Application of an ethical decision-making model to a clinical practice model

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Professional Practice Issues  

Introduction

Professional ethics describes the consensus that is used to determine an action that can be termed as morally correct in the nursing practice (Hawley, 2007; Staunton & Chiarella, 2008).  Nurses are faced with situations that require ethical decisions on a daily basis and this can be a challenge especially where there needs to be balance between quality care, rights of patients, and logical decision-making.

The purpose of this paper is to identify the nursing practice principles and articulate them with the ethical and legal frameworks for professional practice.  Importantly, the essay incorporates evidence-base practice in relevance to quality patient care.   Data gathering and analysis is carried out from a case study of 70 year old patient-Jim Walters-who experiences cardiac problems and declines resuscitation treatment.  The case is analyzed and articulated in the ethical decision-making model by Kerridge, Lowe, and McPhee, 2009).

Problem statement

The case analysis for ethical decision making model concerns a 70 year old male client with a history of Coronary Artery Disease that has been present for 10 years.  The patient has also suffered two Myocardial Infarctions (MI) within this period, and he currently suffers from Congestive Cardiac Failure.  Currently, the patient uses cardiac medications to manage his cardiac output.  However, the patient insists that he neither wants to live as a Cardiac cripple nor receive heroic treatments (resuscitations) when he gets cardiac arrests.  The patient’s wife is also aware of the decision and has discussed it with the client’s nurse.  The patient is also involved in a motor accident in which he loses consciousness for a short time and he later complains of angina pain.  600 mcg of sublingual Glyceryl Trinitrate is administered and twenty minutes later, 30 mg of Morphine Sulphate is administered subcutaneously but has little effect.  The nurse manager then decides that the patient is transferred to the Coronary Care Unit (CCU) to upgrade management of the problem.  The client suffers another Myocardial Infarction but is treated appropriately and recovers at the CCU.  However, the patient warns the doctor of any further resuscitation should he suffer another heart attack but the doctor promises that the patient will receive all the necessary treatment for his condition while under the doctor’s care.  The nurse is also made aware of the decision by the client’s wife.  Nevertheless, during the recovery period in the CCU, Walters suffers another Cardiac arrest and he is given heroic treatment of which the patient is now considering legal action.

Problem analysis

Medical, ethical, social and legal issues all form a platform of conflict that needs consideration in the process of decision-making (NMBWA, 2007).  Medical issues that arise include Walters Cardiac problem of which the problem is appropriately managed using cardiac medication and heroic treatment whenever the patients gets a cardiac arrest.  The patient is treated with Glyceryl Trinitrate and Morphine Sulphate when he complains of angina pain, and transferred to the CCU for further care.   This practice is in accordance with the ANMC national competency standards for registered nurses (2006) in which the nurse is required to recognize the responsibility to prevent danger or harm that can befall the patient.  Ethical issues concern the patient wishes vs. the health care team wishes.  The patient believes that he has had enough of medications and resuscitation and does not want to be treated further.  However, the health care team believes that the patient should get the best of treatment under the healthcare team.  According to the ANMC (2006) the nurse must fulfil the duty of care in accordance to the national competency standards.  The duty of care includes performing of nursing intervention in relevance to the standards of practice.  Therefore, it may seem out of norm to let the patient’s health deteriorate when an action can be taken to prevent harm.  However, legal issues results when the patient considers suing the health care team because they do not fulfil his wishes.   Although the nursing ethical practices require the nurse to accept the rights of others and maintain an effective care process when confronted by differing beliefs and values, the legal principles require that the nurse identifies legal implications of the nursing interventions (Nurses and Midwives Act 2006); for example, granting the rights and wishes of a patient.   Social issues imply the impact for social factors to the health plan and nursing interventions.   Walters in this case discusses his preferred care plan with his wife who also discusses it with Walter’s nurse.  Moreover, it appears that Walters considers himself a burden to the household because of the cardiac arrests that he suffers, and this is why he considers a lack of resuscitation for cardiac arrests moment while at home.  Walters’s wife assists in the care plan of the husband by communicating with the health team on matters that concern his husband’s health.   Additionally, the national competency standards require that the nurse to accept the individual despite the age, or physical state (ANMC, 2006).  The patient is 70 years old and has repeated cardiac arrests but the health care team strives to provide quality health care despite the fact that the problem is common at this age.

Facts

Walters suffers from Coronary Artery Disease for over 10 years in which he also experiences Myocardial Infarction.  Coronary Artery disease or coronary atherosclerosis refers describes an indication in which the coronary arteries harden and narrow and thus reduce the supply of blood to the heart muscles, leading to angina, myocardial infarctions, abnormal heart rhythms and heart failure among others.   Angina which is chest pain experienced as a result of low blood supply to the chest tissues is usually prevented by sublingual Glyceryl Trinitrate (GTN). According to the Chemist and Druggist (2007) drug is more useful in preventing angina before it starts rather than after it has commenced.  However, in this scenario, Walters is administered sublingual GTN after the commencement of angina and this already shows that outcome is not as successful as expected.  Additionally, over use of sublingual GTN in chronic conditions is shown to have tolerance effect on the patient and thus acts less effectively as the drug is mostly suitable in acute conditions (Fonarow, 2004).  In this case, Walters has suffers a cardiac condition for the past 10 years and this indicates that he has already been in use of the drug.  This explains the low effect that the drug had on his pain and thus leading to the administration of Morphine Sulphate which is used in relieving any nature of chest pain (Fonarow, 2004).  This practice demonstrates a form of inadequate information about the patient and the kind of care that he deserves.  This contradicts the national competency standards for nursing practice in which the nurse is supposed to maintain current knowledge of professional standards and incorporate these standards into practice (ANMC, 2006).  The nurse and health team should have first carried out comprehensive examination to find out the cause of chest pain because it could have resulted from the car accident that Walters experienced rather than as a result of the cardiac problem.  On the other hand, it can be argued that the health practitioners integrated the patient’s history of the illness presented to make a decision of confirming that Walters has angina as a result of the Coronary Artery Disease.  Nevertheless, patients who do not respond to sublingual GTN are supposed to be admitted in the emergency unit straight away (Fonarow, 2004).  Walter’s nurse meets the nursing regulations by providing an intervention in which the patient is not harmed by referring Walter to the CCU for advanced care (Nurses and Midwives Regulations, 2007).

Principles of the ethical model

The model of ethical decision making operates under four principles-autonomy, beneficence, non-maleficence and justice.

Autonomy

Autonomy indicates the preferences of the patient in relevance to the health condition and care provided (Kerridge et al., 2009).  Walters, the patient in this case has declined heroic treatment in form of resuscitation in the event of a cardiac arrest.  Autonomy occurs if the patient is competent and cardiopulmonary resuscitation confers with potential benefit.  In this case, Walters can be considered a competent patient who has informed consent and understands his condition well.  The heroic treatment and cardiac medication seem to help Walters recover from incidents of heart attacks but the patient no longer wishes to live as a cardiac cripple. Walters, has talked to his doctor and his wife about his preferences and the nurse also knows about t through the wife.  However, Walters suffers a cardiac arrest and resuscitation is performed on him.  The client is therefore right in seeking legal action.   The patient is competent and resuscitation confers potential health benefits.  The doctors should have therefore conceded with the wishes of the patient and avoid proceeding with heroic treatment. Nonetheless, the doctor and nurse do not involve in a full discussion with the patient considering his need or lack thereof, resuscitation.

Beneficence

Beneficence refers to the benefits that the health intervention can provide for the patient (Kerridge et al., 2009).  Beneficence is applied when the patient is incompetent to make decisions, and hence family members should be involved in discussions and give views as to whether resuscitation the patient requires resuscitation or not.  However, the health practitioners should confer the views that align with the patient’s views in the past rather than the views of the family members (Kerridge et al., 2009).  Therefore, Walters’ nurse and doctor should have avoided proceeding with resuscitation because this was Walters’ preference; considering that the preference has been re-stated by the wife.

Non-maleficence

Non-maleficence considers risks and their avoidance (Kerridge et al., 2009).  This involves a competent patient but where heroic treatment does not seem to confer benefits.   In this case, it is seen that resuscitation benefits Walters by making him conscious again after incidences of cardiac arrest.  However, Walters does not consider this a benefit because he considers that he is crippled by his cardiac condition.  The doctor should have considered discussing the heroic treatment as part of an effective and realistic treatment plan with the patient if the patient is willing.  Nevertheless, the doctor should have made a decision not to attempt resuscitation because the patient does not consider it as beneficial.

Justice

Justice shows the balance of the interests of different parties involved in the health intervention (Kerridge et al., 2009).   The doctor who should make the resuscitation decision should involve the relatives and the nursing team on the best decision for their patient.  Conflicts in ethical decisions

Ethical decisions are always presented with conflicts considering that the interest of the patient and the family can be different from that of health care givers. According to ANMC Code of Ethics (2008) nurses are principled to value the access to quality nursing and health care for all people regardless of demographic and physical backgrounds.  For instance, in this case, the nurse ensures that Walters get quality care for the cardiac condition by referring him to the CCU when treatment with medication does not seem to improve Walters’ condition.  The nurse is also expected to practice ethical management of information; for instance in this case, Walters’ wife explained to the nurse on Walters’ wish not to have resuscitation.  The nurse should have discussed this information with Walters’ doctor prior to the resuscitation.  However, as much as the nurse serves in the best interest of the patient, the patient could have other preferences that conflicts the decision to quality care.  For instance, the health team in this case provide medication and heroic treatments to help Walters attain quality management to his cardiac problems but Walters considers otherwise.  The ethical conflict occurs where the health team believes that it is ethical to provide quality treatment to the patient yet on the other hand, it is also ethical to honour the patient’s preference to decline treatment.

 Law and clinical-ethical decision making

According to the law, a patient who is competent has the right to decline treatment and so the doctors and nurses should confer with the patient’s preferences (Hawley, 2007; Staunton & Chiarella, 2008).  Moreover, a patient is competent unless other factors prove otherwise.  The law relates to clinical-ethical decision making in that the nurses value informed decision-making from their patients (ANMC Code of Ethics, 2008).  According to the Code of Ethics for nurses (2008) and Code of Conduct for nurses (2008) the nursing profession should be committed to respect, protect, promote, and uphold the people’s fundamental rights in provision and reception of care.  The nurse is expected to comply with the common law and relevant legislation which govern the nursing practice and incorporate the law into practice (ANMC, 2006).

Making the ethical decision

Do not attempt resuscitation (DNAR) for Jim Walters is the clinical ethical decision.  The decision is arrived at after considering both clinical ethics and legal issues surrounding nursing practice.  Walters is a competent patient who has clearly stated his wish not to have resuscitation to his wife and the health team. At 70 years, Walters is experiencing more cardiac arrests and documented evidence suggests that the efficacy of resuscitation reduces with age in people with chronic heart conditions (Leung & Lo, 2000; Snyder, Loschener & Kepley, 2010).  Therefore, the patient has informed consent, his family member is aware of his wish, and this should be respected as the competency, ethics and conduct codes suggest (ANMC competency, 2006; ANMC Ethics, 2008, ANMC Conduct, 2008).

Evaluation

The analysis of Walters’ case and the ethical model reveals that the client is a competent patient capable of making viable decisions and taking an informed consent. The ethical principle of autonomy is highly considered for Walters’ case as it is a decision of a competent patient who does not prefer to undertake further resuscitations for any cardiac arrest conditions.  Considering Walters age of 70 years, it is only realistic to state that the overwhelming benefits of resuscitations are residing and the client is now experiencing frequent cardiac arrests.  The principle of beneficence is therefore observed as the patient no longer considers the heroic treatment as beneficial.  Non-maleficence is also observed when considering the need to avoid resuscitation because of the patient’s age and frequency of heart attacks.  Finally, considering the ethical principle of justice, the interests of both parties are put in balance.  The client, his wife, physician and nurses have listened to, and understood the client’s wish of not having resuscitation in case of a further cardiac arrest and they respect the client’s decision.  The physician and nurse will sign a form stating that they acted in accordance to the patient’s will.

Recommended Documentation

Jim Walters should not be subjected to any further resuscitation; however, the client continues to take medication to manage the condition while at home.  This shall remain in the current client’s history and should be put in consideration by other physicians or nurses that may handle the patients.

Conclusion

Ethical issues in the clinical practice of nursing are common.  As matter of fact, nurses face a lot of challenges in trying to balance both ethical issues and requirements of the nursing profession.  Ethical decision-making models like that of Kerridge, Lowe, and McPhee (2009) assist nurses to make and ethical decision concerning a clinical practice dilemma.

References

ANMC. (2006). National competency standards for the registered nurse. Available at             http://www.anmc.org.au/userfiles/file/competency_standards/Competency_standards_      RN.pdf

ANMC. (2008). Code of professional conduct for nurses in Australia. Available at             http://www.nrgpn.org.au/index.php?element=ANMC+Code+of+Professional+Conduc     t.

ANMC. (2008). Code of ethics for nurses in Australia. Available at            http://www.nrgpn.org.au/index.php?element=ANMC+Code+of+Ethics.

Chemist and Druggist. (2007). Case studies: Angina. Retrieved October 14^th 2010, from             http://www.chemistanddruggist.co.uk/c/document_library/get_file?folderId=103703&      name=DLFE-436.pdf.

Fonarow, G. (2004). UCLA chest pain and acute coronary syndrome: Patient management           guideline. Retrieved October 14^th 2010 from      http://www.med.ucla.edu/champ/ACS05a.doc.

Leung, L., & Lo, C. (2000). “Prehospital resuscitation of out-of-hospital cardiac arrest in   Queen Mary hospital,” Hong Kong Journal of Emergency Medicine, vol. 7(4): 191- 196. Available http://www.hkcem.com/html/publications/Journal/2000-4/191-         196.pdf.

Hawley, G. (2007). Ethics in clinical practice an inter-professional approach.

Kerridge, I., Lowe, M., & McPhee, J. (2009). Ethics and law for the health professions, 3rd           ed. Sydney: The Federation Press.

NMBWA. (2007). Medication management guidelines for nurses and midwives. Available at             http://www.nmbwa.org.au/cproot/855/2/NMBWA%20Medication%20Management%       20Guidelines%2020100611.pdf.

Nurses and Midwives Act 2006. (2006). Available at             http://www.nmbwa.org.au/cproot/657/2/Nurses_and_Midwives_Act_2006.pdf.

Nurses and Midwives Regulations. (2007). Available at       http://www.nmbwa.org.au/cproot/731/2/Nurses%20and%20Midwives%20Regulation  s%202007.pdf.

Snyder, J., Loschener, L., & Kepley, H. (2010). “The effect of patient age on perceived    resuscitation outcomes by practitioners,” NC Medical Journal, vol. 71(3): 199-205.       Retrieved October 14, 2010, from http://www.ncmedicaljournal.com/May-Jun- 10/SnyderJE.pdf.

Staunton, P. J., & Chiarella, M. (2008). Nursing and the law, 6th ed. Sydney: Churchill     Livingstone.

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