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Case Study of an Ethical Dilemma

Published: 23rd March, 2015 Last Edited: 23rd March, 2015

This essay has been submitted by a student. This is not an example of the work written by our professional essay writers.

Introduction
An ethical dilemma arises when the clients and health care providers di¨er in their understanding of what is right or wrong (Narrigan, 2004). As
nurses we often deal with ethical dilemmas in our everyday clinical practice; and as professionals we have the responsibility to analyse and
examine any ethical problems that may arise. Any decision should be based on ethical principle that protects the best interest of both the
patient and the health care provider. This paper will outline a critical incident which occurred in one of my clinical experience in intensive care
unit (ICU).It presents the clinical case, identi�es the ethical dilemma, and discusses the principles that apply to this situation.

The Case
Mrs G was a 76-year old woman who was brought to emergency department (ED) after her carer found her in respiratory distress.

The ED doctor noted that the patient was minimally responsive to verbal stimuli, afebrile, normotensive, tachycardic to 130 bpm, and tachypneic
to 30 breaths/min.A chest radiograph revealed a right lower lobe consolidation. Based on her old notes it was found out that she had been
recently admitted for investigation of signi�cant weight loss and it was found to be a result of advanced bowel cancer ,with lungs, bone and
brain metastases. While in ED Mrs G's respiratory functions deteriorated and a referral for ICU was made. She was then seen and reviewed by
our junior registrar and after discussion from the ICU consultant, Mrs G was admitted to ICU for closer observation. I was then tasked to look
after this patient for that shift. After knowing the brief history of the patient from my team leader, I was then asking the doctor of what do we do
for this coming admission? Are we going to intubate and ventilate this patient in case she developed respiratory failure? And what are the
chances of her recovery from this critical illness? Has it been discussed to the next of kin before the plan for ICU admission? The doctor then
replied that it was his consultant's decision, and so we will just have to wait when this patient will arrive in the unit.

. Within 24 hours of being transferred to the ICU, Mrs G's condition deteriorated rapidly and a decision was made to talk with the family of what
we should do in the event of cardiac arrest. Relatives need to be involved in discussions about end-of life issues so that they are fully aware of
the appropriate decisions to be made; and that all parties involved understand the situation (McDermott, 2002).The son was immediately
informed about his mother's condition and it was revealed that Mrs G had previously stated to him that she does not want any heroic measures
in the event of cardiac arrest. The conversation with Mrs G's son over the phone resulted in the decision to initiate a not for resuscitation (NFR)
order. The purpose of the NFR order is to deliberately withhold life-saving measures when the patient's respiratory or cardiac function suddenly
stops (Costello, 2002).

The next day the patient's daughter arrived. During my conversation with her she mentioned that she had a distant relation with her mother and
not had been in contact with the patient over the past 3 years. But despite of all that she still wanted that everything done 27-11-116

for her mother. At this point in time I am not sure whether the daughter was aware of the condition of the patient before admission (especially
her mother's diagnosis of bowel cancer and the chance of survival is slim knowing it has metastasised to other organs). I then told her the need
to speak the medical sta¨ and the meeting was arranged for her later that day.

In this case, a clinical ethical dilemma has been identi�ed. The daughter's request for care con෺icts with the patient's advance directive and
places us in a di cult position of either honouring the patient's wishes or satisfying the daughter's request. The doctor decided to call the
patient's son, the health care proxy and legally appointed decision maker for the patient. He was able to reach the son by phone and discussed
to him the planned course of treatment. The son emphatically agrees with the ICU team's plan to continue the current supportive treatment
regimen. He (son) stated that his mother would not want any aggressive measures, and he agrees to comfort care for the patient. He said he will
speak to his sister about her concerns and will join the arranged meeting later that day.

27-11-116

In analysing a clinical ethical dilemma, the �rst step is to further characterize the situation in terms of the underlying ethical principles that apply
and the possible related ethical concepts that may be involved for example advance directives (Alfandre, 2007). To understand the decision-
making process in this case, one must consider the ethical principles of autonomy, bene�cence, normale�cence, and justice. These principles
can guide primary care physicians and nurses to implement the care of the dying patients in general (Rousseau, 2001; Basket, 2006; Beauchamp
& Childress, 2001). The healthcare team consultation meeting held prior to the family conference regarding Mrs G's status provided the
opportunity for healthcare team members to agree that Mrs G was dying. Even if more treatment was attempted for his individual systems,
 death was the expected outcome for Mrs G. Therefore the aim of good critical care medicine should be to establish a meaningful tension
between the aim of preserving life and making a peaceful death possible (Callahan, 2003). At the meeting later that day, I could feel the
emotional tension between the son and daughter, and being the nurse that involved in the care of their

27-11-116

dying mother I was overwhelmed with 27-11-116feelings of uncertainty. I also felt that because of the disagreement with the plan of care, it
3
 could compromise my moral
UKESSAYS  (/) obligation which is to support the patient's wishes and respect her preference for treatment.  
As we are all aware that the patient's condition was failing, the con෺icts of reciprocal autonomy (cooperation in a decision or action) should be
resolved (Mick, 2005).

Autonomy

It de�nes the freedom to make decisions of oneself without interference from others (Urden, Stacey, & Lough, 2006).The ethical dilemma
presented in this case is whether to respect the patient's autonomy or ignoring her wishes by giving in the demands of her daughter. In this
situation the ICU consultant was concerned about providing additional medical treatment that the patient may not have wanted. Respecting
patient's autonomy "yields satisfaction for that person ( the patient) directly" while interfering with an individual's autonomy may be experienced
as "a form of pain or su¨ering" (Ozar & Sokol, 2002). I believe that without compelling reasons to override 27-11-116

the patient's prior stated wishes, respecting the patient's autonomy takes precedence over bene�cence, as the care the patient would have
chosen is the care that has been proposed. Thus the team aims to continue with comfort care including oxygen, frequent suctioning, and pain
relief for respiratory distress.

However, to do otherwise would be uneasy without the cooperation of the patient's daughter.

Bene�cence

This principle directs the doctor to act in the patient's best interests (Alfandre, 2007). As the nurse that looks after Mrs G, I also wanted to
provide the care that is in her best interest as possible. Making her more comfortable and free of pain is an example of this principle During the
end-of-life dilemmas, the stress of illness and dying can create a tension that makes barriers to communication even if there was an advance
directive (Tulsky, 2005). The consultant suspects that part of the daughter's concern may have been related to a sense of grief and loss and its
associated guilt and regret. Being mindful of one's emotions in complicated ethical dilemmas can help 27-11-116

the health care professionals have more empathy for patients and thereby improve the therapeutic alliance (Halpern, 2007).

During the meeting, since both the son and daughter were present, the consultant starts the dialogue about the value of comfort care and its
importance with dying patients. Emotional statements about end of life are di cult to express yet provide crucial information to family
members that can help create consensus around the next medical decisions and course of action. In this case, it would be appropriate to also
consider the extent of Mrs G's illness (metastatic involvement to major organs) and its impact on her quality of life. But what are the doctor's
obligations when one of the family members disagree about the prior stated wishes of the patient? This is the ethical question raised in this case
scenario.

Non-male�cence

The decision of not resuscitating Mrs G was in෺uenced by this principle. Instituting full cardiopulmonary resuscitation measures to a patient who
is terminally ill could have a devastating e¨ects and contributes to poor care at the end stage of their illness (Edmonds,2003).

According to a recent study by Redman and Fry (2000) on ethical issues in nursing practice, prolonging the living-dying process with
inappropriate measures is one of the most profoundly disturbing experiences that we nurses face and witness. I do feel that aggressive
treatment to the patient is a violation of this principle as what exactly what the daughter wanted.

The consultant returns to Mrs G's room the following morning and �nds the patient with more laboured breathing. Mrs G's daughter, who is at
the bedside, appears distraught. The doctor decides to quietly observe. Few minutes passed as he is evaluating the patient's general condition,
when the daughter says, "The last time I saw her she was so strong". The doctor decides to remain silent. After a few moments, the daughter
says, "I didn't visit her as often as I should have". The doctor turns to the daughter and says, "I imagine it's hard to watch a parent so sick". The
doctor realizes the daughter's sorrow for her mother's imminent death. "Your mother is very sick- that's why she's not talking- but I want to
reassure you that she's not uncomfortable. She is getting morphine to relax her breathing and manage her pain.

27-11-116

This is part of the dying process and we are making her comfortable." The tension in the daughter's shoulders releases and says, "I know you are
doing what she would have wanted. I guess I'm scared of losing her…This is so hard for me. Thank you for listening."

The next day the consultant schedules a joint meeting with the son and the daughter. At the meeting, he allows time for the family's grief to be
expressed, for the son and daughter to come to agreement about the plan of care, and have all their concerns addressed. The son and daughter
together agree to proceed with comfort care.

After the meeting, the consultant returns to the station and places an order to titrate Mrs G opioid infusion for comfort. The patient dies 7 hours
later in no acute distress, with the family at the bedside. I felt that without careful and e¨ective communication techniques with the doctor, it
would not have resulted in a "good death" of my patient.

27-11-116

Justice

It implies that all people should be treated fairly and available resources should be used equitably (Cohen, 2006).

The application of this principle was not implemented right at the beginning of this incident. Failure to facilitate this ethical principle has
contributed to the con෺ict situations of this case. When patient is admitted to ICU the use of high technologies often may have the e¨ect of
unrealistic expectations (by family members) of what should be achieved at end-of life care. The respect for autonomy did not empower the
 patient's right at the start and this leads to a breach in the justice principle. However, the doctor also has the right to apply that autonomy to
exercise ethical belief in responsibly

handling requests for inappropriate treatment (Fisher, 2004).

27-11-116

Outcomes of Re෺ection 3
 UKESSAYS (/)  
Clinical situations that raise ethical questions are a challenge to navigate. Often, there are multiple clinical facts to consider. In addition, patient
preferences and the concerns and values of family must be taken into account (Schumann & Alfandre, 2008).

Analyzing this scenario I am pretty sure that events on this speci�c case have some contributing factors which were not under my control. I felt it
extremely di cult to be in a situation I know is hopeless but all available measures are being implemented to prolong a patient's life and I am
powerless to do otherwise. It is very distressfull for me especially if the patient that I cared for is a terminally ill patient. I can always relate it to
my father who had liver carcinoma and died 3 months after the diagnosis. I know in my heart and how I wish I could turn back the time, that I
would be able to look after him the way I look after my patient nowadays (I was still a student nurse by then). I can't help but cry reading this
lines. In the study by Wilkinson(1988) of situations in patient's care that were associated with moral distress, prolonging life and performing
unnecessary tests and treatment on terminally ill patients were 27-11-116

mentioned and experienced more often by nurses. The feeling of dissatisfaction and distressed in providing end- of- life care includes the
overuse of life-sustaining technologies, a profound sense of responsibility for patient's welfare, and a desire to relieve su¨ering (Asch, 1996).The
kind of care which I provided for this client was not in෺uenced by her age or social status. In my quiet thoughts, I was convinced that this patient
could have better and appropriate care if there was a proper referral system in place like getting in contact with the palliative care. This should
have been done during her previous hospital admission as there was already a clear diagnosis at that time.

The admission to ICU I believed was inappropriate as getting a NFR order could have been done in emergency department and comfort
measures in place as soon as possible. The goal is to improve patient's condition by alleviation of pain and su¨ering and we could reach this by
working together and supporting each other. My practice is not perfect and there is always room for improvement. If I would approach this
situation again for sure I would be more assertive. I think it is bene�cial to explore other alternatives and

27-11-116

encourage other coworkers or professionals to discuss the possibilities of di¨erent actions plus to decide together what would bene�t our
patient. After all, we are the most responsible for the care which we give to our client and if there is an indication that the care is not appropriate
we shall make attempts or steps to provide better and more satisfying care.( word count 2548)

27-11-116

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