BIOETHICAL

Situation 1:
Dina Navarro has accepted a position as the nurse manager in a very busy emergency
department. Among Dina’s many responsibilities is assigning nurses to work each shift, 24
hours a day, 7 days a week. Another responsibility is implementing the hospital’s policy of
offering all patients the right to an advance directive for end-of-life care. Dina must also ensure
that each patient who enters the emergency department receives appropriate, high quality care
from competent, professional care providers who respect and respond to patient’s individual
needs and desires. With these responsibilities come challenges, sometimes so significant that
the nurse manager is faced with ethical dilemma.
QUESTIONS:
1. How will ethical and bioethical issues in nursing and health care affect my professional
nursing practice in the future?
Ethical issues in healthcare includes maintaining patient privacy and confidentiality,
staffing patterns, advance care plan, advocating and protecting patients rights in
different private settings and autonomy and informed consent. These issues in the
clinical practice might become a problem in my nursing practice in the future because
maybe as a young nurse I will likely to be burnt out taking into consideration the situation
here in the Philippines wherein understaffed and underpaid is likely to happen.
According to a research by Ulrich (2010), younger nurses and those with less years of
experience encountered ethical issues more frequently and reported higher levels of
stress. That being said, it might also challenge me emotionally and psychologically.
Summing all the difficulties about ethical issues, I might not be able to provide high
quality care to clients, alleviate their suffering and I might not be able to preserve my
own integrity.
2. What ethical theories and principles serve as a basis for nursing practice?
Ethical principles include autonomy, beneficence, justice and non-maleficence, veracity,
confidentiality, fidelity and accountability. Autonomy is respecting the decision of the
client and the family. Informed consent is a method that respects a person’s autonomy.
Non-maleficence is avoiding and doing no harm during the performance of nursing
actions. Beneficence is doing good which is done by balancing the benefits and risk for
harm, providing helath benefits to clients and considering how a client can be best
helped. Justice is the equal and fair distribution of resources which is done by ensuring
fair allocation of resources by appropriate staffing to all clients and determining priority in
treatment care. Veracity is the principle of truth telling grounded in respect and the
concept of autonomy. In the principle of veracity, the nurse must make sure the patient
understood the information before the client makes a decision. Confidentiality is making
sure all information about the client remains private. Fidelity is the principle that requires
loyalty, fairness, truthfulness, advocacy and dedication to clients. Accountability is the
definite standard that measures a professional in a situation that is unclear. These
principles of ethics always guide nurse’s action and decision making in the clinical area.
3. How can I assist patients and families who face difficult ethical decisions?
I will assist patients and families who face difficult ethical decisions by providing them with all
the information about the treatment, making sure that they understand the risk and benefits and
the client is capable of doing the decision about his care and not being coerced by a relative or
other close individual to make certain decisions. In case that the client himself is not able to do
the decision, making sure that the family member or the decision maker take into consideration
the past beliefs, ideas and expressed wishes of the client. I believe that as nurses we can only
offer options, information and support for their decisions.
Situation 2:
The 80-year old patient had not issued a legal advance directive for her care before her
hospitalization. Once admitted to the ED, she was in no condition to be counseled about the
advance directive concept.

QUESTIONS:
1. Plan and implement a strategy that could have prevented this ethical dilemma.
End-of-life care and advance care planning discussions may also be initiated during
outpatient setting, not only during past hospitalizations. Decision-making about the end
of the client’s life should occur over years and not just minutes or days before the client’s
death. It should be discussed when the client is able to do decisions for himself. Ask
about her plans and beliefs regarding the possibility or probability of the client’s
impending death. The client and the family should both participate in decision making,
including identifying the use of advance directives about the client’s preferences at the
same time respecting the client’s autonomy. In these ways we can prevent the ethical
dilemma of unissued legal advance directive for her care during impending death.
2. During a brief stable period, the patient calls her nurse to her bedside late at night. She
asks the nurse whether the medication for her pneumonia is working. The nurse is fully
aware that the aggressive antibiotic not only is ineffective for the pneumonia but is also
causing significant adverse effects. Discuss the nurse’s ethical obligation to truth telling
versus obligation to encourage, instill hope and inspire a will to live.
Abiding with the principle of veracity, the nurse has the responsibility to tell the truth with
regards to her treatment. Being honest is difficult when we know the treatment isn’t
working for our client and we can’t alleviate their suffering. Nevertheless, we are still
obliged to encourage the client through helping client recognize areas which she has
control versus those that are not within her control. Discussing current options and list of
actions that may be taken to gain some control over the situation and correcting
misconceptions expressed by the client might also instill hope. Lay out all the
information, its pros and cons and let the client decide. The nurse should also help the
client process her emotions by letting her vent out and listening actively, just to make her
feel that someone is there for her.
 3. Later that night, the patient expresses to her family and health care providers her desire
to forego further resuscitation efforts. Her family does not agree with her decision. The
health care providers believe that the patient is sufficiently competent to make her own
choices. However, a second cardiac arrest occurs before legal action is taken. Discuss
the issues involved when patients, their families and health care providers disagree.

There are certain issues that may arise when patients, their family and health care
provider disagree. Concerns include managing family disagreements, inadequate
education for providers and limited time to complete legal action. Without DNR order,
the health care team has no choice but to proceed with CPR taking into consideration
that the benefit outweighs the risk but if it’s the other way around, the surrogate decision-
maker must decide whether to withhold or continue CPR. In this scenario wherein the
client decided to forego further resuscitation efforts and no legal action was taken, the
health care provider should explain the risk and benefits of CPR to the family members
and respecting their autonomy. When the preference of the client and her family is in
conflict, the only thing that the nurse could do is to respect client’s autonomy and
support the family to adjust to the impending death of their family member.

4. Late in the course of the treatment, the physician is faced with a decision about whether
to institute parenteral nutrition. The family asks the nurse manager about the choices
involved in the decision. Describe how a nurse might respond to the family.
The nurse must listen to the concerns of the family regarding the course of treatment at
the same time honoring the recommendation of physician. Explain to them the risk and
benefits of the treatments and tell them that the physician will explain it to them further
and remind them that whatever decision they have to make about the treatment will be
honored. After that the nurse should be and advocate for the client and discuss potential
outcome of the treatment with the physician and the family.

5. Given the entire scenario of this patient’s care needs, describe the kind of professional
nurse the patient needs.
The kind of professional nurse the patient needs might be a nurse practitioner. Nurse
practitioners are registered nurse who are formally trained in caring for the sick and have
knowledge of how to diagnose, treat and manage many common ailments. Generally,
nurse practitioners perform the important task of educating clients about preventive care
and prescribed treatment.

LEGAL ISSUES IN NURSING AND HELATH CARE

Situation 1:
Cristine Diaz is a Registered Nurse employed in the ED of a large for-profit hospital. The facility
treats the clients who are privately insured and individuals with Medicare coverage. Nurse Diaz
is the assigned triage nurse when Mr. Juan, a 48-year old man, walks in for evaluation. He
states that he has persistent, mild substernal pain that is now radiating laterally toward both
shoulders. His skin is pink and dry, and he does not appear to be in obvious distress. He reports
eating half of a garlic pizza and drinking three beers 1 hour ago. “I’m pretty sure it’s just
indigestion. This happened before when I ate garlic.” He also tells the nurse, “ I know I’m
supposed to go to community hospital; I have ‘Feel Well’ insurance, but I’m miserable and don’t
want to drive 10 kilometers across town in rush traffic with this much pain.
Mr. Juan is enrolled in a health maintenance organization (HMO). The HMO may not reimburse
the for-profit hospital for Mr. Juan’s visit if it is determined that his condition was not a true
emergency after review by the HMO’s utilization review department. In that case, Mr. Juan will
have to pay out of pocket for the medical evaluation and care received in the ED. In this cost-
conscious health care environment, the nursed in the emergency department are well aware of
the financial losses the hospital has recently suffered as a result of unpaid emergency services.
Nurses in this facility are expected to contribute to the facility’s success in reducing operating
costs.
QUESTIONS:
1. What is Nurse Diaz’s legal duty in this situation?
Nurse Diaz will provide all aspects of nursing care according to standard of care but also
complying with centers for Medicare and Medicaid services. Nurse Diaz must
communicate, document and report to appropriate personnel with regards to the present
case.
2. What legal principles underlie the nurse’s obligations to the patient?
The legal principles that underlie the nurse’s obligation to the patient include
understanding the law, knowing the standards of care, nursing practice acts and client
advocacy. According to ANA provision 3, the nurse promotes, advocates for, and strives
to protect the health, safety and right of the patient. No matter what, it is the
responsibility of the nurse to assess and monitor, follow standards of care,
communicate, document, act as a patient advocate and follow the chain of command.

3. What laws, if any, would govern the nurse’s decision-making process in this case?
In the Philippines, there is RA 11223 which is known as the Universal Health Care Law.
This law seeks to progressively realize universal health care in the country through a
systemic approach and clear delineation of roles of key agencies and stakeholders
towards better performance in the health system and ensure that all Filipinos are
guaranteed equitable access to quality and affordable health care goods and services,
and protected against financial risks. We also have statutory laws and federal statutes.
Violation of these laws is subjected to fines and imprisonment. It is not right to turn
down clients seeking medical help, because they have the right to be treated.

4. If Mr. Juan is not evaluated or treated and suffers a myocardial infarction while driving to
community hospital, who would be legally accountable for his injuries? The nurse? The
for-profit hospital? The HMO that may not have reimbursed for services?
The nurse will be legally accountable for the injuries of the client. It is because
according to Institute of Medicine (2010) there is a new rule that requires nurses to be
greatly equipped with evidence-based patient care, case management and discharge
planning. It is of the nurses own judgment to discharge the client from the emergency
department without considering certain laws and grounds for negligence. Ignorance of
the law excuses no one.
Situation 2:
A new graduate nurse is working in the pediatric intensive care unit. She has been employed a
total of five months, 3 of which were spent in orientation. Her patient, a child with a cardiac
defect and pneumonia, is very unstable and has required increasing supplemental oxygen
during the night. This is the most complex and unstable patient the new nurse has cared for.
The physician has been called four times during the night with reports of the deterioration in the
child’s status. Telephone orders have been issued each time but have not yet resulted in the
patient’s improvement. The nurse has kept her charge nurse appraised of the child’s changing
condition and physician’s orders. The charge nurse advises her, “Try to get the doctor in here a
little earlier this morning and make sure he sees your patient first; she’s not looking good.”
Twenty minutes later, the child arrests and cannot be resuscitated.
a. What are the four elements that must be proved to uphold a claim of negligence?

To claim negligence, the four elements must be proven by the plaintiff: the nurse had a
duty to the patient, the nurse breached the duty, a patient injury occurred and there was
a causal relationship between the breach of duty and the patient injury.

b. Can the child’s family assert a claim of negligence against a new graduate with very
limited experience and seniority?
No, because the nurse did not breach the standard of care. She was able to assess and
monitor the client’s condition and accurately report changes in condition of the client to
her charge nurse and to the attending doctor.

c. What duty, if any, did the charge nurse have to the child?
It is the duty of the charge nurse to assess the overall needs of the individual patients
before allocating resources and the nursing staff responsibilities appropriately, providing
supervision and guidance where necessary.

d. Would the physician’s knowledge of the child’s condition serve as a defense against a
claim of nursing negligence, particularly since the new graduate had spoken to the
physician four times?
Yes, the statement of the physician can be made as defense statement against a claim
of nursing negligence because he was been updated with the condition of the client by
the nurse. His statement will prove that the nurse did not breach the standard of care.

REFERENCES:

American Nurses Association. (2010). Nursing: Scope and standards of practice (2nd ed.). Silver
Spring, MD. https://www.nursingworld.org/endoflife-positionstatement.pdf

American Nurses Association. (2015). Code of ethics for nurses with interpretative statements.
Silver Spring, MD. Retrieved September 2020 at https://www.nursingworld.org/code-of-ethics
Kasule, Omar. (2012). Outstanding ethico-legal-fiqhi issues. Journal of Taibah University
Medical Sciences Volume 7, Issue 1, pp. 5-12. Retrieved September 2020 from
https://www.sciencedirect.com/science/article/pii/S1658361212000042

Smith, Timothy M. (2020). When patients, families disagree on treatment: 6 ways forward.
American Medical Association. Retrieved Semtember 2020 from https://www.ama-
assn.org/delivering-care/ethics

Journal of Palliative Medicine, 14(11), 1197. doi;10.1089/jpm.2011.0158.