ETHICAL SCENARIO TEAM ASSIGNMENT #2The Patient Who Needed Help Getting Out of Bed

Question Answered step-by-step ETHICAL SCENARIO TEAM ASSIGNMENT #2The Patient Who Needed Help Getting Out of Bed Isaac Livingston had led a good life. He had worked as a pharmaceutical salesman for 45 years before retiring 6 years before his most critical medical problems began. Now, at 72, he was hospitalized for what the nursing staff suspected might be his last time. He was suffering from carcinoma of the prostate that had metastasized to the bone and sapped his strength. His current hospital admission was triggered by several episodes of fainting, undoubtedly related to a serious drop in blood pressure. The pain of the tumor, the side effects of the medication (Dilaudid, 4 mg q 3-4 hours as necessary and chlorpromazine 10 mg qid as needed for nausea from the chemotherapy), and his lethargy combined to make him somewhat groggy. Moreover, Mr. Livingston often desired to get up and leave his room “to get some air” as he put it. To make matters worse, Mr. Livingston suffered from a partial paralysis of the left leg of some 15 years’ duration, apparently caused by spinal cord damage related to pressure from a spinal disc. All of these facts led the nursing team to be concerned about potential injury should Mr. Livingston fall getting out of bed. To protect him from such injury, Mr. Livingston was placed in a room across from the nurses’ station. His bed was lowered as close to the floor as possible, he was observed closely, his bed rails were raised at night, and he was instructed to press his call button to summon the nurse or nurse’s aide whenever he wanted to get out of bed. Despite these precautions, however, the nurses frequently found Mr. Livingston trying to get out of bed by himself without help. His safety became a serious issue the night Ms. Howard found Mr. Livingston on the floor at 1:00 A.M. Apparently, he had slipped to the floor while trying to get out of his bed. He was not injured, but he could easily have suffered some injury. To prevent this from happening again, Ms. Howard told Mr. Livingston that he absolutely could not leave his bed without someone else being present, left a light on in his room at all times, and moved his bed so that he could not get out of it without observation by the nurses. During the next day, Mr. Livingston vociferously objected to having to wait for a nurse or aide in order to get out of bed, use the toilet, or walk in the hallway—something he wanted to do quite frequently. Although he understood that these precautions were intended for his own good and that the nurses thought it was dangerous for him not to have someone accompany him when he was out of bed, Mr. Livingston intensely disliked all the constraints to his freedom. That evening, Ms. Howard was approached at the nurses’ station by Mr. Livingston’s son during visiting hours. The son explained that Mr. Livingston had been trapped in a burning building when he was a child and since then had been severely afraid of suffocating or being enclosed or otherwise confined in small rooms. He needed to be able to get out of bed and leave his room whenever he felt confined. Were the nurses’ constraints on his freedom absolutely necessary? This explained some of Mr. Livingston’s behavior, but Ms. Howard was still seriously concerned about the danger to a 72-year-old man, groggy with medication and partially paralyzed, falling as he attempted to get out of bed. It was her judgment that continued use of the protective measures were indicated for good nursing practice and Mr. Livingston’s safety. Ms. Howard explored her options. She could follow Mr. Livingston’s urgent request that he be allowed to get out of bed without assistance whenever he felt like it. Or she could insist that, in her clinical judgment, good and safe nursing care required nursing assistance and close observation. Then again, she could ask for guidance from the resident on call or ask that Mr. Livingston’s physician to be consulted in the morning for an increase in the patient’s sedation, which would make it unlikely that Mr. Livingston would try to get out of bed for any reason.Commentary The problem faced by Ms. Howard and her colleagues, at first, seems rather mundane. Placing Mr. Livingston’s bed across from the nurses’ station and requiring him to call for nursing assistance when getting out of bed hardly falls in the same class of moral controversy as the more exotic ethical issues of genetic manipulation, defining death, or even discussing a terminal diagnosis with a patient. Yet, upon reflection, it is clear that evaluations took place throughout Ms. Howard’s interaction with Mr. Livingston. The brief case report presented here is full of value judgments. Mr. Livingston’s life was a good life. He was suffering from carcinoma of the prostate and from partial paralysis. Suffering must necessarily be considered an evaluation. One cannot suffer and judge the sensation to be good in this respect. The evaluations continue in the account of the immediate problem facing Ms. Howard. Mr. Livingston found it desirable to get out of his room, whereas the nursing team was worried about injury, something that necessarily has a bad connotation. Moreover, Mr. Livingston protested vociferously and objected to constraints on his freedom, many times. On the other hand, Ms. Howard was concerned about the danger to Mr. Livingston’s health if he did not have nursing assistance when out of bed. Three different levels of evaluations are taking place: choices about mental and physical health, choices about more fundamental value orientations, and choices about what is ethically acceptable behavior. At the first level, evaluations related to physical and mental outcomes seem to be in conflict. The nurse was naturally concerned about the real and significant physical risk to Mr. Livingston if he were free to get out of bed at will in his mildly sedated and disoriented state. Mr. Livingston, on the other hand, seemed to have a rather different agenda. He was relatively unconcerned about the risk of physical injury from a fall, but he was extraordinarily concerned about the psychologic sense of well-being that came from being free to move about and “get some air.” That concern was, in part, derived from a unique experience in Mr. Livingston’s past. When Ms. Howard learned from Mr. Livingston’s son of Mr. Livingston’s history and preferences, she was able to include in her considerations the unique psychologic trauma brought about by constraints on his freedom to get out of bed at will. Still, however, she did not reach what was apparently Mr. Livingston’s conclusion—that on balance, greater benefit would come from avoiding all constraints on his freedom. It could well be that the two simply compared the importance of avoiding physical injury and psychologic distress differently. If avoiding a broken hip is worthy of substantial psychologic trauma, then Ms. Howard’s evaluation regarding the two kinds of benefits makes sense. If, on the other hand, one places more emphasis on the potential psychologic harm involved, then Mr. Livingston’s behavior is understandable. So far, this suggests only that differences are possible in essentially nonmoral evaluations. It does not yet get us to the level of ethics. However, other levels of evaluation may be going on in this case. Underlying the specific evaluations of physical and mental outcomes may be a second level of evaluation involving deeper, more fundamental beliefs and values. These more basic evaluations are sometimes called value orientations or, taken together, a “worldview.” They deal with the human’s relationship with nature, whether one ought to be active and aggressive or more passive in letting nature take its course, whether it is better to be oriented to goals in the future or to focus more on the present or past, whether people are to be regarded as tending toward good or evil, and how individuals relate to other individuals and teams. Individuals as well as cultures tend to take stands on these basic value orientations. Moreover, they sometimes regard them as moral obligations rather than simply matters of preference. People sometimes believe they have a moral duty to plan for the future or to avoid intervening aggressively with the natural processes. It is possible that differences in basic value orientations will, in part, account for disagreements over what counts as good nursing care of patients. In Mr. Livingston’s case, physicians and nurses have made judgments about proper medication levels, but these are not the only possible levels of medication. For example, if Mr. Livingston were to remain in pain, the nurse could increase the administration of Dilaudid up to the prescribed amount. Because the narcotic has been authorized for use “as necessary,” certain judgments must be made balancing pain relief and side effects of the medication. In this case, because the sedating effect of the medication is creating a significant part of Mr. Livingston’s risk, the nurse has several options. If the nurse takes the view that the role of the health professional is to make full use of pharmacologic and other medical means to control natural processes, the nurse could take steps to increase the narcotic to the limits of the prescribed amount. The nurse could even go beyond that, asking the physician to increase the dosage. More frequent administration, higher dosage levels, or adding a drug with tranquilizing effects are all available options. They would reveal a take-charge value orientation leading to increased pain relief, mood alterations, and even more sedation, perhaps decreasing the tendency for Mr. Livingston to want to get out of bed. These actions would constitute the use of chemical restraints on Mr. Livingston’s autonomy. On the other hand, if the nurse took the attitude that the health professional should use great caution in tampering with natural processes, the toxic and addictive potential of the drugs might be feared to the point that blood levels would be lightened as much as possible. The nurse could, for example, extend the time between administrations of the doses of both the narcotic and the anti-nausea medications. This attitude of respect for natural processes in its extreme form could lead to abandoning narcotics altogether in favor of Tylenol or other analgesics presumed by many to be nonaddictive. One of the effects of working from this value orientation might be the reduction of sedation to the point where Mr. Livingston’s risk of falling due to dizziness or a feeling of dis- orientation would be lessened. At the same time, however, he would be able to be more active in getting out of bed, thereby decreasing his chances for injury. These basic differences in value orientation begin to sound like differences in what may be called ethical values. They are often perceived as differences in obligation rather than mere personal preferences. A nurse might argue that it is wrong, even morally wrong, to sedate a patient in order to avoid having to watch a patient closely or to put in a Foley catheter in order to avoid having to help a patient out of bed to the bathroom. The nurse might also argue that it is morally wrong to eliminate the problem by lightening a patient’s medication to the point that he or she is in excruciating pain or nauseated from chemotherapy or by adding medication that makes a patient more compliant with the nurse’s instructions. Beyond these value orientations, there is a third level of evaluation going on in Mr. Livingston’s case. It is at this level that true moral judgments are involved. True moral problems are likely to arise if Ms. Howard remains convinced of her conclusion that preventing Mr. Livingston’s getting out of bed without assistance is in his interest, on balance, even after she learns of the uniquely discomforting psychologic impact on him. If, under those circumstances, Mr. Livingston continues to insist that his freedom to move about at will should not be constrained, we have before us one of the classical ethical problems in healthcare ethics. If the nurse acts on the traditional, rather paternalistic principle that she should do what she thinks is in Mr. Livingston’s interest, he will not be allowed out of bed without assistance, morally violating his autonomy (and possibly raising legal questions). If, on the other hand, she acts out of the principle of respect for the autonomy of persons and allows Mr. Livingston to move about at will, she temporarily abandons her commitment to the health, well-being, and safety of the patient. Good nursing care will be directly dependent upon whether the nurse should act to promote autonomy or should act to do what she thinks is in the interest of the patient’s health, well- being, and safety. Which ought to be done is a matter of ethical principle. Even if Ms. Howard decides to abandon her conception of patient welfare in order to promote Mr. Livingston’s autonomy, she may consider the impact of the decision on other patients, coworkers, or herself. In not requiring Mr. Livingston to have nursing assistance in getting out of bed, Ms. Howard may feel compelled morally to spend more time checking on Mr. Livingston, thus providing less adequate care for other patients. If the patient falls again, as anticipated, she and the other hospital staff will have additional burdens. Even if the hospital is so well staffed that other patients are not put at additional risk, Ms. Howard and her coworkers will still suffer the inconvenience of extra work and worry in the form of an incident report. On the one hand, it is ethically questionable that a nurse should sedate a patient simply to lighten her workload and avoid a potentially troublesome situation; on the other hand, nursing ethics has to include the question of the limits of the burden a patient should be able to put on a nurse or coworkers. It seems that there should be some moral limit on how much extra work a nurse should have to do to cater to the idiosyncratic preferences of a single patient. In dealing with these concerns about the interests of other parties—the other patients and the nurses—a full analysis of the ethics of nursing practice has to consider the legitimate moral role of various social interests. Is the welfare of others totally irrelevant morally, as some traditional ethics would have us believe? If not, is it the aggregate total of benefits and harms of an action that count? Or do certain kinds of benefits and harms take precedence—benefits to the neediest, for example? Finally, when Ms. Howard explores her options, she has to take some stand on the ethics of her relationships with other professionals and with the patient. In deciding among her options, she will have to decide whether she stands in a relationship of obligation with the patient, her nursing colleagues, the hospital administration, the resident on call, Mr. Livingston’s attending physician, and others in her personal life. Morality is, in part, a matter of loyalty and fulfillment of commitments. If Ms. Howard feels bound morally to the profession of nursing as a source of moral insight, she may well turn to sources within the profession for help in resolving her problem. She may consult a code of ethics, standards of nursing practice, or the advice of her nurse colleagues. If she feels bound in loyalty to the hospital as an institution, she may consider the legal liability of the institution as well as the standards for appropriate care established by the hospital administration. If she feels obligated to the physician involved in the case as her source of authority, she will turn to him or her for advice or even for “orders.” If she sees the patient as the center of moral authority regarding his own care, she may yield to the patient—not only on the question of restraints on his freedom but also on what moral norms ought to be used for resolving the problem. Finally, because she has other centers of moral loyalty in her personal life—her church, her family, her personal system of beliefs and values—she will have to decide how these are appropriately integrated into the decision.Using the above information, apply this scenario to the ethical decision-making framework:1. An INDIVIDUAL Reflection on the Case and Commentary. One team member will combine all of your individual reflections into one document to be submitted. It’s important as a team to take the time to see and understand everyone’s perspective.2. Your team will identify the following using the framework:Who is involved in the caseThe Ethical IssueEthical Values – CNO/CNA- Identifies and describes all relevant ethical values in this case scenario.Ethical Principles – CNA-Code of Ethics- Identifies and describes all relevant ethical principles involved in the case scenario.Legalities – Identifies all relevant acts, standards and regulations involved in this case scenario.Options and Alternatives – Identifies at least 2 options for action to solve the ethical issue Course of Action – Identifies the step by step action plan including the rationale for the choice. Health Science Science Nursing NLM 201 Share QuestionEmailCopy link Comments (0)