The contemporary world of nursing is full of the diversity of ethical issues, which tend to take its place in practice of every nurse. Experience makes it a mandatory step in the extension of knowledge and awareness on the various ethical issues, which can arise at any moment. It should become a goal of every nurse to accept ethical issues as problems, which should not be repeated in the future. The current paper is a reflection of the personal experience related to the ethical dillemmas in nursing, analysis of personal mistakes, and applicable theories according to the experienced situation. The paper offers the reader to get an insight in the lesson taught by the patient at the beginning of the nursing practice. The following discussion is a reflection of a mixture including theoretical background and personal point of view on the actions aimed to reduce the probability of facing the same ethical issue again.
The situation took its place during the work as a preoperative nurse in the ambulatory outpatient department. The responsibilities of the job included providing all of the required procedures to prepare the patients undergoing endoscopy procedures. They focused on the establishment of intravenous access and obtainment of informed consent among other necessary aspects. In the role of a caregiver, it became possible to observe a situation creating an ethical dilemma. The situation involved a legal power of attorney (POA) of the patient’s closest relative and the patient. The patient suffered from the advanced dementia as a result of pneumonia and required a nutritional intake in order to fulfill the food and water needs of the organism. The gastroenterologist (GI) placed the patient in the outpatient department for percutaneous endoscopic gastrostomy (PEG) placement. The moment the son came to the hospital, he refused to take nutritional injections. From the point of the young health care worker, it was hard to understand the son`s decision, as he seemed heartless, which was ethically unacceptable and hardly understandable. In addition, the idea that the healthcare service deprives a patient of food and service was utterly disturbing. In general, the situation was distressing and led to the chain of conclusions, which created much tension in the work with the patient. Despite of the fact that a nurse spoke to the son, he did not change his decision. As a result, the patient continued the former process of recovery as long as the son insisted on the refusal from PEG nutrition. However, the nurse often experiences internal conflicts, accordingly, they could hardly look at the situation from the moral point of view. Nevertheless, it was also clear that a medical assistant should have respected the autonomy of the patient and his right to refuse the offered procedures. Presently, it is possible to think about the same situation in terms of the previous experience and theoretical background. In particular, the situation covers the fact that PEG feedings have doubtful benefits for such patients, as described in the situation. On the other hand, PEG nutritions are simple enough to promote its inclusion in the recovery process. Moreover, PEG feeding prolongs life of the patient and has a positive influence on the process of the recovery. It is the main reason, which led to the development of the ethical dilemma confusing both a nurse and the patient’s son. It means that the decision of the son was difficult to the level needed to make him deal with an ethical confusion of his own. The following analysis reveals prospects and facts of the ethically complicated situation. It discusses ethical principles, barriers, characteristics, and theoretical background of the problem that occurred several years ago. In essence, it is necessary to pay attention to the ethical characteristics of the case involving a nurse, a patient, and a son. In general, the discussion introduces enough theoretical backgrodund and examples aiming to avoid the same situation in the future. The following investigation includes a third person representation of the situation in order to consider a situation as a common problem encountered by the majority of nurse practitioners.
The situation that happened in the healthcare institution a few years ago had a range of characteristics. It is possible to reflect typical ethical features involved in the case by analyzing every process, which took its place during the search of the appropriate resolution of the conflict. In general, it included a patient refusing to take a treatment and a healthcare institution, whereas in particular, it is possible to see three characteristic features, which prevail in the situation development. Firstly, the it involved communication problems, which proved that a nurse is not capable of providing a relative of the patient with the necessary information regarding the process of recovery. In other words, it proved hard to find an effective approach to the son who denied providing his parent with a proper treatment. The lack of experience in nursing created the misunderstanding between the son and the medical attendant and created a confusion. In addition, the communication issue happened for the reason that neither the son nor the nurse could explain the purpose of enteral tube feeding. However, this problem could be solved before it started, if not the misinformation about the role of PEG feeding in such cases. If the required experience had been provided earlier, it would have been possible to understand the son’s decision to refuse the PEG feeding. In cases of dementia, PEG feeding does not provide any guarantee that a patient will survive, it should be used only as a palliative intervention in specific circumstances. Otherwise, there is no evidence that such intervention is beneficial for the patient’s health. However, the mistake of the nurse is a lack of explanation provided to the son willing to save his parent’s life. A nurse did not have enough information to think about both sides of PEG feeding.
Furthermore, the elements of interdisciplinary conflict, which had its major reflection on the situation, prove to be the primary reason of a breakdown. Such ethical conflict arises when the nurse continues to insist on the PEG feeding, while the patient’s son refuses to let him undertake the procedure. Thus, the contradiction continued as long as one believes that the assuring of the procedure is their responsibility. However, the conflict found its resolution by a nurse feeling that there was a need to support the patient’s autonomy and accept the son’s refusal. Nevertheless, both sides of the dispute pursued their points of view until the principle of autonomy has appeared, which should be prevailing in the practice. Finally, the situation included multiple commitments, which refer to the obligations of the nurse to both the healthcare professionals and family of the patient willing to receive a high quality service. All in all, the conflict had an interdisciplinary character, however, a complex view of the conflict allowed to see its characteristic features and reasons that led to misunderstanding, stress, and uneasiness.
To begin with, it is necessary to mention that the case included several ethical principles, which were violated in the process of dealing with the difficulties of taking care of the patient. Each specific case frequently violates one or another moral principle, which means that complex problems always lead to a conflict. The violation of the principles in the described situation was not intentional, however, it was based on the personal wish to take care of the patient and provide him with everything needed. The refusal of the son to take the procedure of PEG feeding became the object of the conflict, which led to the complex situation. Afterwards, the son’s response became a motivating factor for a nurse to make a false conclusion about his heartlessness. Which, in its turn, led to other violations of the ethical principles, which should have been followed. Despite of the fact that the non-compliance was not severe, there is a need to point at it and discuss its causes.
A lack of experience in nursing led to the violation of beneficence. On the one hand, this principle was established by the supposed performance to be in the interests of the patient. Considering all facts, the nurse was not fully aware of the influence of PEG nutrition on the patient’s health based on his illness. On the other hand, it contradicts another principle, the one of nonmaleficence. It means that each medical attendant must not perform the activities, which may potentially harm the patient. In the given situation, the attendant tried to insist on providing a patient suffering from dementia with PEG feeding, which in this instance would not be beneficial. Moreover, principles of integrity and totality mean that a caregiver accepts a patient as a whole, which means that there is a need to consider an overall effect of each treatment on the their organism. The PEG sustention can be applied only in specific circumstances, hence, each procedure needs to be specifically considered before insisting on it. Moreover, the caregiver turned to help of a social worker, potentially violating the principle of autonomy, which claims that every decision taken by a patient or his family should be the final decision. One should accept the decision taken by family or patient regardless of the attitude to this decision: “Advanced Practice Nurses are expected to be leaders in recognizing and resolving moral problems, creating ethical practice environments, and promoting social justice in the larger health care system”. Otherwise, a medical assistant creates tension by insisting on the procedures, considered inappropriate or ineffective by the receiving side. Fortunately, there were no severe violations that could have led to disappointing results. All in all, the information and the experience were the two missing components that composed some ethical barriers, which prevented medical assistant from acting in an appropriate way, while aiming to satisfy the patient’s needs.
The event under investigation had the diversity of ethical barriers, which prevented from the initial evaluation of the situation in its essence. Notably, the conflict was caused by the lack of knowledge on the treatment of the patient. On the one hand, a nurse acted in the interests of the patient and his health. On the other hand, they were mistaken in insisting on the procedure and making false conclusions about the son`s actions, by doing that they provoked an ethically complex situation. A sense of powerlessness was another barrier, which motivated the turn for the help of a social worker striving to convince the son in assigning PEG nutrition to his parent. A subsequent barrier, involving both sides, was an absence of trusting relationship with the son of the patient. Otherwise, a caregiver would have felt free to discuss the need of PEG feeding. Loss of confidence and powerlessness developed the inactivity in terms of the professional competence. As a result, the cooperation with the family of the patient in order to complete the healthcare service and rouse the process of the recovery became impossible.
In addition, the caregiver could not manage a patient-centered conflict due to insufficient competence and experience. Such diversity of barriers accompanied by stress and uneasiness resulted in the imbalanced performance. Regardless of the fact that contemporary workers have a broad range of responsibilities, carefulness should be a priority. However, at the moment of conflict, it was hard to navigate through the knowledge and information received earlier in the practice. In general, it is the role of practice to show the essence of each principle and teach the way to avoid routine barriers. They reflect the difficulty of choices, which a medical attendant had to make trying to act ethically appropriately in a complicated case. However, each action has to be initially revised in order to prevent devastating consequences and unexpected outcomes, which may contribute to the development of a social conflict.
In terms of the updated knowledge of the ethical perspectives of nursing, it is possible to review the problematic situation and locate the appropriate ways applicable to the encountered dilemma. The provided discussion is a reflection of the nurse’s actions in terms of the combination of such theories as deontology and principlism (Ethical Principles).
Deontology is an ethical theory in nursing, which concerns the diversity of theoretical backgrounds, aiming to generate the appropriate solution in any morally complicated situation. It focuses on the rights and duties that help respect each individual along with his needs and requirements. The remarkable peculiarity of the doctrine is that it emphasizes the individual’s intentions, rather than prioritizing the outcomes of any process in the healthcare facility. Deontology is appropriate for the solution of ethical conflicts if they involve duties, obligations, roles, and responsibilities of a healthcare practitioner. It defines the roles of every member providing patients with the services and care, which they require, and envisions every action performed in terms ethically appropriate duties. Other activities require revision and need a special regulation in order to act in terms of the defined responsibilities. Nevertheless, strict application of deontology may lead to the imbalanced representation of the activities performed by healthcare providers.
An additional doctrine required in the existing then situation is a theory of ethical principles or principlism. Principlism consists of four major keys of ethics in nursing, which include autonomy, non-malificence, beneficence, and justice. All these components could provide guidance in the solution of a dilemma. For example, it can help find the keys to the effective communication with the family of the patient, build trusting relations, and discuss the necessary points.
Both theories taken separately would assist with misinterpretation of information and improvement of the theoretical background. Whereas a mixture of the selected theories could help build a comprehensive approach towards usage of experience, knowledge, and personal character traits necessary for the overall improvement of the patient’s condition. In general, the proposed theories lead to the establishment of the effective management of complicated cases.
Practically, a medical attendant needs to gather enough information previous to assisting the patient. It is important to study the diagnosis and find the most efficient solutions, especially, if a nurse is not aware of the processes, which may harm or even waste health resources. According to Barbara Dossey, PhD, Florence Nightingale also emphasized ethical decision making in personal and professional aspects of life:
Florence Nightingale is indeed a role model for us when we are faced with ethical dilemmas. She saw ethical knowing as valuing and clarifying situations to create formal behaviors, expressions and dimensions of both morality and ethics intersecting with duties; today these would be considered legally prescribed duties. Ethical knowing included daily decisions of right and wrong; what should be done in practice, in personal conduct and behaviors; priorities; responsibilities; and advocacy for the patient, nurse, hospital, clinic, environment and society.
If a caregiver experiences the lack of confidence, it is important to clarify each point of uncertainty. Looking back, it is obvious that there was a need to gather information on clinical indications, the patient’s way of life, contextual factors, and the patient’s preferences. Furthermore, when any deviations from the normal dialogue with the patient and his treatment, evaluation whether the perplexity has an ethical character, and if it does, its object, is crucial. Thus, an effective communication with the son could prevent from further complications. Moreover, awareness of the possible negative outcomes of medical procedures in addition to a respect for autonomy could prevent a moral perplexity. Besides, all of such omissions would disappear with the growth of experience, knowledge, and competence.
The moral dilemma had a significant effect on a young nurse. It was hard to follow a principle of autonomy and believe that a patient does not need PEG nutrition. A significant level of discomfort occurred as a result of the feeling that the responsibilities of the medical worker were not completed. Subsequently, the inappropriate decision to insist on providing a patient with PEG feeding created much tension for everybody involved. With hindsight, building trusting relations with the family of the patient would have needed to be a priority together with preparatory research. When the situation is out of control, terms of any ethical theory might be covered by fear and stress, despite it, one should find patience and confidence to make the appropriate decision. The lack of information prevented the physician`s assistant from acting in terms of moral principles, resulting in a violation of autonomy and other ethical values. On the contrary, the evaluation of theoretical approaches, ethical principles, values, and nurse’s responsibilities helped build a comprehensive understanding of the rise of ethical dilemmas that would prevent such situation in the future. Needles to say, the research on moral problems would be continued in order to prepare for other possible ethical confusions with patients and their families. Nursing and prevention of ethical dilemmas associated with the nursing practice are one of the most valuable aspects of high-quality healthcare services. Further research should be another stage in the improvement of the personal knowledge and experience aiming to minimize the occurance of ethical problems.