Question

Mrs. R., an 87-year-old patient, has a past history that includes coronary artery disease, a previous stroke, and advanced Alzheimer’s disease. Ten days ago, Mrs. R. was hospitalized for aspiration pneumonia and has been ventilator dependent since being admitted to the intensive care unit in a small rural hospital. Family members visit daily and have repeatedly voiced their concern to the nursing staff about the continued ventilator support that Mrs. R. is receiving, most notably the fact that Mrs. R. would never have wanted such care. They also note that Mrs. R. has not recognized them in past months and that they plan to visit less in future days, but can be contacted should any change in Mrs. R.’s condition occur. Her primary care physician has practiced in this community for multiple years; he is well-known for his reluctance to discontinue any type of life support for any patient. When questioned, Dr. G.’s consistent response is, if this were his frail 92-year-old mother, he would prescribe the very same treatment for her. Dr. G. has now requested that the nurses talk to the family about moving Mrs. R. to a major medical center, where she can receive more advanced care, including vigorous rehabilitation and physical therapy, so that she may eventually return to a long-term nursing care facility. Questions: How might the nurses in this scenario respond to the physician’s request? What ethical principles have potentially been violated in this scenario? How would this scenario begin to cause moral distress among the nursing staff? What are actions the nurses can take to have moral courage in dealing with this situation?

Answer 1

• Respect to patients’ autonomy is a cornerstone of medical ethics and nurses have a key role in respecting patients’ autonomy. Here patient does not wish to have any care as she is in end stage. But physician forefuly want to give advance care. So nurse can act as advocate of patient to protect autonomy/ respect for patient's right. Here the ethical principle violated is Autonomy. This scenario will cause moral distress among staff as nurse want to act as patient advocate focusing on following code of ethics while she will have conflict with the physician for standing behalf of patient and opposing phydician's advice. Sometimes, speaking out for the patient requires them to demonstrate moral courage—for instance, in the face of conflicting loyalties, in highly charged conflict situations, or when the patient’s rights are being violated. The actions nurse can take is:
• Evaluate the situation to determine whether moral courage is needed to address.
• Inform the scenario to authorities.
• Discuss the ethical principle and its importance to the physician
• Be conscious about the consequences as we are accountable for the decision.