SELF DIRECTED ACTIVITY #1

Case Scenario 1:
1. You are the nurse-in-charge of the patient. Identify possible ethical issues found in
the case.
 The doctor made the client to understand that it is impractical to return him to life and
had him signed DNR
 The client did not sign a written informed consent
 The client signed a DNR but without witness.
2. Informed consent.
a. Briefly explain what informed consent is. It is informing and ensuring that the
client had understanding of the rationale behind the proposed intervention, its
benefits and risks, and the meaning that signing a consent form means agreeing with
the intervention.
b. What are its components? According to the Patient’s Rights by the Department of
Health, the following are the components of informed consent: (1) Name of the
person who will perform the proposed intervention and his/her credentials, (2)
“possibilities of any risk of mortality or serious side effects, (3) problems related to
recuperation, (4) probability of success, and (5) reasonable risks involved.”
c. Who should sign it?
o (1) Client of legal age and sound mind; (2) physician performing the proposed
intervention; (3) 2 witnesses who are not a relative or a physician
o In case of imminent risk where death is possible if treatment is withheld or
postpone, the physician can perform an intervention even without consent
d. What are the nursing responsibilities? The client has the right to informed
consent. The nurse should (1) support the decision making of the client, (2) promote
the relationship of the client and professional staff, (3) coordinate with the client,
family, and/or caregivers, (4) be aware of the code of ethics so that no right of the
client will be abused.
3. Advance directives.
a. Briefly discuss what advanced directive is. Also known as a living will, advance
directive is a written agreement that is approved by the law of the state and provides
directions concerning the provision of care in case the client is unable to make the
decision. It may also include having another person as the representative of the
client in case the client is incapable to make decisions.
b. What are its components? The components vary per institution and country. In the
Philippines, there is no legislation yet. However, in the proposed senate bill 2573,
this will include the following in the future in case the client is incompetent to make a
decision for himself/herself: (1) specific type of medical care including medical
treatment and life-sustaining procedure in case the client becomes permanently
unconscious or dying, and (2) transfer of the client to another physician who will only
honor the provisions of the will.
c. Who should sign it? (1) Client of legal age and sound mind; (2) health care proxy or
decision maker; (3) attorney

QUIBINIT, Carina B.
2015-13468
 d. What are the nursing responsibilities? The nurse should support the decision-
making of the client. The nurse should be aware of her own beliefs and values and
be comfortable with it. The nurse should assess and be informed of factors that can
affect decision-making such as knowledge on advance directives, ethics, client’s
medical and nursing care status, sociodemographic characteristics of the client and
his/her family that might influence the decision-making. The nurse should discuss
with the client and family to help in clarifying their values, beliefs, and understanding
of themselves in the context of their current situation.
4. How will you provide psychosocial support to a patient who will undergo an invasive
procedure? Provide emotional and social support that will reduce anxiety and fear to the
client, which includes family patient communication, family and client anxiety prevention,
and protection of human dignity.
5. As the nurse-in-charge, how will you respond to the patient’s request to be removed
from the ventilator? I will discuss and consult with the client, the family of the client, the
healthcare team, and people who are ethics experts. In case there will be an ethical
dilemma, I will respect the client’s decision-making and will agree with the removing from the
ventilator support.
6. How will you provide psychosocial support to the wife who is confused about the
situation? I will provide an environment that will help us discuss with each other. I will assist
her in identifying factors that affect her psychologically and socially.
7. What is/are the ethical dilemma/s?
 What is the best interest for the client?
o The client has tried, but the treatment did not contribute to the bettering condition
of the client and had worsened the condition of the client. The client believes that
his best interest is to stop the treatment and die.
8. Discuss the concepts of withholding treatment and withdrawing treatment. What
is/are the difference/s between the two?
 Withdrawal of treatment is the removal of a treatment that was started. Withholding
treatment means the client not wanting to have treatment such as the DNR.
9. What could be done by the healthcare team in this situation to protect them from
lawsuit?
 Discuss with the client and document everything.
10. As the nurse-in-charge, how will you ensure that the patient will have a dignified
death?
 Provide an optimal quality of life at the end of life by promoting comfort, relief of pain and
other symptoms, and supporting the client, family, and other people close to the client

Case Scenario 2:
1. What is/are the ethical dilemma/s?
 Should I promote life or prolong dying?
According to a journal, the client has a life expectancy of 1 month with brain
metastases regarded as the terminal stage of cancer. The wife claims that there
was a verbal agreement over the past 5 years and repeatedly asserted that her
husband wanted to die peacefully when the end comes.

QUIBINIT, Carina B.
2015-13468
 However, there is no way of knowing how long the client is going to survive,
because there are clients who can survive for more than 1 month even if they
have brain metastases.
 Should I respect the client’s representative by honoring the verbal living will or
should I continue with the intubation because there was no written living will which
is required by the hospital?
There are no legal provisions for advance directives dealing more with
medical issues in the Philippines. There was a proposed senate bill 2573
authored by the deceased Senator Miriam Defensor Santiago but only reached
the congress and did not become a law. In this proposed bill, it explains that a
living will should be in written form. As of now, there is no law in the Philippines
mandating how a living will should be.
 How extreme did the client mean when he said that he wanted to die peacefully
when the end comes?
It is not clear what the client meant by dying peacefully when the end
comes. It does not necessarily mean that he wanted to be extubated or he really
wanted to be extubated.

2. As the nurse-in-charge, how should you respond to the wife’s statements?

 “I understand what you are feeling and you are making decisions in behalf of the
client as the spouse. Both options are ethical, but we only need to choose one. We
will bring different disciplines including the ethics experts and hold a family
conference.”

3. How will you incorporate psychosocial care in this situation?

 (1) Conducting assessment on psychological and emotional well-being including self-
esteem, social functioning, and social relationships. (2) Providing emotional and
family support.

Reference

User, S. (n.d.). Department of Health. Retrieved August 16, 2019, from

https://samch.doh.gov.ph/index.php/patients-and-visitors-corner/patients-rights

Hamaguchi, K. (n.d.). [Role of Nursing Informed Consent]. Retrieved August 16, 2019, from
https://www.ncbi.nlm.nih.gov/pubmed/9546141.

Advance Directives: The Nurse's Role. (n.d.). Ethics in Practice. Retrieved August 16, 2019,
from https://cna-aiic.ca/~/media/cna/page-content/pdf-
en/ethics_pract_advance_directives_may_1998_e.pdf.

Advance Directives: The Nurse's Role. (n.d.). Ethics in Practice. Retrieved August 16, 2019,
from https://cna-aiic.ca/~/media/cna/page-content/pdf-
en/ethics_pract_advance_directives_may_1998_e.pdf.

QUIBINIT, Carina B.
2015-13468
American Nurses Association. (n.d.). Nurses’ Roles and Responsibilities in Providing Care and
Support at the End of Life. Retrieved August 16, 2019, from
https://www.nursingworld.org/~4af078/globalassets/docs/ana/ethics/endoflife-
positionstatement.pdf.

Liu, Tong, & Wang. (n.d.). Management of brain metastases: History and the present. Chinese
Neurosurgical Journalvolume. Retrieved August 16, 2019, from
https://cnjournal.biomedcentral.com/articles/10.1186/s41016-018-0149-0.

Defensor Santiago, M. (2010). Senate S. No. 2573(Philippines, Senate).

QUIBINIT, Carina B.
2015-13468