Question

Read the case in Group Activity Two “Mrs. Hewlett.” In your posting indicate what you would do if you were Ms. Copeland, the case manager.

Discuss how the following concepts play a role in this case.

Autonomy

Informed Consent

Paternalism

What would you do if you found yourself in “moral distress” because you feared for your job if you did not follow the doctor’s instructions?

Mrs. Hewlett

Mrs. Hewlett, sixty-five years of age, was diagnosed as having cancer of the colon with metastases to the lymph nodes and bone. Ms. Copeland, a young but experienced case manager, developed good rapport with Mrs. Hewlett during the three days before a scheduled operation to fix a hip fracture. Mrs. Hewlett fell in her yard, resulting in a trip to the hospital and her subsequent diagnosis. Everything had happened quickly. Several doctors had seen Mrs. Hewlett and a number of tests were ordered. All Mrs. Hewlett remembered was she would need a surgical repair of her hip and was placed on an orthopedic unit. Ms. Copeland did not work the day after surgery. When she returned, she could not locate a physician to ascertain what the patient had been told about her condition. The patient's nurse indicated that the patient had not requested or received any information from her. In talking to Mrs. Hewlett, Ms. Copeland discovered that she did not know that she had cancer, that it had metastasized, or that her condition was serious. Mrs. Hewlett, however, was concerned about the sharp pain in her abdomen, and specifically inquired about the results of the tests. She also wondered when she might be able to return to her gardening. The case manager avoided direct answers to these questions, and Mrs. Hewlett's two daughters tried to divert the conversation. When Mrs. Hewlett asked, "Is everything all right," no one answered. Later Mrs. Hewlett's daughters, who knew the truth, asked the case manager to reassure Mrs. Hewlett about her condition. They were worried about the possible impact of the truth, especially were worried since Mrs. Hewlett had recently undergone very difficult divorce proceedings. They thought that she would not be able to bear this additional burden. Although the case manager made no promises, she did try to keep the conversation with Mrs. Hewlett as light as possible until she could talk to the attending physician -- a procedure recommended by the head nurse. The attending physician was employed by the hospital and cleared her medically for the hip surgery. He had not met Mrs. Hewlett prior to this admission. When the physician arrived in the patient's room, Mrs. Hewlett indicated that she felt "pretty good," but asked no questions. He left after a brief examination. The orthopedic surgeon had visited early that morning. No family was available and the surgeon quickly examined the wound, asked Mrs. Hewlett if she was in any pain and left. Later when the case manager was finally able to talk to the attending physician, he indicated that no one had told Mrs. Hewlett about her cancer because such information would only cause her unnecessary anxiety and suffering. The physician said he had talked extensively with the family about this decision. The oldest daughter had medical power of attorney and would make decisions in her mother's best interest. Furthermore, he ordered Ms. Copeland not to disclose this information, warning her that he would consider such an act a violation of the patient's best interests and a breach of professional responsibility. Beauchamp and Childress, Principles of Biomedical Ethics.

Answer 1

Moral distress is common in everyday life. Ms. Copeland knows that it is ethically incorrect action but unable to do any action. This distress makes her leave the job. This is an ethically challenging situation because the older daughter has legally authorized to take decisions for Mrs. Helwett. The case manager Ms. Copeland knows the patient very well and have clinical knowledge of Mrs. Helwett clinical condition and she is opposing the decision due to her outcomes. Both can justify their decisions, but to think of comfortable and desirable to the client's health condition.

Professional autonomy is very important in every profession. Nurses have their own autonomy in clinical decisions and judgments. When the case manager is unable to make her own decisions then it leads to job dissatisfaction. She knows that Mrs. Helwett is suffering from metastatic cancer and wants to tell the truth to her. The case manager wants to respect the client's personal values but the professional obligation conflicts here. The nurse should be on the side of compassion and full autonomy is always not possible.

Informed consent is very important in clinical condition. Mrs. Helwett decisions are taken by her daughter. She made her own decisions without discussing with others. Even though Mrs.Helwett can understand her situation and able to choose her treatment choices, the decisions were taken without informing her. It is legally against of informed consent.

Paternalism is the one where there is a limited autonomy and the patient own wishes are not considered. The older daughter of Mrs. Helwett thought the real truth will make her mother further angry and disappointment. She has the autonomous to take the decision, so she feels to hide the truth. But in the point of the case manager, everyone has the right to know the health condition and decide upon the treatment choice. So the actual situation and the truth should be told in an empathetic way to Mrs. Helwett.

The case manager has looked upon the social surroundings, families, legal surroundings of the client before taking any decisions. She should not grow up the moral distress. Clinical care is a multidisciplinary approach, so everyone has responsibility for this. The healthcare is a system of hierarchy and everyone should have power of their own. The only thing, the case manager can do is she can take up of her powerlessness to the higher authority and make possible changes in her profession to become more skilled in her work.