What are the top 5 ethical dilemmas faced by nurses?

Vito Andolini · Jun 25, 2009

jnrsmommy said:
The terminally ill pt who has his DNR paperwork in order, whose wife watched him sign not 3 hours before, after a lengthy discussion about this being his wish. When he passed, having her scream "Do something!" and having to proceed to code him.

That's the time to just stand one's ground, in a quiet way, reminding her nicely and respectfully that he did not want "something" done, or to do a slow code. You can't blame the wife, who apparently was not really ready to let go or in synch with her husband's wishes. It doesn't mean you have to go full steam just because she screams to do something. You can kind of sit her down, take her hand, remind her that he wanted to be let to cross over, and that he is now in that more peaceful place where he is no longer suffering. That could help with regard to her feelings about him. As for her anger and fear at being left, well, holding hands is good, quietly reminding her that it's all ok, it's all right, everything is all right, etc. (even if you think it isn't, even if you don't believe in Heaven or Hell or eternity - because it's not about our comfort right then, it's about the patient's comfort, the family's comfort) can work wonders. It also could help if a chaplain or family member or friend could be with the wife right then.

The wife has to face facts sooner or later but she is angry and/or terrified about losing her beloved husband and being cheated out of a father for their kids, the income he used to bring in, her companion, her mate, and on and on. It's no fun becoming widowed, that's for sure. But it is part of life and many of us get to experience it, willingly or not.

Vito Andolini · Jun 25, 2009

rachelgeorgina said:
beneficence vs non-malfeasance
patient autonomy vs patient advocacy
the provision of justice
i'm a student and just toke ethics and law in healthcare. we did three really interesting assignments:
1) pt has history of alcohol abuse, currently in remission. pt pregnant and shows no signs of drinking throughout pregnancy whilst monitored by her middie at home. upon birth of the baby, dr. tells mum that baby has fetal alcohol syndrome in order to scare her out of drinking. the baby doesnt have anything wrong with it. mother is exceptionally distressed and proceeds to hysteria. what does nurse do?
she should talk to the doctor and inform him of what is happening. doc should straighten this out with the patient. he wouldn't even have to admit what he did. he could just say that, upon re-exam of the baby, the baby looks fine.
one problem is that we don't know that mom would not have become hysterical, whatever that means, if doc had not lied to her. we can only speculate. doc might have had baby's best interest at heart, which is commendable, but he should not have said what he said to her.
2) pt has stevens-johnson syndrome with uncertain prognosis (50/50 chance). pt arrests, is unconscious vented and needs dopamine to maintain her bp constantly. pt disclosed to family and nurse prior to arrest that she doesnt wish to be kept alive should she become a "vegetable". she also has an advanced care directive stating that should she become terminal, she doesn't wish for life sustaining measures. nurse says to doc that perhaps we should discontinue treatment in accordance with pt and family wishes. doc says no. nurse hangs a bag of normal saline, labels it dopamine, pt arrests and dies. was this ethical?
what nurse should have done was hand doc the bag and the dopamine and tell him he should prepare it and hang it himself if he wanted to but that she could not, in good conscience, be party to violating the patient's clear, legally written wishes. she also should have shown doc the signed advance care directive. and she should have gotten ethics committee and her own boss involved. instead, what she did, though well-intentioned, was get herself in hot water. what happened to the patient? how did it become known that nurse hung only saline?
3) does mental health legislation (in australia) violate pt autonomy, dignity? and does it enhance and enforce unrealistic stereotypes regarding the mentally ill. do nurses play a part in this?

i know nothing about australian legislation.

ktwlpn, LPN · Jun 25, 2009

--- #1 -- Patients whose family and physicians have overthrown their advance directive...

#2 -- Under or over -medicating patients due to family's demand (either for pain, agitation or aggressive behavior) and physicians unwillingness to get involved in educating them.

#3 -- Family members who insist on keeping bad news from a loved one-this can involve either their own diagnosis or a tragedy involving another family member.

#4 -- VIP patients actively receiving extraordinary care at the expense of everyone else on the unit . ALL of our patients are VIP's to someone..I have a real problem with docs pulling out all the stops for a friend of a friend when this same doc will run down the back stairs to avoid another patient's family.

#5 --When to blow the whistle on a dangerous caregiver (doc,another nurse,aide)-What a mess..

jnrsmommy · Jun 25, 2009

Vito,

My story was just an example of a system that seriously needs to be fixed. As it were, that took place in Louisiana. At the time (have no idea if it's changed or not), did not matter if the DNR was signed by the Lord himself, if your 3rd cousin twice removed came up and said do something, we were obligated to do it. I was a new nurse at that time, and have learned how to better handle the situations that come up.

Woodenpug, BSN · Jun 26, 2009

An ethical dilemma is a situation where upholding one principle violates another. So the nurse who mislabeled the normal saline upheld the principle of self determination by following the patients wishes, while violating the principle of beneficence by not providing necessary treatment.

Ethical dilemmas are nothing other than an academic exercise. In real world nursing ethical decisions are made by following the money. Futile CPR will only be attempted when the vip has yet to sign for the hospitals endowment. Non-futile, probably effective, CPR will be withheld if it seems that the vip, who has already signed, may change his mind.

Following the money upholds the principle of distributive justice and becomes a dilemma when that violates another ethical principle.

arelle68 · Jun 26, 2009

Vito Andolini said:
And? What's the end of this story?

I thanked God I hadn't given the Morphine 10-15 minutes before this woman died, which I would have if there hadn't been the confusion about the Ativan, which caused the delay. I would have felt bad enough to quit Nursing.

mama_d, BSN, RN · Jun 26, 2009

Let's see...top five....

Code status issues. Quality vs. quantity. Or the age old "Why the heck is my patient with a stage four that is larger than my baby, no arms, no legs, blind, deaf, demented, on a PEG tube, on bipap, on dialysis, and with cancer mets everywhere a FULL CODE??? For real?"

Management issues. Honestly, I feel sorry for a lot of them. They get flack about meeting the bottom line from above while getting (probably more) flack from us floor nurses about the staffing and ridiculous policies. I think that if all those corporate people had to spend some time in our shoes, things would be different.

Incompetence and indifference. I'm fine with nurses and techs needing some time to get adjusted to the flow of the floor, and acknowledge the fact that there is a learning curve in our profession unlike in most others. But for crying out loud, if a nurse has been working on the same floor for three years straight and still is making critical errors on a regular basis, there is something wrong with the system.

Noncompliance and how much we treat them. Honestly, how many times can we admit the same patient for the same problem, knowing that they're just going to keep on coming back b/c they don't follow their regimen? And I'm not talking about the folks who are having transient financial hardships or life crisis...I'm talking about the people who have had social work set up their dialysis transportation, get them free meds, and set them up at a free clinic...who are still noncompliant.

Customer service. It's not the Hilton, no matter how much "room service" gets hyped. It's a hospital. That means that I WILL be waking you up for vitals and assessments, I will not be bringing you popsicles and soda when you have a blood glucose of 600, and yes, you will be getting stuck with a needle. Just b/c my NM thinks it's more important for you to be happy than for you to get well does not mean she and I share priorities...my job is to get you better and get you home.

You touched a nerve there, in case you didn't notice...there's so much messed up with healthcare nowadays that sometimes I swear there's a conspiricy afoot trying to keep me from getting my patients the care they deserve.

SunnyAndrsn · Jun 26, 2009

Advocating for patients can be a minefield. We have an MD who specialized in geriatrics who brought an article in that discussed when to stop treatment and begin palliative care. The question posed was "What are we doing TO this patient instead of what are we doing FOR this patient."

An example I can think of is with a pt. I've had that has terminal brain cancer. Her family wants "everything" done. Woman is in mid 70's. Poor appetite, so the MD prescribes Megace to increase appetite...then writes orders for 1/2 dozen supplements, including extra calcium, vitamin D, multivitamins, and iron. Takes this poor woman 1/2 the morning to get the meds down. Still, she continues to lose weight--although slowly. MD prescribes Med Pass TID. Still no weight gain, appetite remains poor and now her family visits are all about getting the medications down and how much she's been eating.

Nursing continues to communicate with the MD (who is a royal PITA, treats nurses poorly, SHE is the MD and knows what is best for her pt!) however, this family and MD make it difficult to advocate for the pt.

If Nursing had their way, the MD would have listened to us when we described her difficulty with meals and medications, and would have looked at hospice care long ago. I think that the quality of her last several months was compromised by the difficulty that her family's unrealistic goals presented. The MD supported the family's goals, setting nursing up as the nay-sayers and "bad guys".

The pt. is now finally on hospice and continues to decline at about the same rate. Her family visits are much more peaceful now...it's too bad we couldn't have done this months ago.

Again, what are we doing FOR the pt, not TO the pt.

DLS_PMHNP, MSN, RN, NP · Jun 30, 2009

1. Futile Care

2. Futile Care

3. Futile Care

4. Futile Care

5. See 1-4....

Shenanigans, RN · Jun 30, 2009

This happened on a ward I was on once, pt was miscarrying her 7th pregnancy (multiple rounds of IVF all failing) and putting her in a room in a bed next to a woman who was due for a second trimester TOP the next day. Eventually women get to chatting, TOP minded woman decided not to kill the child and instead give it to the miscarrying woman. I don't support TOP but this was probably going to be a great big social working mess.

I'm adopted. My biological mother told me my biological maternal grandmother was in the hospital and could I look up her name and find out a) what's wrong with her, b) where in the hospital is she. I told her I couldn't do that ethically. And then she blasted me via text that I was a bad and inconsiderate.

Another one I saw, pt was pregnant, and wanted to keep the child, she was 15 and didn't want us to tell her parents. I didn't tell. I got social work involved to help assist the girl. Then another nurse, who wasn't even caring for this teen told someone who rung up asking how the pt was. The person on the phone claimed to be the pt's parent. It wasn't, it was her boss. Who then fired the teen, and then rung the parents!

And yeah, all the DNR antics!

cursedandblessed · Jun 30, 2009

patient vs. family wishes

fullcodes on patients like the one described above.

working a shift with inadequate staffing: to rock the boat--don't rock the boat

caring for an obviouslyabused child and still be able to talk to his/her suspected parent/abuser without accusations because it's in the best interest of the child until social services/police come.

to approach a coworker who smells of alcohol and ask them about it.

these might not be the top five, but they were examples used in one of my classes.

southernbeegirl, BSN, RN · Jul 1, 2009

top 5 ethical dilemas...

1. i cant kill my patients.

2. i cant kill the visitors.

3. i cant kill my coworkers

4. i cant kill the docs

5. i cant kill the visitors.