Standard of Practice 7: Ethics
In the ANA’s Nursing: Scope and Standard of Practice book, 2010 edition, one of the responsibilities of the registered nurse is to practice ethically. The registered nurse must be able to deliver care in a manner that preserves and protects healthcare consumers autonomy, dignity, rights, values, and beliefs.The registered nurse must also be able to assist healthcare consumers in self determination and informed decision-making. These are the two points I will write about here, because I was able to apply this standard in practice during one of my recent management shifts.
One of my patient’s, a young and healthy 29 year old woman, arrived at the hospital over the weekend (Saturday night) and was diagnosed with pyelonephritis. She was transferred to the Med Surg floor for observation and antibiotics. She is 15 weeks pregnant, and her husband does not leave her side. He sleeps in the pull out chair every night and makes sure that her every need is met. He often speaks up for his timid wife, asking for pain meds, updates of her status or if they can walk the halls. They are a very sweet and happy couple and they’re both very excited with the thought of having their first child. At about day 2 of their visit, I can sense their desire to get home and out of the hospital. However, this is not an option for the patient because during the early hours on Monday, the patient complained of having chest pain and SOB. Her telemetry box showed her heart running tachycardic on the monitor. An EKG was done, and troponin labs were drawn. Both the EKG and troponin’s gave normal results. Then Tuesday, a 2D echo was ordered and I still don’t know the results, because my shift concluded before the echo was read. However, I was able to attend a serious conversation between Dr. Brown who is a pulmonologist and the patient.
Dr. Brown walked into the patient’s room, sat down on the end of her bed and started asking the patient questions. The questions included wether or not she had taken a recent long flight, her medical and surgical history, her activity status, and wether or not she or any of her family had ever had a blood clot or died from a blood clot. She answered “no” to the everything; no recent long travel, no medical or surgical hx, and no family history of blood clots. Then he continued in a very clear, un-rushed and empathetic manner to give his opinion for why he felt she was experiencing chest pain and shortness of breath. He explained to the patient that because she is pregnant and the composition of her blood has changed, she has a higher risk of developing a blood clot. Additionally, because she has been in the hospital for several days, and because of the fact that she had not received Lovenox or used SCD’s (because she is young and sometimes we assume young patients don’t need theses preventative measures) and she has been in bed much of the time, that increases the risk of blood clots. But most importantly, her sudden symptoms of shortness of breath, tachycardia and chest pain are all indicators of a pulmonary embolism. He continued by saying that sometimes a pulmonary embolism resolves and isn’t a problem in a young patient, but then that same patient is very likely to have a second occurrence, which can kill the patient.
Then Dr. Brown gave the patient her options, and this is where ethics comes in to play. He started by sharing the dilemma the patient and her husband would have to face. Because the patient was so early on in her pregnancy, doing a chest x-ray and using the dye involved could cause harm to the fetus. So, how would the doctor or patient know wether or not a pulmonary embolism was the culprit for the sudden onset of symptoms? Because of the nature of a pulmonary embolism and the severity of the diagnosis, it’s not something one should take lightly. The mother and fetus could die if not treated. It was at this point that Dr. Brown took note of the scared and unsure patient and her husband, and that’s when he cut to the chase and gave them their options. Option 1: “You receive Lovenox injections for the rest of your pregnancy. The only downfall is that it’s an expensive route, about $100 a day, and no normal person can afford that, so we can set you up on some kind of program to help you financially.” Option 2: “You have the x-ray done, and wear a lead shield, which will help protect the baby but the dye that is used can cause harm.” Option 3: “We keep you here for a few more days and give you the Lovenox injections, observe how you do, and do an ultrasound on your legs to see if you have any blood clots there. If you have clots in your legs, then there’s a good chance a pulmonary embolism was the culprit.” Option 4: “You do nothing and take your chances”. Doing nothing is always an option for the patient, wether we like it or not.
The patient and husband were clear on their options, and also fairly quick on deciding how they wanted to proceed. They chose option 4: do nothing. The husband gave his rationale by stating, “It was just a few hours of these symptoms and she feels fine now and hasn’t had a problem since. I really think it could be from all of the fluid she got. She has had 6 bags of fluid, and now that she isn’t getting it anymore, she feels fine.” Dr. Brown followed with, “It’s very standard for a patient to receive that much, especially with an infection.” Dr. Brown continued to listen as they waffled back and forth and tried to justify the symptoms. Then Dr. Brown said to them, “ I know you’re scared and there are lots of options, but please talk this over. We will leave you alone to think and discuss everything.” Then right before he left the room, he leaned over the end of the bed, placed his hands on the patients feet and gave a light squeeze, then he pleaded with the patient to at least have the ultrasound done on her legs before leaving. The patient stated “We believe in God, and he’ll take care of us.” Dr. Brown then ran to the phone and placed a “favor” call to what sounded like an old friend, “Hey man, can you do me a huge favor. I know we’re at the end of the day, but I have a young lady here who I suspect has a PE. Is there any way you can squeeze her in for an ultrasound? I don’t want her or her baby to die…….ok, uh huh…..oh, thank you so much, I appreciate it.” And like that, the ultrasound was on the check-list of patient care for the evening. When I went back in to inform the patient that they could squeeze her in for the ultrasound before leaving, she and her husband said “no”.
How can you say “no” to that?!?, was the immediate question that popped up in my head, but did not exit my mouth. This is where ethics comes into play. This was my opportunity to put into practice Standard of care 7, which states: The registered nurse must be able to deliver care in a manner that preserves and protects healthcare consumers autonomy, dignity, rights, values, and beliefs. I’m not going to lie, it wasn’t easy. I understand the decision to deny an x-ray, I’d have denied that too. But, a very quick and un-invasive ultrasound, that could cause no harm to mom or fetus seemed like an obvious option. The nurse manager, my preceptor and myself made sure the patient and her husband was well aware of all her options, and tried to make sure there were no hurdles the patient was trying to overcome when making her decision. There may have been a moment or two when the nursing staff involved wanted to go in and scare her into staying, yell at her for making what we thought was a bad decision, or beg her to stay for the sake of her baby at least. But that’s not an option. Instead, we have to honor the patient’s decision and do it kindly, without a “your crazy” or “I hope you know what you’re doing” or “mad” face. That’s what I did. When I went back into the room to remove the patient’s IV, help her pack and get dressed and sign the form to leave AMA (Against Medical Advice), I made sure to do it kindly and without a guilt trip. I gave my patient a hug, and wished her and her husband all the best. I also congratulated them again on their pregnancy, and said that I hoped to see the baby someday….in the grocery store while shopping with momma.
There are many ethical conflicts that arise when dealing with patients in the hospital. Every person who visits the hospital has a different story and a different life then the next person. Each person has a different set of values, thoughts, beliefs and feelings. We as nurses, don’t have the right to interfere with those thoughts, beliefs or feelings. Yes, we can offer up our opinion is asked, and we must state the risks to a patient who may be putting themselves in danger, but if we’ve given the patient all the tools and knowledge possible, we have to let the patient decide. We have to treat the patient kindly and with respect, despite wether or not we think they’re making the dumbest decision they will ever make. It’s our duty. I hope and pray the mom and baby I cared for will remain safe. That’s all I can do now, because the rest is out of my hands. It’s hard to step back, because I went into nursing to help people and help save lives, and I felt helpless to do that with this patient. But, perhaps I still helped her with my kindness and support of her decision.