Ethics question

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I have a question on ethics.

I work in a CD treatment center. From what I understand, they are considered vulnerable adults. Pt has a history of psoriasis...patient point out healed scars on legs to show how bad it had been before he was put on Humira.

The patient complained of abdominal pain at history and physical, so the nurse practioner put a hold on the next dose of Humira, which was due in 1 day, until liver panel could be done. This was to 'do no harm, because the side effects had the possibility of causing death. Also, the CNP stated that though the condition was disfiguring, and bothersome it was not terminal. To the CNP, the risks outweighed the benefits. The CNP explained to the patient, all of this. Also that the psoriasis wouldn't 'erupt' all of a sudden in a few days. The patient felt that the benefit of the medication outweighed the risks. He was told by the prescibing doctor that there were no side effects ( pt's claim that is what was said).

The patient did not have insurance or MA and county pay for treatment wouldn't cover the lab work. Management was looking into funding options, but in the meantime, the patient was begging for his medication. He had brought 2 doses in with him on admission...each dose to be given 2 weeks apart. The patient stated that he was already getting some white spots, indicating to him that the psoriasis was becoming less suppressed. The patient also expressed that to him, it was a self esteem issue, that he was presently experiencing a lot of stress and anxiety because of the fear of how bad the psoriasis would become without the medication, and also that it was not a narcotic medication, so he didn't see why he couldnt' have it.

As a nurse, I am supposed to be advocating for my patient. In this instance, is it autonomy, nonmalificence or benificence that are the higher ethical issue? Should the pt be able to get the medication, because he wants it...it has been prescribed and he does have the right of refusal, so why not be able to get the med?

Should he not get it because of do no harm? Or get it because it benefits him the most? Can I advocate that he see another doctor for a second opinion....or send him to the ER so he might be more apt to get the med there? Is sending him to another doctor, putting me in the role of doctor shopping for him?

So my question is, since nurses are supposed to be advocating for their patients...what seems to be the best option for the patient?

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Yes, you have a duty to advocate for your patient. However, when there is the possibility that the risks outweigh the benefits then your duty is to try to get the patient to understand the risk/benefit analysis that the CNP is required to do by law and moral obligation.

In the case of potential liver damage vs disfiguring skin condition...protect the liver wins. This is this do no harm ethic. A really good comparison is the use of estrogen therapy to treat hot flashes and other pre-menopausel symptoms in a woman over 40 who smokes. In case that doesn't raise red flags the risk for stroke, blood clots and other adverse effects goes up considerably in this population with estrogen therapy. The patient really wants the relief afforded from the estrogen therapy. But, the risks outweigh the benefits...and no patient has ever died from hot flashes or mood swings. Family members are a different story. :jester:

There may be different treatments that work. Try researching those. There may be a way to get the lab tests done gratis. I highly suggest you sit down with the CNP and discuss the issues and proactively create a treatment plan that minimizes risk, advocates for your patient and doesn't jepardize your professional relationship with the providers you work with.

The ethics are fairly straight forward. Do no harm is the duty of the healthcare provider. Knowingly administering the medication when there is a potential to do harm can be considered malpractice even if it is at the request of the patient. The provider will have no legal or moral justification for administering the medication just because the patient is willing to take the risk.

The concept of benificence is pretty easy in this case. The risk of death vs nice appearing skin. The "bad" definitely outweighs the "good". it would not be beneficit if the patient dies from the treatment.

Autonomy is also pretty straight forward. The patient has the right to choose to take the medicine and may very well do so on his/her own. The provider is under no obligation to perform the risk taking action or to jepardize the patient by administering the medication. This is different from the "right to refuse" which all patients who are competent have. Right to refuse is part of the concept of autonomy.

Jkesler

the-travel-nurse.com

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I'm sure you know this, but the emotional scars of having psoriasis can be extremely severe. I know because my brother has suffered with it for most of his life. And I don't mean "I occasionally get a patch on my knee", I mean severe and chronic covering most of his extremities psoriasis as well as psoriatic arthritis. Is there even a reason to be 100% healthy if you are too depressed and ashamed of the way you look to enjoy it? I don't know the answer to that because thankfully i've never been in that position. My parents and I have BEGGED my brother not to go on Humira and have successfully convinced him it is not worth it but sometimes I wonder if he'd be happier on it... Therapy could help but of course your chances of convincing someone to take it are slim. Not everyone's self esteem is as fragile as my brother's of course.

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Significant amounts of research now show an increase in heart attacks and cancer in those living with psoriasis. You may think you are doing them a favor by stopping Humira to protect the liver, but how long can you stop living when your heart stops?

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Specializes in M/S, MICU, CVICU, SICU, ER, Trauma, NICU.

Two issues:

CNP HAS to rule out potential liver involvement. That is her job, that is her critical thinking, that is what she has to do. There are no two ways about it.

The patient then CANNOT get the meds until that is done.

The other issue: Patient wants the medications right away, stress, etc., Understandable. Patient should then be tested to rule out all potential problems ASAP. As the advocate, you need to get the orders/implement all testing asap/stat.

Then regroup with CNP and see what course to follow.

Patient is upset, understandably, but he/she can sue whether or not he wants the meds and signs a waiver because the CNP didn't follow through.

Unfortunately, the lawyers take precedence here.

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Specializes in M/S, MICU, CVICU, SICU, ER, Trauma, NICU.
Significant amounts of research now show an increase in heart attacks and cancer in those living with psoriasis. You may think you are doing them a favor by stopping Humira to protect the liver, but how long can you stop living when your heart stops?

That's very nice, very sweet, but unrealistic.

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Specializes in M/S, MICU, CVICU, SICU, ER, Trauma, NICU.
I have a question on ethics.

I work in a CD treatment center. From what I understand, they are considered vulnerable adults. Pt has a history of psoriasis...patient point out healed scars on legs to show how bad it had been before he was put on Humira.

The patient complained of abdominal pain at history and physical, so the nurse practioner put a hold on the next dose of Humira, which was due in 1 day, until liver panel could be done. This was to 'do no harm, because the side effects had the possibility of causing death. Also, the CNP stated that though the condition was disfiguring, and bothersome it was not terminal. To the CNP, the risks outweighed the benefits. The CNP explained to the patient, all of this. Also that the psoriasis wouldn't 'erupt' all of a sudden in a few days. The patient felt that the benefit of the medication outweighed the risks. He was told by the prescibing doctor that there were no side effects ( pt's claim that is what was said).

The patient did not have insurance or MA and county pay for treatment wouldn't cover the lab work. Management was looking into funding options, but in the meantime, the patient was begging for his medication. He had brought 2 doses in with him on admission...each dose to be given 2 weeks apart. The patient stated that he was already getting some white spots, indicating to him that the psoriasis was becoming less suppressed. The patient also expressed that to him, it was a self esteem issue, that he was presently experiencing a lot of stress and anxiety because of the fear of how bad the psoriasis would become without the medication, and also that it was not a narcotic medication, so he didn't see why he couldnt' have it.

As a nurse, I am supposed to be advocating for my patient. In this instance, is it autonomy, nonmalificence or benificence that are the higher ethical issue? Should the pt be able to get the medication, because he wants it...it has been prescribed and he does have the right of refusal, so why not be able to get the med?

Should he not get it because of do no harm? Or get it because it benefits him the most? Can I advocate that he see another doctor for a second opinion....or send him to the ER so he might be more apt to get the med there? Is sending him to another doctor, putting me in the role of doctor shopping for him?

So my question is, since nurses are supposed to be advocating for their patients...what seems to be the best option for the patient?

It's good you are posting here. Emotion shouldn't get in the way of logic. THINK of the end result of potential harm before autonomy.

I believe that is lawyerspeak.

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Thank you for the input. I forgot to mention that the pt said he wasn't experiencing any more abdominal pain after he was told he wouldn't get the medication due to c/o of abdominal pain. The CNP wanted to rule out liver problems and possibly pancreatic tumor( which he said was a reported complication of taking the med).

My supervisor talked with the patient, but the patient got increasingly upset about not being able to take the Humira on schedule. We even met with the patient's counselor about the matter. The counselor said if it was him, given the severity of the condition when exhibited on the patient, he would want the medication, if it was him. He was promoting sending the pt to the ER or even discharging the patient so pt could give himself the med and the re admitting the pt. the pt even stated that he wouldn't be able to stay in the treatment program and would leave AMA if he couldn't get the medication on schedule. Sometimes this stuff doesn't make sense...if he can leave AMA why can't he sign a disclaimer while in treatment to absolve facility of potential legal and ethical issues?

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That's very nice, very sweet, but unrealistic.

Not exactly sure what you are trying to get at here JoPACURN. Really nothing nice or sweet about it. And you aren't very explicit about just what is unrealistic. Nothing was proposed. Just an observation that sometimes we do one thing that seems to be the way to go and there apparently are other just as serious consequences to following that new direction. The person is question is between a rock and a hard place. Save their liver or save their heart.

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