Nurses Struggle with Ethical Dilemmas

By Janet Boivin, RN
Monday May 25, 2009

A surgical liaison nurse at Boston Childrens Hospital recently found herself caught between doing what
was best for her patient and his family and the rigid rules of the operating room suite. She followed the
hospitals rules, but then, together with the patients family, helped turn the old policy around by
explaining why the rule needed to change.

The ethical quandary the liaison nurse faced arose when the mother of a baby who was dying asked to
be with him in the operating room. The baby had unsuccesfully undergone heart surgery and could not be
removed from the heart-lung machine. The mother wanted to go into the OR and be with her child when
he died.

The nurse told the mother she could not go into the OR, as anyone would have, says Christine Mitchell,
RN, MS, FAAN, director of ethics at Boston Childrens Hospital and associate director of clinical ethics at
Harvard Medical School in Cambridge, Mass.

The parents were allowed to see their baby after he died and his chest had been stitched back up.

The next day the parents returned to the hospital and paged the liaison nurse. They told her they wanted
to see the baby again before returning home, Mitchell says. The nurse told the family to meet her in the
chapel. She then went to the morgue, warmed the babys body, wrapped him in a fresh blanket, put a
cap on his head, and carried him to the chapel. The parents held their babys body for about an hour,
talking about him and what had happened the previous day. Eventually they said their final goodbyes and
went home.

A few weeks later, they wrote the nurse, thanking her for what she had done for them but restating their
sorrow about not being with the baby when he died.

Still disturbed by the experience, the nurse went to see Mitchell, asking if there was anything that could
be done. Mitchell says she suggested they discuss the experience with the OR governance committee
and the ethics advisory committee. She also asked the nurse to call the babys parents and invite them to
the discussion. The parents accepted the invitation and told the nurses and physicians why she needed
to be with her baby when he died.

We now have a policy that allows parents to be with their children in the OR [in those rare instances
when a child dies in the OR and the parents want to be there], Mitchell says.

Mitchell told this story during her presentation of the Evolution of Moral Responsibility in Clinical Practice
during the Massachusetts Association of Registered Nurses annual spring conference, which focused on
ethics in nursing practice. Nurses, she told the audience, are often caught in the middle between their
many responsiblities to patients, physicians, hospitals, and their units.

This can be a difficult place from which to assess the right course of action, Mitchell says.

In the majority of cases, what patients, their families, and physicians want is the same and does not
conflict, she says. If nurses suspect an ethical issue is developing, they should talk about what they are
experiencing during clinical rounds and with team members to determine what other people think about
the situation at hand.

Is what you think ought to be done in this situation and what others think ought to be done in synch?
says Mitchell.

The trigger word for ethics is ought (or should), as in ought we be taking this particular action or ought
we be making this decision, Mitchell says.

The important thing, she says, is for nurses to listen to their inner voices and ask themselves, Are we
doing the right thing? Pay attention to that voice.

Often nurses are reluctant to openly address an ethical issue, Mitchell says. Instead they will tell the
family what questions to ask the physician or that they should request an ethical consult. This is easier
than confronting physicians directly.

Nurses are more comfortable raising ethical issues when they work in hospitals that value the input of
nurses in determining patient care, Mitchell says.

Mitchell encourages nurses to think in ethical terms and says it took her a long time to do so. I hope it
doesnt take new nurses as long as it took me to figure out what we ought to be doing.

Patient advocacy alone is not enough to do what is best for patients. When you intensify time and
relationships with patients, you get to the heart of things that patients and family are really dealing with,
she says.

Early in her nursing career, Mitchell cared for a boy with leukemia whose parents forbade the staff to tell
him about his diagnosis. As she came to know the boy better, he one day said he was glad he didnt have
a life-threatening disease such as leukemia. Wouldnt it be awful if I had something like leukemia?
Mitchell says the boy told her. I was horrified. I had no idea what to say.

What Mitchell said was something like, What makes you say that?

Mitchell calls this attempt to avoid anwering the question the nursing duck.

We used to just duck the hard, ethical questions because we were not sure what nurses responsibilities
to patients were when it came to telling and talking about their diagnosis and prognosis, she says.

Today she would respond differently. I should have replied, Are you scared and do you want to talk
about it? I had only that moment to talk to him. I could clean up the mess later.

Science and technology tend to drive the ethical issues nurses encounter in their practice, in part
because technology is often assumed to be beneficial to patients without hard evidence to prove it.

New technologies that are already causing ethical questions include ventricular assist devices and
preimplantation genetic diagnosis, Mitchell says.

Patient Who Smokes: A Home Health Care Challenge

One of the greatest safety risks to home healthcare patients is the risk of fire in the homes of those who
are on oxygen therapy, says Carol Bourne, RN, BSN, patient service manager at the Visting Nurse
Association in Boston.

This risk recently created an ethical dilemma for a VNA nurse who was caring for an elderly woman who
was put on home oxygen therapy after a hospitalization.

The nurse educated the patient about the dangers to herself and other residents in the building if she
smoked while using oxygen. The patient said she understood and agreed to have a no smoking sign
placed on her door, says Bourne, who is a member of the VNAs ethics committee.

She did very well at first, giving up cigarettes, and her breathing improved, says Bourne. But as time
went by, the patient found it increasingly difficult to not smoke and eventually started lighting up again.

One day during a home visit, the nurse noticed the womans oxygen tubing had a brown substance on it
and realized the woman had been smoking and dropped the cigarette on her oxygen tubing.

Upset, the nurse called the oxygen company and asked them to replace the tubing and tried to educate
her patient about the dangers of smoking, not only to herself but to her neighbors.

The patient said she understood, but not long after began smoking again, even after she was given a
nicotine patch.

Frustrated, the nurse brought the case to the ethics committee. After many hours of discussion, the
committee decided the patient would be given a choice between continuing the oxygen therapy or
continuing to smoke, Bourne says. She chose to continue to smoke. Eventually the patients condition
deterioritated, she was rehospitalized, and brought to an LTC.

The ethics committee felt it made the right decision by considering the welfare of the larger group the
residents in the building rather than just the welfare of the patient, says Bourne.







NICU Nurses Struggle with Mothers Indifference Toward Baby

Calming anxious and distraught parents of premature infants is second nature to the NICU nurses at Beth
Israel Deaconess Medical Center, Boston. But when a mother of a 25-weeks preemie showed little
interest or concern about her baby, the staff found her indifference difficult to understand and they
became conflicted about what to do.

The mother was a professional woman whose pregnancy, her first, had been achieved through in vitro
fertilization. Yet when the woman was hospitalized with preterm labor, she rarely followed the advice of
nurses and physcians to remain on bedrest and relax, says Susan Young, RN, MS, clinical nurse
specialist in the NICU. Instead, she continued to work from her bed and place additional stress on the
fetus, despite the NICU nurses appeals that she could harm her baby.

When attempts to stop premature delivery failed, the mother asked the medical team not to take
extraordinary measures to save the baby, Young says. The preemie lived, but the mother showed little
interest in his welfare. The nurses did everything they could think of to spark the womans maternal
instincts, but nothing worked.

She didnt want to talk to the staff or social services, says Young. Her detachment was difficult for the
staff.

Her interest waned even further when the baby developed a bleed that resulted in some permanent brain
damage. In fact, she was angry at the staff for saving the baby against her wishes. Ultimately, the mother
chose to put the baby up for adoption, a choice difficult for the NICU nurses to comprehend, says Young.

The nurses had no choice but to accept the mothers decision, says Christine Mitchell, associate director
of clinical ethics at Harvard Medical School in Cambridge, Mass. They tried to the best of their ability to
support the mother and help her connect with the baby, she says. When that didnt work, they had to
help find the best outcome.









A Voice for a Dying Patient and his Wife

The nurses of a surgical trauma intensive care unit recently served as the voice for a dying man and his
wife so they could be together during the last few minutes of the husbands life. The patient was a middle-
aged man who came to the hospital to have elective, but complex, surgery that could be complicated by
his multiple medical problems, such as hypertension, diabetes, obesity, and sleep apnea, says Sharon
Brackett, RN, BS, CCRN, a staff nurse in the Surgical Intensive Care Unit at Massachusetts General
Hospital in Boston.The patient arrived in the unit from the OR in precarious condition because he had
started to hemorrhage, says Brackett. The man was not Bracketts patient but she was in the room
multiple times to assist because his condition was so critical. The mans family was in the waiting room
and had not yet been invited into the room to see him.

The nurses thought it was important for the wife to be with the patient, especially because her husbands
condition was continuing to deteriorate despite maximal efforts. They were aware that several
professional organizations and the hospitals ED were in favor of this process, and they had seen family
members be present with patients during resuscitation. In fact, just a few nights prior, a long-term patient
on the unit had rapidly deteriorated, and his wife had been allowed into the room, where she spent the
last few hours of his life caressing his face and speaking to him. He died despite resuscitation, but his
wife was able to share the last moments that he was awake. He had not been able to eat in weeks but
they shared a cup of coffee (at his request) and memories of their life together. On the heels of this recent
positive experience, several SICU nurses were voicing a desire to encourage a family presence in this
currently evolving case. The medical staff needed to continue aggressive treatment to try to stabilize the
husband and get him back to the OR, and they initially preferred that the wife not be present as this took
place.

As the senior ICU physician went out to talk to the wife and again update her on her husbands condition,
the patients condition further deteriorated indicating impending cardiac failure. Brackett went to the
waiting room to alert the physician to the patients sudden change in status and also used this opportunity
to assess the situation and see how the family was coping. The wife was appropriately distraught about
this life-threatening complication but appeared quite reasonable. Again, her husbands condition further
deteriorated requiring CPR and defibrillation. It was clear he was now too unstable to move to the OR and
preparations were initiated to explore his abdomen at the bedside to locate a source of bleeding.

The nurses approached the physicians about having a family presence at the bedside as the patient now
appeared to be actively dying. They shared their assessment that his wife appeared able to handle the
situation, and it was now even more important for her to be by his side. The physicians agreed, and the
wife was escorted into the room, where she could sit by her husbands side, hold his hand, and tell him
that she loved him, even as resuscitation and preparation for re-exploring him continued. Although the
teams efforts to save his life were unsuccessful, he and his wife were able to share his last moments.

It allowed her time to say her good byes, and allowed the team to witness a positive experience that
would not deter their efforts to resuscitate further, Brackett says.

Both cases were discussed during the SICUs ethics rounds, in terms of what went well, what might have
gone better, says Brackett. The multidisciplinary staff of the unit are also now reviewing the guidelines
from various professional associations and are in the process of developing a new policy about family
visitation during resuscitation, thanks to the advocacy of the units nurses.




















Ethical Dilemmas in Nursing
Nurses face ethical dilemmas on a daily basis regardless of where they practice. No
matter where nurses function in their varied roles, they are faced with ethical
decisions that can impact them and their patients. There is no right solution to an
ethical dilemma.
So what is an ethical dilemma? It is a problem without a satisfactory resolution. The
significance of ethical decision-making lays in the fact that very different ethical
choices regarding the same ethical dilemma can be made resulting in neither choice
being a right or wrong decision.
Ethics involve doing good and causing no harm. But how one defines what is
ethical can vary differently from nurse to nurse. Classes on the principles of ethics
give the nurse the tools to base ethical decisions upon. However, this knowledge is
then shaped by the values, beliefs and experiences of the nurse. Consequently,
very different choices may be made involving the same dilemma.
There are many ethical issues nurses can encounter in the workplace. These include
quality versus quantity of life, pro-choice versus pro-life, freedom versus
control, truth telling versus deception, distribution of resources, and empirical
knowledge versus personal beliefs. Quantity may address how long a person lives
or perhaps how many people will be affected by the decision. Quality pertains to
how good a life a person may have and this varies depending on how a person
defines good. So how does the nurse support a patient deciding between a
therapy that will prolong life but the quality of life will be compromised? The person
may live longer, but will likely experience significant side effects from the therapy.
What should the nurses position be?
1. Pro-choice versus pro-life. This issue affects nurses personally. Many of
the positions nurses assume in this dilemma are influenced by their own
beliefs and values. How does a nurse care for a patient who has had an
abortion, when the nurse considers abortion murder? Can that nurse with
very opposing values support that patients right to choose, her autonomy?
2. Freedom versus control. Does a patient have the right to make choices for
ones self that may result in harm, or should the nurse prevent this choice?
For example, a patient wants to stop eating, but the nurse knows the
consequences will harm the patient. Does the nurse have the right to force
the patient to eat?
3. Truth telling versus deception. This is another issue that nurses may have
to deal with, especially when families want to deny telling the patient the
truth about the medical condition. What should a nurse do when a family
insists telling the patient the prognosis will cause harm? How can a nurse
know if this is true? Does the patient have the right to know?
4. Another dilemma involves the distribution of resources. Who should
get the limited resources? For example, nurses working with patients that are
in a vegetative state; should these patients be left on life support? Look at
the cost of maintaining these patients. These patients are consuming
resources that could be used for patients in whom such costly interventions,
if available, could save their lives. What is the role of the nurse when a
family wants to continue life support for a medically futile family member?
5. Empirical knowledge versus personal belief. In these dilemmas, research
based knowledge is contrasted to beliefs gained from such things as religious
beliefs. For example, what should a nurse do when a patient is admitted to
the hospital that desperately needs a transfusion to live but has the belief
that transfusions are unacceptable? The nurse knows this patient will die
without the transfusion. How does that nurse deal with the patients family who
supports the family members choice and still be supportive of the patients
and familys right to this decision?
Nurses are faced daily with ethical dilemmas in which they must make a decision.
The decisions they will make will be affected by so many factors including principles
learned in school and their own personal beliefs, values and experiences. Are these
choices right or wrong?