CASE 2Manguba, Mangubat, Mansukhani, Manzana,

Manzano, Maranion, Marayag, Marcelo, Marcial

Bioethics III

E.P., a nurse in the intensive care unit takes care of Lola, a 70 yr. old with terminal colon cancer who is suffering from pain which has been increasingly difficult to control. The attending physician has ordered moderate doses of morphine. The family was told that at these doses it may depress respiration and therefore may possibly hasten death. Lola and her family have accepted her condition. All the members of the team except E.P. see no problem in giving her an increasing dose of morphine.

Case 2

E.P .believes that the morphine may hasten Lola’s death thus she cannot in good conscience, give the injection. The attending physician regards her refusal as a serious form of disobedience. One night Lola became very restless and unable to sleep and was on severe discomfort and was asking for the injection, E.P. refused even with the pleading of her daughter.

Case 2

1. Do nurses have the right to refuse medical orders?

2. Do they have the right to ignore the wishes of the patient and the family on grounds of conscience?

Discuss the ethical issues involve in this case.

Questions:

DOCTOR-NURSE RELATIONSHIP

Doctor-Nurse Relationship• Primary bond is mutual concern for patient• Nurses should NOT BE FORCED to follow orders

if they are contrary to standards if good medical-nursing practice

• We have an ethical obligation to explain to the nurse concerned any order that they may consider as contrary to customary medial and nursing practice

• Philippine Nursing Code of Ethics– obligations to the patient takes precedence over the

nurse’s duties to the colleagues and employees

Autonomy Double effectBeneficenceNon-malefecence

Principles

AUTONOMY

AUTONOMYGreek: autonomia, meaning "self-rule." Capacity for self-determinationRespect the choices and wishes of persons

who have the capacity to decide and protecting those who lack this capacity

to acknowledge that person’s right to make choices and take action based on that person’s own values and belief system.

DOUBLE EFFECT

Double EffectThe action must not be intrinsically evil.The direct intention of the agent must be to

achieve the beneficial effects and to avoid the foreseen harmful effects as far as possible, that is, one must only indirectly intend the harm;

The foreseen beneficial effects must not be achieved by the means of the foreseen harmful effects, and no other means of achieving those effects are available;

The foreseen beneficial effects must be equal to or greater than the foreseen harmful effects ;

The beneficial effects must follow from the action at least as immediately as do the harmful effects.

BENEFICENCE

Beneficenceis to produce benefit, to do good, to

always act in the best interests of the patient whatever is done or said must be for the

patient's good includes being honest with patients, which in

nearly all circumstances will be of benefit to the patients

patients should not be subjected to unnecessary investigations

Beneficencepatients should not be subjected to

unnecessary or futile therapies applies not only to physical good but also to

psychological, social and existential well-being must be distinguished from paternalism

('doctor knows best')

NON-MALEFICENCE

Non-maleficence• is to minimize or do no harm – whatever is done or said must not harm the

patient, physically or psychologically – includes being honest with patients; lying to

patients or telling only part of the truth will very probably cause harm

– for every intervention, the potential benefits must be weighed against possible adverse effects

– treatments should not be prescribed unless there is a strong chance they will help the patient and only a small chance of unpleasant

– adverse effects

Withholding or Withdrawing Treatments

Withholding or Withdrawing Treatments

• The goal of palliative care is to maintain the quality of life while neither hastening nor postponing death

• death is the natural end of life • there is no ethic, in any culture or religion,

which say that a terminally ill patient must be kept alive by any means

• what matters is the quality of life left to the patient, not the time which is left to them

• palliative care must never become an exercise in prolonging life

• Whether it is appropriate to offer or to withhold or withdraw a particular therapy depends on the balance between the possible benefits and the potential risks of the treatment, i.e. what is in the patient's best interests

• it will depend on individual clinical circumstances

• it is often difficult and complex • futile therapy, with no chance of benefit (“You

have to do something!”), can never be justified

depends on many factors, including the patients' nearness to death the wishes of the patients and their families the expected benefits from the patients' point

of view

The following excerpt is adapted from the book, Speak Your Truth: Proven Strategies for Effective Nurse-Physician Communication, HCPro, Inc. 2004:

 When I have a good working relationship with a physician, I feel comfortable approaching him or her, asking questions, and more respected for my own expertise. And the patient also benefits because they receive the best care.

-Lynsi Slind, University of Washington MSN student

Nurse Physician Workplace Collaboration

Collaboration is a complex process that requires intentional knowledge sharing and joint responsibility for patient care.

In the interest of safe patient care, neither profession can stand alone, making good collaboration skills essential.

Each health care profession has information the other needs to possess in order to practice successfully.

Three categories of collaborative strategiesself-developmentteam-developmentcommunication-development

Self-Development Strategies• Develop Emotional

Maturity

• Ideally, physicians and nurses have matured as individuals so that they possess a balanced understanding of their professional contributions and limitations, and the contributions and limitations of others.

• Mature team members are life-long learners, vigilant in identifying the latest best practices and in keeping their skills current. 

• Understand the Perspectives of Others

Physicians and nurses do bring different perspectives to patient care but It can be seen as an asset rather than a detriment to patient care.

Physicians and nurses can discover their common goals and collaborate in patient care, with patient well-being as the central focus.

• Avoid Compassion Fatigue

 Timely lifestyle changes and self-care measures are critical to prevent these negative states that work to the detriment of effective collaboration.

• Compassion fatigue and burnout can also pose barriers to effective communication.

Team-Development Strategies Build the Team

Collaborative practice is a drawing together of the valued contributions of all team members to reach the best possible solutions.

Through the competence and commitment of collaborative group members, valuable partnerships are created.

Collaboration requires intentional team building.

A common goal of patient well-being also enhances team unity. 

• Negotiate Respectfully

It is best to function and negotiate within hierarchical structures and respect the chain of command.

It is never wise to jump over levels of authority to be expedient.

When mutual goals and respect are woven into the fabric of a workplace, issues of hierarchy become secondary to the sharing of knowledge by competent group members.

• Manage Conflict Wisely

When conflict is acceptable, multiple solutions emerge.

Encouraging productive conflict without destroying group cohesiveness requires mature team members and humble, practiced leadership.

Healthy conflict is a sign that diverse ideas are welcome at the table.

Avoid Negative Behaviors

Productivity and positivity can counteract debilitating influences and restore team

...be frank while remaining flexible and open-minded.

Communication-Development Strategies Getting the facts

from informed sources, not blowing issues out of proportion, responding promptly and calmly, and divulging only what others need to know and ethically ought to know.

When communication is precise and unencumbered by unnecessary detail, collaborators are more likely to perceive interactions as beneficial.

Q1: Do nurses have the right to refuse medical

orders?

Yes, they do

Philippine Nursing Association’s Code of Ethics

Obligation to the patient takes precedence over the nurse’s duties to colleagues and employer.

Conscientious objection

The nurse who finds her/himself involved in practices of which his/her conscience do not approve of, will make every effort possible to bear witness to her/his personal conviction

Primary bond is mutual concerns for patients

Nurses spend more time with patients so listen to what they say as expressed by patients

must work as a team for the best interest of patient

Respect nurses as sharer of responsibility and team member and not just a subordinate.

Does the nurse have the right to ignore the wishes of the patient and the family

on grounds of conscience?

YES

The nurse as a conscientious objectorNurses who find

themselves in situations wherein the proposed patient care clashes with the nurse's religious or personal beliefs are sometimes referred to as conscientious objectors.

https://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=797663

The nurse as a conscientious objectorThe classic examples of a

nurse becoming a conscientious objector arenurse in the obstetrics unit

who does not want to participate in an abortion

administering certain contraceptives

withdrawing life support and feedings

participating in an assisted suicide

transfusing blood products.

https://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=797663

Conscientious objectionConscientious objection

in the healthcare setting can be defined as the refusal of any member of the healthcare team to take part in some aspect of care for a patient on the basis of conscience.

3 characteristics of Conscience 1. an internal sense of

responsibility that influences judgments regarding right and wrong actions,

2. the consequence of internalization of norms and mores of the culture, and

3. a representation of the uprightness and totality of the person.

Patient Abandonment Versus Refusal of an Assignment

Patient abandonment occurs when the nurse engages in a patient assignment and ceases to provide nursing care without appropriately transferring the responsibility for the patient to another professional nurse

When the nurse accepts a patient assignment, the nurse maintains responsibility for that patient until :1. the nurse-patient

relationship is ended by the patient's discharge

2. the transfer of responsibility to another nurse, or

3. the patient's refusal of the nurse's services.

• The ethical physician should neither expect nor insist that nurses follow orders contrary to standards of good medical and nursing practice. In emergencies, when prompt action is necessary and the physician is not immediately available, a nurse may be justified in acting contrary to the physician’s standing orders for the safety of the patient. Such occurrences should not be considered to be a breakdown in professional relations. (IV, V) Issued June 1983; Updated June 1994.

RESOLUTION

First is that as physician it is our duty to assure and clarify to the nurse that giving the morphine for pain relief of the patient is different from assisting the patient to die. However, if EB would still insist upon not giving the morphine then he should be excused for a conscientious objection to an act that is personally morally unacceptable. In which case, if no other would like to administer the drug then the doctor himself must do the act of administration.

Resolution