Need more inference on ethical dilemma issue regarding restraints.

KelRN215, BSN, RN · Sep 8, 2012

I can't give you any suggestions about the ethics of the use of restraints but can offer you examples of real cases I've encountered that have actually gone to ethics committees:

Teenage girl with acute mental status changes found to have Anti-NMDA receptor encephalitis. This is a rare disease and is sometimes associated with ovarian teratomas. Parents discovered this through the internet/youtube and elected for a complete oophorectomy. The entire work-up the child had had revealed NO ovarian involvement but the parents were convinced that this would cure her. The child is now infertile and still having problems from her encephalitis. The Ethics Committee at the hospital and the court system sided with the parents because their goal was not to sterilize her but to cure her disease.

On that note, there was a very famous case a few years ago about parents' decision to sterilize their severely developmentally delayed daughter: Ashley Treatment - Wikipedia, the free encyclopedia

Child with end-stage brain stem tumor whose parents refused to believe that she was dying and requested a permanent tracheostomy and long-term ventilation. Ethics committee sided with the parents. Support was eventually withdrawn on the order of the ICU team after brain death was pronounced.

Previously healthy child diagnosed with X-linked adrenoleukodystrophy after presenting with a new seizure. This led to discussions of testing the child's younger brother and, if he was found to have the disease, whether to proceed with experimental treatment despite the presence of no symptoms. Specifically, the question was whether to proceed to stem cell transplant for the brother without knowing when his disease would onset and to risk death from the transplant itself. I do not know what the outcome of this case was.

Children with congenital brain malformations who are likely to live but with severe impairments. In rare cases, parents do not want this life for their children and choose not to treat them. What then? Nursing Center - Journal Article

Pediatrics and genetics are FULL of ethical issues, especially when you combine the two.

J-Swish · Sep 9, 2012

Thanks. It seems like those cases are rather very complex to have gone to the ethics committee. My situation was in Med-Surg and was not severe enough to have gone to the ethics committee.

RunninOnCoffee · Sep 10, 2012

If you are looking for an ethical dilema, I seem to remember a case in the news a few years back where there was a child with some form of cancer. It was against the parent's religion or some type of morals (I don't remember where actually the belief system came from) against cancer treatment. With out the treatment the child would have died. So basically it boiled down to do parents have the freedom of religion and autonomy to raise their children in their beliefs or at what point can the state jump in and force the child to recieve the life saving cancer treatment.

Another ethical dilema I actually sent up to our ethics committee was a pt had a specific living will that the family was refusing to follow. Pt was actually trached and asking his wife to turn off the vent, problem was he was on a low dose of propofol and ativan for anxiety so he wasn't "of sound mind" to actually make the call. With out the propofol & ativan he was bucking the vent alittle so we couldn't just turn it off.

Good luck!

KelRN215, BSN, RN · Sep 10, 2012

If you are looking for an ethical dilema, I seem to remember a case in the news a few years back where there was a child with some form of cancer. It was against the parent's religion or some type of morals (I don't remember where actually the belief system came from) against cancer treatment. With out the treatment the child would have died. So basically it boiled down to do parents have the freedom of religion and autonomy to raise their children in their beliefs or at what point can the state jump in and force the child to recieve the life saving cancer treatment.
Another ethical dilema I actually sent up to our ethics committee was a pt had a specific living will that the family was refusing to follow. Pt was actually trached and asking his wife to turn off the vent, problem was he was on a low dose of propofol and ativan for anxiety so he wasn't "of sound mind" to actually make the call. With out the propofol & ativan he was bucking the vent alittle so we couldn't just turn it off.
Good luck!

I've seen the kiddie cancer thing a few times as well. Basically, at least in my state, what it usually comes down to is: if the treatment and standard and the child is likely to survive, the parents cannot refuse. I.e. Standard risk ALL has something like a 90% survival rate and the treatment is considered "standard". For something like stage IV neuroblastoma, the treatments are still trial-based and the outcome is poor, treatment or no treatment, so it's considered more acceptable to not treat. We once had a case of standard risk medulloblastoma (85% survival with the standard treatments) where the parents stated they didn't want chemotherapy because they didn't want the child to lose her hair. The hospital out-right said that it would take the case to court but it didn't end up coming to that.

On the same lines, there's the "mature minor" rule. A 17 year old wants to terminate treatment but parents want to continue. What happens then? I forgot that I also had a case such as this go to ethics committee- the child was 2 months away from turning 18 and the ethics committee actually sided with her. She ended up dying a few days after her 18th birthday.

And then, in the world of pediatric oncology, the endless Jehovah's witness-blood transfusion debate. In my state, the hospital will go to court to get an order to administer blood products despite parental objections. The state feels that adults are free to be martyrs for themselves but that they cannot make that decision on behalf of their children.

Alnitak7 · Sep 10, 2012

There was one patient who I put a sheet around, not because I was told to or because there was an order but because I was afraid she might fall.

She had severe arthritis and I did not think her chair was safe for her. There was nothing I could do about it. She was mine and the anxiety was driving me insane.

I told a visiting relative that I would rather get in trouble for restraining her without an order than to see her fall.

No one argued with me.

Davey Do · Sep 10, 2012

an LVN gave me restraints to tie down a patient who was acting up. RN was not present and attending to patients elsewhere.
Of course, I chose not to...

Wise move, J-Swish.

In the Facility where I work, and this may be Statewide, only an RN with a Physician's Order, may institute Mechanical (or Chemical) Restraints. Of course, the Order may be obtained after the Restraint Episode, but the decision has to be that of an RN.

There is a Formal Procedure to follow in the Restaint and subsequent Documentation Process: Our Facility utiizes a Packet containing several forms, including the Physician's Order, Restriction of Rights, Flowsheets, etc.

An MAR is a Medication Administration Record which is utilized, along with the Packet, in documenting a Chemical Restraint.

Check out the Psychiatric Nursing forum on this site. There are a lot of discussions on Restraints. Fact is, I'm surprised the Moderators didn't move this Thread to Psychiatric Nursing.

Good luck to you, J-Swish,

Dave

J-Swish · Sep 12, 2012

All great ideas and this one particularly gave me some more insight as well. Thanks all. You rock.