Introduction
Nurses encounter more ethical dilemmas than other health care professionals during their practice, particularly when charged with the responsibility of providing care to terminally ill patients (Jie, 2015). The NMBA (Nursing and Midwifery Board of Australia) has developed a Code of Ethics that governs nursing professionals and midwives in the country in their provision of care. The code identifies nurses as moral agents who may at times be compelled to embrace a personal moral stance and possess the right to decline partaking in certain procedures if they are strongly opposed to such procedures on moral grounds. However, even as nurses exercise their discretion on providing care, they are required to remain responsible in order not to compromise patient safety and care provided (Nursing and Midwifery Board of Australia 2013). This therefore is dependent on the underlying principles of nursing practice, as well as the beliefs, values, and experiences of an individual nurse. The case study under review involves Mrs. Elsie, an 88-year-old patient who has been admitted to the RAC (Residential Aged Care) Facility with severe rheumatoid arthritis, vision impairment, and short-term memory. The Nurse Manager on duty has suggested that the patient (Elsie) consider making out an ACD (advanced care directive), to which she agreed after consultation with her family on a Sunday. However, she developed complications on Friday night that include an irregular pulse and severe chest pain. The RN on duty calls for an ambulance. Elsie pleads with the paramedic to leave her “as she was” but the RN insisted that they transport her to the hospital seeing as she had not filled out an ACD. However, Elsie suffers a cardiac arrest on the way to hospital and dies. The family establishes that their mother died due to stress of moving her from the RAC to another facility. They therefore decide to sue the registered nurse, health care facility, and the paramedics for battery and assault. The paper shall endeavour to determine the stakeholders involved in the case scenario, their rights and dignity, and the healthcare professionals involved. Additionally, the virtues and principles of health care ethics as they affect the nursing profession shall also be examined, as well as the code of professional conduct/ethics to the conflicts involved. Finally, the paper will attempt to propose an ethically and legally defensible resolution to these aforementioned conflicts.
Dignity and rights of stakeholders involved
The case study involves various stakeholders such as the patient, a registered nurse, and paramedic. Jackson and Irwin (2011) opine that the patient has a right to access care irrespective of their sex, race, creed, or sexual orientation. In addition, patients deserve to be accorded respect and dignity by health care professionals at all times. Moreover, nurses have a legal obligation to involve patients in decision-making about the kind of care or treatment they are going to receive. Before a patient can be transferred from one facility to another, it is important to ensure that they are fully informed of such a development, why it was deemed to make such a decision, and the different options available to them (University Health, 2014).
Nursing staff are expected to treat everyone with whom they come into contact with in their delivery of care in a humane and dignified manner. In this case, nurses are expected to understand the individual needs of people in their care, show sensitivity and compassion, and provide care with respect and equality for everyone (Jackson & Irwin 2011). The right to equality, dignity, and humanity is universal to everyone in various settings. The ANA (American Nurses Association) identifies respect for human dignity as a basic principle that underscores all nursing practices. The ANA, in its code of ethics, stipulates that while providing care to patients, nurses should respects the customs, values and beliefs of the individual, his/her family, and the community in which he/she lives (Slate 2015). Consequently, nurses, while executing their duties, should demonstrate respect in their professional relationships with patients (Molewijk, Hem & Petersen, 2015). This includes relationships with the patient whereby the nurse is expected to deliver nursing services with respect for human values and needs, devoid of any prejudice. Nurses are also expected to observe and respect patient autonomy in their daily practice. In this case, patients have a legal and moral right to decide what ought to be done with their individual selves, to get help in weighing the burdens, benefits, and alternatives in available treatment, including refusing, accepting, or terminating care or treatment without undue influence, coercion, deceit, or duress, and to receive the support needed though out the decision-making process, and the treatment process itself. This support encompasses the opportunity to involve family members in decision making, and the provision of support and advice from knowledgeable health professionals, including nurses. Accordingly, the nurse should protect, preserve, and support patient’s interests by evaluating their understanding of information presented to them, and the likely implications of decisions. Paramedics should also demonstrate respect for human dignity in their practice, within the legal the confines of legal parameters dictated by law. This should be the case for all areas of their practice, especially in gaining consent, issues of confidentiality, and administering of drugs (Clarke, Haris & Cowland 2014). All of these have to be carried out within the existing legal framework that defines the paramedics practices.
Principles and virtues of health care ethics that inform professional practice
Nurses frequently encounter situations of moral difficulty, like feeding terminally ill patients, taking part in termination of pregnancy, and whistle blowing (Griffith, 2014). Dealing with most of these moral dilemmas involves the principle-based approach which hinges on the four moral principles of non-maleficence, beneficence, autonomy, and justice.
Nonmaleficence
Nurses are expected to demonstrate competence in their practice to avoid causing injury and suffering to patients. Lawson (2012) defines non-maleficence as the ethical principle of ‘doing no harm’ (p. 2). In line with the non-maleficence principle, nurses are also expected to report any suspected form of abuse (Jackson & Irwin, 2011).
Beneficence
This is the fundamental principles of patient advocacy and doing good or as Lawson (2012) puts it, beneficence entails an attempt to provide benefit. It encompasses taking positive actions in order to assist others, demonstrating compassion in executing your duties, and following through on in ensuring that patients receive the best form of care and treatment possible, in order to realise optimal results.
Autonomy
Nurses should respect the client’s right to independence, self-determination, and ability to self-direct. Accordingly, patients have a right to decide what will happen to them (American Nurses Association, 2016). For this reason, competent adult patients can either consent or refuse treatment and should this happen nurses are bound by the principle of autonomy to respect the patient’s wishes, even though they may be opposed to their decision. The 1990 Patient-Determination Act acknowledges the right of competent individuals in making their wishes known with regard to their end-of-life experience (Jackson & Irwin, 2011). The act further acknowledges the durable power of attorney which involves allocating a competent individual to help the patient in making decisions regarding their health in case of incompetence or critical health issues.
Justice
According to Lawson (2012) the justice principle as practiced by health care professionals involves accountability, transparency, and consistency in ensuring that limited resources have been distributed appropriately. Nurses are expected to treat all clients equally and fairly. Nurses encounter the challenge of executing justice in organising care delivery to patients on a daily basis. The principle of justice also entails exercising fairness in distributing resources and taking into account a patient need.
Relevant Code of Ethics
Historically, nurses have demonstrated a desire to enhance quality of life for patients, their families, as well as communities, in all stages of life’s journey. Nursing care is especially crucial in fulfilling the comprehensive needs of individual patients and their families at end of life to alleviate suffering and pain often associated with dying. In this case, nurses demonstrate their traits as vigilant leaders and advocates in delivering humane and dignified care. Nurses are thus actively involved in evaluating and assuring the appropriate and responsible use of interventions in order to minimise patient suffering (American Nurses Association, 2016).
The Nursing and Midwifery Board of Australia (2016) demands that registered nurses endevour to utilise various thinking practices and evidence in providing quality and safe nursing practice, as well as in making decisions regarding the provision of such care. In addition, registered nurses are expected to respect diverse experiences and cultures, and to recognise the role of family and community in health care provisions among diverse cultures. In all their evidence-based practice activities, registered nurses are expected to comply with the laid down regulations, guidelines, legislation, policies, as well as other requirements or standards relevant to their context of practice ( Nursing and Midwifery Board of Australia 2016). Nurses should thus ensure that their professionals practice meet their obligations to individuals to whom they provide care . As a means of enhancing the contribution registered nurses make to society, health care providers need to ensure that the autonomy and dignity of nurses is respected in the workplace.
The Aged Care sector acknowledges that patients under their care need to receive care in a manner that portrays respect and protection of fundamental human values (Leditshke, Crispin & Bestic, 2015). Registered nurses are key stakeholders in the delivery of care to patients in residential aged care facilities and as such, individual nurses are expected to recognise and accord human dignity to patients under their care. In particular, registered nurses must ensure that individuals are treated with respect and that their right to liberty, security, and life are respected (van der Dam, Molewijk & Widderrshoven, 2014). The Australian Code of Ethical Standards states that ‘Every effort should be made to ensure that institutional environments for older persons respect their individuality and are as homelike as possible.” (cited by Ghosn, 2013, p. 72). Nursing professionals within an aged care facility are therefore expected to assign the aged with respite and residential care services, in addition to seeing to it that they live a secure, rewarding, and dignified life (Ghosn, 2013).
Advanced care directives (ACDs) are an important consideration for patients in residential aged care as they enable an individual to plan for personal care needs and future health should they be incapable of communicating or making decisions. In this case an advanced care planning enables an individual’s personal beliefs, preferences, and values to guide future decisions made regarding the type of care or treatment received. It is important therefore that the nurse practitioners, along with other health care professionals, be acquainted with the existing clinical guidelines regarding ACDs, as they affect delivery of care to patients in aged care facilities. More importantly, registered nurses working in aged care facilities should be conversant with the legal environment of their jurisdiction of practice (Leditshke et al., 2015). They must also respect and value individual wishes and beliefs and take these into account when executing their duties as professional nurses.
Propose a legally and ethically defensible resolution to these conflicts
From the case scenario provided, a contradiction between patient’s rights and respect for dignity on the one hand, and registered nurse code of ethics is evident. The patient had communicated to her family that she did not wish to be resuscitated in case of health deterioration, and neither did she wish to receive any form of aggressive treatment. Although the Nurse Manager had suggested that she consider taking out an ACD, she developed complications that necessitated her transfer to another facility before filling it out. The health care professionals attending to her were also not privy to her wishes about not being resuscitated. She died on transit to another health facility, and her family have sued the health care providers and professionals on grounds that her death was occasioned by stress induced by this move. Considering the contradicting between legal obligations and patients and health professional rights, it is important to find a suitable resolution to this dilemma. Health care professionals should always honour the law, even as they emphasize their commitment to professional code of ethics, and desire to resolve the conflict sufficiently.
When faced with ethical problems, nurses have been shown to use various actions in a bid to create desirable outcomes for patients, and these obviously have differing implications for their practice. Slate (2015) maintains that nurses are expected to promote and uphold planning and participation of an individual patient in making decisions regarding their care, to the extent that the individual is able and willing to participate. Verbal communication with patients and their families has emerged as a key strategy that nurses use to resolve ethical issues. Elsewhere, Molewjuk, Hem and Pedersoen (2015) established that mental health professionals use various means to deal with ethical challenges, usually in an implicit, informal, and reactive manner. Usually, they organise ad hoc meetings with other healthcare professionals to deliberate on the ethical challenges (Hem et al., 2014). Kadioglu et al. (2011) report that physicians request for ethics consultation in an attempt to clear their conscience and gain the patient’s trust.
In the case of the patient provided in the case study, she died due to being moved to another facility when her health deteriorated, against her wish. However, this wish was only known to her family as she had not filled out the ACD. Through verbal communication with her family, the registered nurse can help to clarify this issue and possibly help the family find closure following the death of their mother. The registered nurse can also reiterate her commitment to respect for human dignity and that she had obligations for the patient. Her actions, in this case requesting that the paramedics team move her to another health care facility where she would get better treatment, was based by the fact that she desired to alleviate pain and suffering that the patient was undergoing. This is in line with the principle of beneficence which is a key element of the nursing code of ethics. Moreover, physicians understand that no one should be coerced to undergo treatment save where a specific provision of the law applies (Kadioğlu et al., 2011). However, although nurses have a juridical and deontological commitment to respect and defend patient autonomy, there have been many instances where nurses have reported difficulties in acknowledging a request from a competent patient to miss out on treatment (Coffey et al., 2013; Giantin et al. 2012; Griffith 2014). This is likely to demonstrate that even though the registered nurse actions may have seemed irrational at the time, she acted with intuition and empathy, and in keeping with the existing nursing code of ethics and guidelines.
Conclusion
Registered nurses frequently encounter ethical dilemmas in their line of duty. This is because all too often, they may be expected to make decisions regarding treatment and care delivery to patients and their decision on the issue could conflicts with the values, wishes and beliefs of a patient. Such was the case with Mrs. Elsie, who has been admitted at an RAC. Her wish is that she should not be resuscitated in case her health deteriorates but develops complications that result in her death before she could fill out the ACD. The registered nurse was not privy to this when she directed that Mrs. Elsie moved to another facility. To resolve the conflict, the registered nurse ought to engage in verbal communication with the family and make known her stand namely, that she was acting in the best interests of the patient, and acted in line with the nursing code of ethics that require nursing professional to treat patients in a humane and dignified manner.
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