Jazi, a 59 year old man was admitted to the intensive care unit of a large metropolitan hospital with a diagnosis of septicaemia. Jazi was admitted to hospital for further treatment of his leukaemia at which time his PICC line site became red and inflamed. Communication with Jazi’s doctor occurred after 48 hours of noted redness when pain and a temperature also presented. The PICC line was removed and peripheral access gained. Jazi continued to deteriorate and at the time of admission to ICU he was pale, markedly short of breath, and had a temp of 42. After the ICU physician’s review he was immediately commenced on a regime of intravenous antibiotics. Jazi’s medical history included severe mitral valve stenosis and chronic myeloid leukaemia.
A few hours after Jazi’s admission to ICU, the shift handover occurred for the afternoon shift. During handover, the NUM informed the nursing staff present that she had received a phone call from the treating Oncologist advising the patient was not for resuscitation (NFR). The nurses continued with afternoon handover however they questioned why the patient had been transferred to ICU as he was NFR. Later in the shift the Oncologist called to see Jazi and indicated to him that the treatment plan was sorted and now the focus was to eliminate the source of infection that had occurred. The Oncologist questioned Jazi as to how long the PICC line had been red and sore and Jazi responded that it had ‘been that way most of the time I have been in hospital, however it did get a lot worse over the weekend.’ The Oncologist did not reply to Jazi. He continued to write up his clinical assessment report however did not document the NFR directive which he had phoned through earlier. This oversight was later dealt with by the nursing staff writing the initials ‘NFR’ in pencil, on the top of the nursing care plan.
The intensive care unit became busy throughout the shift and a nurse from another area of the hospital came to assist in the area. This nurse, Pat, discussed with Jazi his condition, what had brought him to hospital and how his family were coping. Throughout the conversation Jazi identified that he really ‘wanted to have further treatment, but they won’t give it to me.’ Jazi was referring to his cardiac valve replacement surgery for which he had been denied surgery recently. Pat questioned Jazi as to whether he had discussed his options with his Doctor. Jazi replied that he has ‘many times but they won’t do it because there is only a 50-50 chance of success.’ Pat questioned Jazi again…’So you would still want the surgery?’ Jazi replied, ‘I sure would, I need to buy some time. My wife is very ill at home, she has cancer and is completing dependent on me. She doesn’t have long to live, and all I want to do is live long enough for her, because she is afraid of being alone.’ Jazi continued with ‘It’s wonderful that the doctors and nurses are doing all they possibly can for me.’
At this point Pat realised that it was highly likely that Jazi had no knowledge of the NFR order verbally established by the oncologist and recorded by the nurses in his file. Pat then went to discuss the matter with Sue, the nurse that had been caring for Jazi. There she asked whether Jazi or his relatives had been involved in the decision making process pertaining to the NFR decision. To this question Sue initially stated that ‘that is not right to worry the patient with the obvious decision, he has leukaemia. We don’t get involved in the decision it is up to the doctor and we’re obliged to obey their orders.’
Pat then attempted to point out that Jazi was of the opinion that he was receiving all the treatment possible to minimise any further health risk to him. He was knowledgeable of his health conditions and was still questioning doctors in relation to cardiac surgery which had been previously denied. One of the other nurses stated ‘doesn’t that just show you that he is in denial to the extent of his medical conditions; he should never have been admitted to an ICU for treatment.’ Pat explained that she did not agree with this and wondered whether the medical staff were aware of Jazi’s treatment preference/s.
As the afternoon shift progressed, Jazi experienced a number of bradycardic episodes with his heart rate dropping to 42bpm at the lowest point. The arrhythmia would have been responsive to intravenous atropine, however this was never ordered. The resident and clinical nurse on duty decided not to treat the arrhythmia as Jazi was documented NFR. Fortunately, Jazi reverted spontaneously to a rate of 90 – 95bpm. Jazi continued throughout the evening shift to have episodes of bradycardia, but each time spontaneously reverted to a rate of 90 – 95bpm.
Several days later, Jazi’s temperature decreased to within normal limits. He stated he felt better and couldn’t wait to see his wife and go home.
Assessment Framework –
Use the Kerridge, Lowe and McPhee’s (2005) modified ethical decision-making framework (below) to examine the facts from this case study in light of their ethical and legal issues.
Remember you need to make comments from a nursing perspective
Clearly state the problem/s
? Identify all the issues (facts) within the context of the case study and distinguish between
o legal issues and
o any other clinical problems such as health/medical, risk, social, cultural, linguistic, gender.
? Explore the meaning in any value-laden terms identified.
? Identify the facts that support or refute the issues, you can include these in your discussions above.
? What else would you like to know about or consider i.e. further information which may be helpful?
Students can grid, list, dot point this section here if they like (or use columns) – see the example below for an idea of set-out.
Legal Issues Facts supporting / refuting Further information which needs consideration
• NFR order……• • Nurses…… • Why did the nurses not follow up….?
Consider and explore the fundamental ethical principles and their meanings and whether they were upheld or breached (you will also have to consider whether or not they apply in the case study circumstance)
? Autonomy: how was this approached from the patient’s perspective?
? Beneficence: what benefits were / were not obtained for the patient?
? Non-maleficence: what are the risks / harms and how can they be avoided?
? Confidentiality /Privacy: what information is private and does confidentiality need to be limited or breached? Is it an issue in the case study?
? Veracity: has the patient and their family been honestly informed and is there any reason the patient cannot know the truth?
? Advocacy: what (if any) are the issues from the scenario?
Students can also grid this section, however be careful to explain where required (& reference of course) e.g. sample below
• (definition given) The scenario reveals Jazi’s autonomy (upheld or breached)….. Clearly in not communicating……..
Consider and explore the Law and Professional Nursing standards and whether they were upheld or breached
? Identify relevant legal principles and laws and nursing standards that indicate unlawful/unprofessional behaviour. Here you need to research both the law and professional nursing standards, and make comment about where there are problems/ breaches and give examples to highlight your argument from the case study.
Consider how the problem would look from another perspective
Consider a range of the following:
? Who are the relevant stakeholders? (e.g. patient, hospital, nurses, doctors)
? What is their interest?
? What do they have to lose?
? How significant are their interests?
? How powerful are they? How legitimate are they?
? How urgent are the problems?
? How would the problem look from an alternative ethical position (e.g. deontological / teleological)?
Only include here what is relevant to the case study
Identify any ethical conflicts in the case study
? Are there any ethical conflicts (e.g. between nurse/s, patient, treatment options) in the scenario? Can you explain why the conflicts have occurred and how they may be resolved?
? Identify the relevant ethical concepts and how they might guide management
? Identify relevant legal concepts and laws and how they might guide management
State the ethico-legal decision and justify it:
? What decision needs to be made, specify how guiding principles were balanced and why
? Outline how you would communicate the decision and assist relevant stakeholders to determine an action plan
state ethico-legal decisions, and need to incorporate the guiding principles in some way. See the Q Health website (sentinel events / clinical incident reporting).