Running head: Ethical Issues in Nursing

Ethical Issues in Nursing: A Bridge to Practice

Molly Higgins Burns
James Madison University

INTRODUCTION

Ethical Issues in Nursing

The management of patient situations that involve end of life care has proven
to be challenging for health care providers. A study published in the Scandinavian
Journal of Caring Sciences reported that most nurses involved in a patients end-oflife care experience feelings of lack of control, discomfort, and lack of cooperation
from the patient (Karlsson, Karlsson, Barbosa da Silva, Gerggren, & Soderlund,
2013). An article published in Nursing Ethics highlights the fact that nurses have a
responsibility to provide care and alleviate patient suffering (Izumi, Nagae, Sakurai,
& Imamura, 2012). Finding an appropriate balance between the responsibilities
nurses hold and the feelings that arise from these difficult situations often leave
health care providers in a state of distress, and determining the most appropriate
plan of care can be difficult.
BACKGROUND
In one particular clinical situation, a 64 year old resident of a nursing home
with a history of Multiple System Atrophy presented to the emergency department
upon recommendation of a speech pathologist. The patient had a tracheostomy
tube placed one year ago in order to help manage implications of this degenerative
disorder, and over the past few weeks had been noticing food particles present in
her tube. Health care providers at her facility ordered a dysphagia evaluation, and
the patient was found to have aspiration of backflow in all consistencies. The
speech pathologist conducting the study deemed this patient at a high risk for
aspiration and further decline, and recommended that an alternate means of
nutrition, hydration, and medication administration be made.
Upon her admission to a medical-surgical floor of the hospital, the patient
received a consultation from a surgeon to discuss the placement of a percutaneous
endoscopic gastrostomy tube. The patient was extremely hesitant and stated that

Ethical Issues in Nursing

she did not want any extensive measures to be taken to prolong her life. She was
given some time to consider her options, and after discussing her situation with her
daughter, the patient agreed to undergo the procedure. However, within the first
few post-operative hours, the patient reported that the tube had fallen out, and
upon further surgical consult refused to have the tube re-placed. Her doctors
educated her on the necessity of this feeding tube and the potential danger she
could be in without it. However, against medical advice, the patient was adamantly
opposed to having the tube inserted again, and was referred to a palliative care
specialist.
This situation caused the health care providers involved to experience a state
of moral distress. The doctors and nurses were able to identify the right action to
take to provide this patient with the best care, but due to other contributing factors
they were unable to carry it out. In this specific situation, they provided the patient
with all of the necessary information regarding her need for this procedure as well
as informed her of the implications of refusing it, but were forced to respect the
patients final decision of refusal even though it was against medical
recommendation. The health care providers were left in a state of distress, feeling
as though they were assisting in her impending death by not taking action to
promote a safer means for this patient to gain nutrients and medications necessary
for her survival. The professionals involved took every action both medically and
legally possible to provide the best care for this patient, therefore it is difficult to
identify a more appropriate alternate response to this situation.
METHOD
In attempt to analyze this situation involving moral distress, James Madison
Universitys 8 Key Questions was applied. This is a framework designed to help

Ethical Issues in Nursing

professionals work through difficult decision making situations in order to come to a

conclusion that is demonstrative of an ethically driven thought process and
approach. These questions consider aspects including fairness, outcomes,
responsibilities, character, liberty, empathy, authority, and rights. By asking how
these components can be applied to a specific situation, one is better able to
identify the best means of achieving the most ideal outcome for all parties involved
(The Madison Collaborative, n.d.).
FINDINGS
Applying the 8 Key Questions to this situation helped me to identify how I, as
an aspiring nurse, would respond to a situation such as this. In order to be fair and
equitable in this situation, it is important to not let her degenerative disease or her
personal ideas of impending death influence the plan of care. Despite the terminal
nature of her illness, health care providers involved should still do everything in
their power to provide her with the best care and quality of life. This patient
deserves the same quality of education and interventions as any other patient. In
determining how to proceed with the plan of care for this individual, it is important
to consider, in collaboration with the patient, the possible outcomes of any actions.
The patient would likely be comfortable and content in the short term without
having an additional surgery, but in the long run, absence of this assistive feeding
mechanism will cause her to deteriorate faster, become increasingly weak, and less
able to enjoy this portion of her life. The short term outcomes of re-inserting the
tube will likely cause her pain and discomfort as well as require her to make
alterations in her lifestyle, but the long term outcomes prove to be beneficial. The
quality of her life would be improved, her safety promoted, and her life prolonged.
In terms of the health care providers involved, the re-insertion of the tube would

Ethical Issues in Nursing

leave them feeling as though they were able to help improve this patients quality
of life, while not continuing with this procedure would lead to a state of moral
distress. The responsibility of the health care providers to implement the best care
for the patient is an important aspect to consider, however it must be noted that
they also have a legal responsibility to respect the decisions the patient makes
about her individual care. Determining what action best reflects the character of
those involved is an additional necessary aspect to consider. Identifying personal
values and vices can aid in determining the best action to take. In this situation,
portraying oneself as a patient advocate who is compliant with the laws and
regulations of this profession seems to be the most beneficial character traits to
express. This idea also continues when considering the liberty of the patient and
respecting the fact that in this situation, she has the freedom to make her own
decisions regarding her care. In taking an empathetic approach, putting oneself in
the patient and her familys position is beneficial in identifying the plan of care one
would want for a loved one in a similar situation. In considering authoritative
powers, one must understand that health care professionals have the legal
obligation to educate the patient regarding the implications of her specific situation,
as well as respect how she chooses to use the information. Lastly, in considering the
rights of those involved, the concept of patient autonomy presents itself again. The
patient has a right to refuse this procedure and the right to have full control over
her care. Provision 2 of the American Nurses Association Code of Ethics states that,
The nurses primary commitment is to the patient, whether an individual, family,
group, community, or population (ANA, 2011). This commitment includes serving
as their advocate, protecting their basic rights, and doing everything possible to
provide the appropriate, desired care.

Ethical Issues in Nursing

CONCLUSION
Upon answering the 8 Key Questions, I was able to consider various aspects
of this situation that could help to guide my approach. In watching this situation
unfold as an observing student, I was able to identify the presence of moral distress
associated with this patients end of life care, and recognize that the health care
providers handled this particular situation in the most appropriate way. It was
apparent that those involved with this patients care knew what interventions would
be most beneficial to her, but were not able to implement them due to patient
preferences. The health care providers acted within their scope of practice and
ultimately respected the rights of the patient despite the distress it caused them. I
now have an increased understanding of the immense presence of ethical issues in
the health care profession, as well as a better understanding of how to manage
them when I am presented with one.
Resources
American Nurses Association. (2011). Code of Ethics. Retrieved from
http://www.nursingworld.org/Mobile/Code-of-Ethics.
Izumi, S., Nagae, H., Sakurai, C., & Imamura, E. (2012). Defining end-of-life care
from perspectives of nursing ethics. Nursing Ethics, 19(5), 608-618.
doi:10.1177/0969733011436205
James Madison University. (n.d.). The Madison collaborative: Ethical reasoning in
action. Retrieved from http://www.jmu.edu/mc/8-key-questions.shtml
Karlsson, M., Karlsson, C., Barbosa da Silva, A., Berggren, I., & Sderlund, M. (2013).
Community nurses' experiences of ethical problems in end-of-life care in the

Ethical Issues in Nursing

patient's own home. Scandinavian Journal Of Caring Sciences, 27(4), 831-838.

doi:10.1111/j.1471-6712.2012.01087.x