An Ethical

Dilemma
BAH!
Get away!

By Jon, Jon, Jon, and Christina

NURS362

Leave me alone.

74-year old female patient was admitted to the medical-surgical floor from the Emergency
Dept. She was brought to the ER by HPD for AMS- altered mental status. The
police were called to a condominium in Waikiki by the manager with complaints of a woman trespassing

and refusing to leave the property. The woman claimed to have lived there. According to the manager, she lived

evicted because of non-payment of rent

there for over 10 years, but was recently

.
The patient supposedly had a trust and someone had been paying her rent, but is no longer. She is a confirmed client
of IHS- the

Institute of Human Services homeless shelter.

Upon arriving at the ER, she was alert to self only. She had labs
drawn, a set of vital signs taken and an IV started. Since then,

refused subsequent labs, vital

signs, assessments and pulled out
her IV. She is requesting to leave the hospital and go back
she

to Waikiki. The patient refused to change into a hospital gown

and has remained in her street clothes. She was diagnosed with

starvation ketoacidosis,
hypothyroidism, metabolic
encephalopathy and has a history
of dementia. The patient refuses to eat and only took
having

small sips of water. Her rationalization for not eating was that she
needed to first have a bowel movement- she

hadnt had

a BM in 4-5 days. The patient agreed only to

walking the hallway and taking a stool softener.

A social worker at the hospital was able to get in touch with a case
manager at IHS and determined that the

patient lives in

Hawaii alone, and has children that live on the mainland.

The hospital is working to get in touch with her children to

provide the patient with a surrogate

and determine her medical care and
placement after discharge. She was seen by a hospital psychiatrist

No.

lack the capacity to make

reasonable decisions regarding
medical treatment and self-care.

and deemed to

Two weeks after admission, she is still hospitalized, refusing

all medications, assessments, lab draws and vital signs. The
social worker is still working to get in touch with the
patients family.

discharge her, not

knowing where she
will go or what will
happen to her?
Establishing
surrogacy can take
weeks to months,
keeping the patient
in the hospital.

ETHICS: PROVISION
1:

The nurse practices with compassion and respect for the

inherent dignity, worth, and unique attributes of every
person.
Based on the code of ethics mentioned above, we, as nurses and
part of the health care team cannot deny care to a patient
regardless of financial status, medical diagnosis, race, etc.. We
respect the patients wishes (autonomy), but perform as much
care as we can as a collective according to what the patient
agrees to.
For this patient in particular, we cannot discharge her based on the fact that the
psychiatrist deemed the patient unable to make reasonable decisions
regarding medical treatment and self-care. Even though the patient denies all
care from the staff, we still offer it and encourage it and provide teaching when
possible during every shift and hourly rounding until a surrogate can step in to make

Provision 1, Section 1.4- The

Right
to self Determination
In situations in which the patient lacks the capacity to make
Ana
Codea of
Ethics surrogate decision maker should be
a decision,
designated
consulted. The role of the surrogate is to make decisions as
the patient would, based upon the patients previously
expressed wishes and known values. In the absence of a
designated surrogate decision-maker, decisions should be
made in the best interests of the patient, considering the
patients personal values to the extent that they are known.
The nurse supports patient self-determination by
participating in discussions with surrogates, providing
guidance and referral to other resources as necessary, and
identifying and addressing problems in the decision-making
process.

medical conditions and denying

care
Hypothyroidsm: goiter, weight gain, heart problems,
mental health issues (depression), neuropathy,
myxedema (coma), fatigue, temperature intolerance
(cold), muscle weakness, dry skin, thinning hair
malnutrition/Starvation ketoacidosis:
Nausea/Vomiting, dehydration, weight loss, abdominal
pain, rapid respiration, altered mental status, coma
Metabolic encephalopathy: altered brain
function/mental status due to an imbalance of water,
electrolytes, and other chemicals such as glucose
(hyper/hypo) and kidney/liver waste products.
Depending on the area of the brain affected, systemic

Ethical Challenges
Optimal health care results from
an exchange between patient
and provider with open
communication about the patients
wants and needs and the
providers judgement and

Veracity: Habitual truthfulness

How much of what information should be involved

in patient care?
Is the patient autonomous enough to effectively
communicate their needs and wants?
Does the patient have a full and clear
understanding of their situation and the options
for treatment?
Should certain information be withheld?

Paternalism: The provider is

Autonomy: Fully informed

consent or refusal

What or who motivates the decision made

by the patient involving their care?
Does
the
patient
have
a
clear
understanding of their situation?
Is the patients refusal or acceptance of
care valid during a state of mental
confusion?

Accountability: Doing the right

Patient choice and respect for

personhood are deemed just as
important as
scientific knowledge and sound health
care advice:
We care for many patients, follow many trends, and predict
outcomes of our many interventions.
At the same time, we have not cared for this current
patient, followed their trends, nor observed their outcomes

Clinician Surrogates
for Unrepresented
There
is a chance that this patient may be
Patients

unrepresented by a family member as a

surrogate to make future treatment decisions. Due
to the patients inability to make their own
treatment decisions, clinicians may act as
surrogates. Clinicians are knowledgeable of
disease processes and the treatments involved to
competing
lack of in an article by
help patients
recover. Its
mentioned
obligations
White, Jonsen,
and Lo (2012)procedural
that clinician
conflicting
fairness
surrogates
should take the role
of advisor rather

How nurses can improve

Insurrogate
the case of an incapacitated
patient, information
decision-making

between the surrogate and the provider is required

for optimal health care. Nurses can improve the
decision-making process of surrogacy by
implementing the Four Support Intervention to help
with the burden and stress that it comes with (White
et al., 2012).
1. Emotional Support
2. Communication Support
3. Decision Support

references
American Nurses Association. (2011). ANA Code of Ethics. Retrieved from Nursing World:
http://www.nursingworld.org/provision-1#four
Cherry, B. & Jacob, S. R., (2014). Contemporary nursing: issues, trends, & management, (6th ed.). St. Louis: Elsevier.
Rid, A., & Wendler, D. (2010). Can we improve treatment decision-making for incapacitated patients?. Hastings
Center Report, 40(5), 36-45 10p.
White, D. B., Jonsen, A., & Lo, B. (2012). Ethical Challenge: When clinicians act as surrogates for
unrepresented patients. American Journal Of Critical Care, 21(3), 202-207 6p.
oi:10.4037/ajcc2012514
White, D. B., Martin Cua, S., Walk, R., Pollice, L., Weissfeld, L., Seoyeon, H., & ... Arnold, R.
M. (2012). Nurse-led intervention to improve surrogate decision making for patients with
advanced critical illness. American Journal Of Critical Care, 21(6), 396-409 14p.
doi:10.4037/ajcc2012223