Advocating on Behalf of Vulnerable Patients

Advocating on Behalf of Vulnerable Patients

The case under review is about an experienced intensive care unit registered nurse who sustained a concussion after falling on the ice during a game and ended up having a brain tumor. Although her clinical team thinks that she has a good prognosis if she goes through surgery, Marianne chooses to sign a do not resuscitate (DNR) order. While placing the order, Marianne states that she would not want to be resuscitated if she suffers a cardiac arrest while undergoing surgery to treat her brain tumor. Marianne signs the DNR order while in the company of her partner, Joanne. However, the situation gets complicated when Marianne suffers a cardiac arrest while undergoing surgery, and her partner Joanne is not at her bedside. Instead, only Marianne’s parents are at her bedside. Marianne’s parents are very religious. They disapprove of her sexual orientation as well as her choice not to be resuscitated. As such, Marianne’s parents request Suzanne to calls a code. Suzanne, Marianne’s nurses, give in to the request of her patient’s parents. However, the efforts of the clinical team to save Marianne’s life are futile, and she is declared dead twenty minutes later. The ethical dilemma in this case study is whether or not calling a code was the right course of action for Marianne’s nurse, considering that her patient had already signed the DNR order. This paper argues that Suzanne failed to adhere to the provisions of the American Nurse Association’s code of ethics and the ethical principles of nurses.

In the case study under review, Suzanne, who is Marianne’s nurse, is facing an ethical dilemma.  Pettersson, Hedström, and Höglund (2018) define ethical dilemmas as “Situations in which a person must choose between actions that are apprehended as equally correct ethically” (p. 2). As such, an ethical dilemma occurs when a person is faced with two equally competing options, each of them having serious implications. Suzanne is forced to choose between respecting the wishes of Marianne and doing what her patient’s parents are asking of her. Each of these options has negative implications. For instance, she chooses to ignore her patient’s request of not wanting to be resuscitated in case she suffered a cardiac arrest. This decision can subject Suzanne to negative implications. For instance, she can be punished by her hospital or the American nurses’ association for disregarding her patient’s wishes. On the other hand, Suzanne could have resolved to ignore the request by Marianne’s parents of calling the code. This decision would have resulted in her facing the wrath of Marianne’s parents. As stated above, Marianne’s parents are very religious people. As such, they are likely to have viewed Suzanne as a murderer for failing to call for help that would have resulted in their daughter’s life being saved. On the other hand, her decision could have saved her from having to face disciplinary action against her by the national professional organization that she is part of for going against its provisions pertaining to the care of vulnerable patients.

According to Mallari and Tariman (2016), there are eleven ethical models/frameworks or values that have been developed for use in nursing research and practice. However, not all these frameworks are relevant in every situation that a nurse professional may face. One of these frameworks is the “International and National Code of Ethics from professional organizations” (Mallari & Tariman, 2016, p. 54). For nurses operating in the United States, the American Nurse Association’s code of ethics is the supreme framework for guiding the conduct of professionals in this field when they are faced with an ethical dilemma.

Thus, nurses have to adhere to the provisions of the American Nurses Association Code of Ethics for Nurses. One of the nine provisions of the ANA’s Code of Ethics states that patients are nurses’ primary commitment, whether as a group, community, individual, or population (Haddad & Geiger, 2020). In the case study, Suzanne’s primary responsibility was the welfare of Marianne. As such, the right thing to do for Suzanne was not to call a code since that was against the wishes of her patient, as expressed in the latter’s DNR orders. Additionally, the ANA’s code of ethics states that nurses should advocate for, promotes and protects the health, safety and rights of their patients (Haddad & Geiger, 2020). One of the rights of a patient entails autonomy and self-determination. The patient has the right to make health-related decisions without outside influence. Nurse’s responsibility is to avail the information patients need to make the best decisions they can and respect what the latter has resolved. In the case study, Suzanne would have demonstrated her respect for her patient rights to self-determination and autonomy by carrying out Marianne’s DNR orders regardless of the wishes of the latter’s parents.

In addition to following the provisions of ANA’s code of ethics, nurses must adhere to the ethical principles of their profession. The ethical nurses that nurses must follow in their practice and research include fairness, beneficence, accountability, fidelity nonmaleficence, autonomy, and justice (Jafari, Khatony, Abdi, & Jafari, 2019). The principle of beneficence requires nurses to do the right thing for their patients. The right decision differs from one situation to the other. Suzanne may have thought that she was doing the right thing by placing the call that resulted in the clinical staff attempting to resuscitate Marianne. However, she forgot that her primary responsibility was neither her feelings nor the wishes of Marianne’s parents. Instead, she owed a duty to care to Marianne, her patient. Comprehension of the disease process is not adequate when making ethical decisions for nurses. Instead, a nurse professional should seek to understand what suffering means for his or her patients (Forte, Kawai, & Cohen, 2018). Comprehension of a patient entails learning about his or her values and attitudes towards suffering. According to Forte et al. (2018), values comprises of a collection of beliefs, expectations, goals and predispositions that individuals hold regarding certain decisions and the potential outcomes they can cause. The case study indicates that Marianne’s colleagues may have opposed her decision not to be resuscitated since they thought that she had a good prognosis after going through surgery even if she was to be subjected to CPR. On the other hand, Marianne had a different point of view regarding her prognosis if she was to go through resuscitation. For her, her quality of life would be compromised if she was to be resuscitated. It is possible that in addition to the request made by Marianne’s parents, Suzanne’s action of calling a code could have been influenced by the perception that her fellow clinical staff had regarding her patient’s DNR orders. However, the only feelings and opinions that mattered in the case study are those of Marianne.

At the same time, the principle of nonmaleficence prohibits nurses from doing harm as they provide care to their patients (Jafari et al., 2019). However, the principle of nonmaleficence may support or disapprove the actions of Marianne’s nurse. Suzanne has the responsibility of not harming Marianne. In this context, not harming the patient may have different interpretations. For instance, it may entail not placing the call for help that resulted in clinical staff trying to resuscitate Marianne. Suzanne’s action subjected Marianne to unnecessary pain since the latter ended up dying a few minutes later, despite going through the agony associated with cardiopulmonary resuscitation (CPR). At the same time, the principle of nonmaleficence can be used to support Suzanne’s action. As a nurse, Suzanne had a responsibility to do everything possible to protect Marianne from harm. The case study indicates that there was a significant chance that Marianne could recover from surgery even after being subjected to CPR. The other principle that applies in the case under review is fidelity. This principle entails nurses keeping the promises they have made to their patients (Jafari et al., 2019). In the case study, Suzanne was present when Marianne was making the DNR order. As such, she must have agreed to fulfill the wishes of her patients. Thus, Marianne failed to adhere to the principle of fidelity by not keeping her promise to her patient.

In addition to disrespecting the patient’s rights and wishes, Suzanne’s action of giving in to the request of Marianne’s parents to call a code demonstrates her lack of moral courage. Courage is a fundamental principle in the field of nursing. A nurse needs to have the virtue of courage to be able to provide high-quality care that is also full of love and respect for his or her patients. According to Sadooghiasl, Parvizy, and Ebadi (2018), moral courage help nurses overcome many challenges, such as fear, that may hamper their efforts to advocate for their patients. Suzanne failed to be morally courageous. The case study makes it clear that Suzanne knew what the right decision was. This is evident in the way she tells Marianne’s parents that her patient had made it clear that she did not want to be resuscitated. As a nurse, Suzanne should have been courageous enough to abide by her beliefs, no matter the consequences of her actions. She should not have placed a call for help that resulted in Marianne being subject to CPR against her wishes. Also, she should have made it clear to Marianne’s parents that their daughter’s wishes must be respected, and there is nothing that can be done about their request.

In conclusion, nurses encounter ethical dilemmas daily. However, things get worse when the patients are compromised by an illness which prevents him or her from airing their opinions.  Nurse professionals have a responsibility to be their patients’ advocates. The case study under review involves a nurse who neglected her duty to care by placing a request for medical interventions after Marianne suffered a cardiac arrest in which the client had said clearly that she would not want to be resuscitated. Suzanne failed to adhere to the provisions of the code of ethics for nurses by not advocating for the needs of her patients. At the same time, she failed to adhere to the ethical principles such as nonmaleficence, fidelity, and autonomy, among others.

References

Forte, D. N., Kawai, F., & Cohen, C. (2018). A bioethical framework to guide the decision-making process in the care of seriously ill patients. BMC Medical Ethics, 19(1), 78.

Haddad, M. L., & Geiger, R. A. (2020). Nursing ethical considerations. Treasure Island (FL): StatPearls Publishing. Web. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK526054/

Jafari, H., Khatony, A., Abdi, A., & Jafari, F. (2019). Nursing and midwifery students’ attitudes towards principles of medical ethics in Kermanshah, Iran. BMC Medical Ethics, 20(1), 26.

Mallari, M. G. D., & Tariman, J. D. (2016). Ethical frameworks for decision-making in nursing practice and research: an integrative literature review. J Nurs. Pract. Appl. Rev. Res, 7(1).

Pettersson, M., Hedström, M., & Höglund, A. T. (2018). Ethical competence in DNR decisions–a qualitative study of Swedish physicians and nurses working in hematology and oncology care. BMC Medical Ethics, 19(1), 63.

Sadooghiasl, A., Parvizy, S., & Ebadi, A. (2018). Concept analysis of moral courage in nursing: A hybrid model. Nursing Ethics, 25(1), 6-19.