he can make a conclusive decision. The nurses need to inform the patient about the possible dangers of the course of treatment that he may choose. The information should be accurate and unbiased to ensure that the patient’s judgment is not compromised. In cases where the patient is in a coma or is not able to receive information concerning his or her health the person with the right of attorney is allowed to receive the information.

 The person with the right of attorney has to ensure that he or she follows the patient’s instructions or wishes if any was left.  Proof that the patient is not in the right mind frame to receive information, however, can ensure that the family conceals the patient health records. The proof is that the patient is not mentally stable and has a history of mental illness, which can severely affect his reaction and decision-making process. Violation of the patient's right to informed consent can lead to a civil suit against the person responsible for the misconduct (Stoljar, 2011). 

A Decision that Demonstrates Integrity

A decision that shows integrity is one that ensures that the nurse’s code of conduct is adhered to, and that prevents violation of the ethical principle and the law. The decision of availing the information on his condition to the patient is the best decision in this instance. This decision goes against the family wishes. This is because the patient still has full rights to his records and is entitled to react as he pleases from the medical report. The patient’s family has the right to make decisions about the patient’s health only when he is not capable due to unconsciousness or poor mental health (Costello, 2010). The family should be encouraged to monitor and communicate with the hospital staff on the patient’s condition. They should also express their fears to the patient and offer their support for any decision that he makes. 

The counseling services that the hospital offers can be used on the patient to ensure that he accepts his medical state and on the family to ensure that they are ready for any outcome that comes from the patient’s illness.  The family should also learn to respect the patient’s decisions and feelings. This decision also protects the hospital and the nurse from civil suit advanced by the patient, which can be very costly. The family cannot sue the hospital for going against their will since the law does not give them the right to patient information when the patient is competent. The family can, however, seek legal action where they can prove to a court of law that the patient is not in the right mind to receive information (Stoljar, 2011). They can convince the judges by showing previous cases where the patient handled bad news in an unfortunate manner. The hospital and the nurses will be obligated to follow the court’s ruling on the matter.

Legal Principles and Laws

The legal principle that applies to the ethical dilemma is the principle of autonomy. Independence means the right to self-determination. Therefore, the person has the right to determine the course of action of his health. For the person to be able to make a good decision on his health the hospital has to offer him all the necessary information on his health. The principle of autonomy ensures that the physicians, nurses or other hospital staff cannot withhold any health information from the patient.

However, information can be concealed if there is proof that the patient might be a danger to himself or others.  However, there is a need for sufficient evidence that proves that the patient is not in the right mental condition to handle the information or to make decisions. In this case, the person that has the patient’s right to attorney will be entrusted with the information and the decision-making process. According to the Patient Self-Determination Act, which was passed by the Congress in 1991 a competent patient, has the right to decide on his or her own (Taylor, 2014). The legal principle not only applies to medical practitioners but the patient’s family as well. They need to respect the patient’s decision and rights. 

Prior Legal Cases

The practice of this law is seen in various court rulings. In the case of Union Pacific R. Co v Botsford, the US Supreme Court ruled against the request by a railway company to perform a surgical procedure on a woman who had sued for a fall. The court argued that only the woman had the right to make the decision. This ruling shows the patient’s right are supreme and though medical personnel are more knowledgeable on health care matters they still have to respect the patient’s wishes.  The New York court of appeals in the ruling of the 1914 case of Schloendorff v. Society of New York Hospital the judge spoke against the action of treatment of the patient without consent (Taylor, 2014).

The judge argued that an adult of sound mind had the right to make a decision on a procedure to be performed on his or her body. This ruling shows that if the patient is not of sound mind then his right to information and decision-making can be taken by someone else mostly the person given the power of attorney.  In Cruzan v. Director, Mo. Dept. of Health in 1990, the US Supreme Court, ruled to terminate artificial nutrition and hydration as per the wishes of the patient as relayed by the family. The Supreme Court ruled that the patient had a right of refusal of treatment (Costello, 2010). This ruling is similar to the case of Harvey v Strickland, 2002; the patient was a Jehovah Witness, who objected blood transfusion during surgery. However, the need arose during surgery, and the patient was unconscious and could not make the decision.

The surgeon sought the mother of the patient who consented to a blood transfusion on the basis that it was an emergency. The patient later on proceeded to court and the ruling made was that the patient’s wishes against a blood transfusion were well known by the surgeon and the mother, and they should not have administered it (Goodwin, 2011). This ruling demonstrates the patient’s wishes should be followed even if the patient is unconscious. The rights of the patient should also be respected even if the patient decision may cause harm or death to him or her. 

In the state of California where the ethical dilemma occurred the statute that governs the law is section 2355. The article says, if the conservatee has been adjudged to lack the capacity to make health care decisions, the conservator has the complete authority to make medical judgments for the conservatee in good faith based on medical guidance determines to be necessary. The conservator shall make medical choices for the conservatee by the conservatee's individual medical wishes and instructions to the extent known to the conservator. Otherwise, the conservator shall make the judgment by the conservator's resolve of the conservatee's best interest.

 In defining the conservatee's best interest, the conservator shall consider the conservatee's  likes and principles to the level known to the conservator. The conservator may need the conservatee to receive the health care, whether or not the conservatee objects. In this case, the medical choice of the conservator alone is enough, and no person is liable because the health care is directed to the conservatee without the conservatee's consent (Goodwin, 2011). Therefore, the only time someone is allowed the patient’s right to information and decision-making is when the patient is not capable either due to unconsciousness or due to mental instability. The person acknowledged the rights should ensure that only the patient’s best interests and wishes are recognized in the choices made.  

Differences between Ethical and Legal Reasoning

The difference between ethical and legal reasoning is that ethical reasoning is an interpretation of events or a subject based on a person views of rights and wrongs (Ulrich et al. 2010). This thinking is based on person’s religious and political ideologies. Legal reasoning, on the other hand, is thinking based on the law. Legal reasoning in nursing is controlled by the state and federal laws, professional standards, and licensure. In a case where legal reasoning is not applied, it might lead to suspension or termination of licenses and or criminal and civil action.

However, professional codes of conduct might prescribe a set of ethical principles that a person should adhere to while performing his or her responsibilities. Deviation from these principles can lead to a disciplinary action from the relevant regulatory body. This happens since ethical reasons are also influenced by the culture and traditions of the community and not only the healthcare worker. A decision may be legal but not ethical or ethical but illegal leading to moral distress.

An ethical-legal decision-making model can be used to assist in coming up with a good decision on the ethical dilemma. A model that applies to the case is principlism theory. This is built on four key principles, which are justice, non-maleficence, beneficence, and autonomy (Halstead, 2012).  Justice refers to equality and fairness while non-maleficence refers to not causing harm to the patient as explained in the Hippocratic Oath. Beneficence refers to the nurse focusing on the patient’s best interest while autonomy refers to the patient’s right to make decisions (Nickitas et al. 2014).This approach focuses on the rights of the patient as opposed to the rights of the family and the hospital staff.  Using this theory the decision to be made has to be fair, should not harm the patient, address the patient best interests and give the patient a right to make decisions.

Resolutions to Resolve Moral Distress

There are ways to resolve moral distress caused by the dilemma of either informing the patient of his condition or to hide the status as per the family’s request. One way is by hospital coming up with proper decision-making and legal framework that addresses ethical dilemmas. Coming up with hospital policies that address the decision-making mechanism on the issue can help solve moral distress since it will make decision making easier (Cerit & Dinç, 2013). The nurse’s code of ethics and other professional policies and laws can also be reviewed to enable easy decision-making.

 A proper decision-making structure and framework will make it easy for nurses to make a decision that affect patients, therefore, avoiding moral distress. The medical worker can also use the hospital use in his or her defense in case of legal issues arising from a decision made. If the worker has followed all the hospital regulations, he or she can gain support from the management. The hospital policies should also outline ways of dealing with patients and family and offer education on legal rights that the nurses have while dealing with ethical matters. Nurses that understand their legal obligations are going to use them in making their decisions.

The second way of solving moral distress caused by the ethical dilemma is the use of interdisciplinary efforts. This is by bringing together nurses, doctors and other staff who have faced the situation and can contribute to coming up with a solution based on their experiences. A support group of people facing an ethical dilemma and moral distress formed by staff members of different disciplines can also help reduce the problem. The staff should also offer moral support and understanding on decisions made by other members even if they are facing civil or disciplinary action. This will reduce the stress caused by the decision that they made. The interdisciplinary efforts should also create and lobby for an environment that allows nurses and other healthcare workers speak up on various ethical issues they face or other matters that affect them and the patients. This will quickly help solve the ethical dilemma and moral distress by ensuring the problem facing the nurses are addressed. Hospital teamwork can also foster unity coexistence, which will ensure that members of different disciplines can quickly consult one another while confronted with tough decisions.

Providing ethics experts to deal all forms of ethical dilemma that affect nurses and other hospital staff can also be instrumental in handling moral distress caused by the ethical dilemma (Burston & Tuckett, 2013). An ethical committee should be formed to address all conflicting decisions. The experts consist of people with experience in solving various ethical dilemmas. This includes people that have knowledge of the federal and state laws. The committee should educate the hospital personnel on the ethical dilemma and ways of avoiding moral distress. The group responsible for the ethical issue in the hospital should also come up with counseling services for nurses affected by ethical dilemmas and moral distress. They should also recommend proper stress coping mechanisms for the healthcare workers while monitoring any employees that abuse drugs or alcohol.

Conclusion

In conclusion, nurses face various ethical dilemmas that cause moral distress while executing their tasks. An ethical dilemma that I faced was whether to withhold medical information from the patient as per the family’s request. The nurse’s code of ethics applies to this particular case with provision 2, 3, and 9 relating to the decision that should be made. The decision on the ethical dilemma can be affected by the principle of autonomy and the patient’s right to informed consent. Autonomy refers to the freedom of making healthcare decisions that patient enjoys while informed consent refers to the patient’s right to all his or her health information so as to make a good choice. A decision that would not violate the ethical principles and laws is ignoring the family’s wishes and informing the patient of his medical condition. This decision is in line with the nurse’s code of ethics, the principle of autonomy, and the right to informed consent. The legal principle that applies in the case is the principle of autonomy where there are many court rulings to show how this particular law is used.

The difference between ethical reasoning and legal reasoning is that legal reasoning is based on the law, and moral reasoning is based on a person’s principles. A decision-making model that can be used in the case is principlism. There are three ways of solving moral distress caused by the ethical dilemma in the discussion. One is by the hospital coming up with policies that address various decisions that have to be made and guidelines on how to deal with moral distress immediately before it negatively affects the nurses. The second way is the use of interdisciplinary efforts to ensure cohesion and support in the work area. The third one is the use of ethical experts who have vast knowledge of solving ethical distress and moral dilemma.

References

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