Running Head: PATIENT ADVOCACY 1. The Nurse as Patient Advocate. MUSC College of Nursing

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1 Running Head: PATIENT ADVOCACY 1 The Nurse as Patient Advocate MUSC College of Nursing

2 Running Head: PATIENT ADVOCACY 2 The Situation Seventy-eight year old Mr. A was a healthy individual. His only complaint was decreased mobility due to hip pain and stiffness. A hip replacement was performed, and after what seemed to be a successful recovery, he was discharged from the hospital. Three days after his discharge, Mr. A was rushed to the emergency room presenting with a high fever, severe abdominal distension, and loss of consciousness. He was admitted to the ICU and a series of tests were begun. It was determined that Mr. A s hip surgery had irritated an underlying infection of unknown origin allowing the infection to enter his blood. Mr. A was put on a ventilator and treatment was initiated with several powerful, broad-spectrum anti-fungal drugs and antibiotics. Three weeks later, Mr. A was still unconscious and no diagnosis had been made. His white blood cell count had decreased slightly and his fever had dissipated. At this point, doctors began to question his level of brain function. They anticipated the oxygen deprivation Mr. A s brain suffered during the time he was unconscious had been so severe that it caused permanent brain damage. An MRI was ordered to determine the extent of the damage. Mr. A s family was very disturbed by the course of these events. They did not understand how he could go from recovering so well to being comatose in a three day time period. They refused to give up hope that Mr. A could overcome the recent turn of events. Mr. A did not have an advanced directive or living will to guide the family in his plan of care leaving several difficult decisions to his wife of almost 60 years. She decided that if Mr. A had incurred debilitating brain damage, life support measures would be discontinued. She and the rest of Mr. A s family were concerned about Mr. A s quality of life if he did recover from the coma.

3 Running Head: PATIENT ADVOCACY 3 Just hours after the MRI was performed, the ICU physician notified the family that their loved one was brain dead. Mr. A s wife, reluctant to give up on her husband, decided to wait just a little longer. The unit physician reported two more times over the next few hours that there was no possibility Mr. A would recover. The family decided to take Mr. A off the ventilator. Mr. A s nurse overheard the family s decision to discontinue life support measures. She knew the full MRI results had not yet been reported and Mr. A s team of specialists new nothing of the situation. Mr. A s nurse now faced a difficult ethical dilemma. Should she allow the illinformed family members to discontinue Mr. A s life support without a firm knowledge base? Should Mr. A s nurse intervene in some way in the situation? Where do the nurse s duties lie within the scope of this situation? Characterization of the Ethical Dilemma According to the American Nurses Association s (ANA) Code of Ethics, one role of the nurse is to strive to advocate for the safety, health, and rights of the client (Ecker, 2009). The role of the nurse as patient s advocate in Mr. A s situation creates a two-sided ethical dilemma for his nurse. Her first option is to advocate for the patient by informing Mr. A s specialists of the situation or telling his family a complete report had not yet been received. On the other hand, since no one knew she overheard the family s conversation, she could choose to do nothing allowing the family to proceed with their decision to suspend life support measures. If Mr. A s nurse decides to inform the family or other doctors that the MRI results had not yet been completed, she would be acting upon several ethical principles. First, she would be acting on the ethical principle of autonomy by ensuring the patient was an active, knowledgeable participant in his own healthcare (Ecker, 2009). In Mr. A s situation, the nurse would be sure the family completely understood the client s situation before making any life-changing decisions.

4 Running Head: PATIENT ADVOCACY 4 Another ethical principle Mr. A s nurse would be carrying out by divulging the truth is nonmaleficence. In other words, the nurse would be ensuring the client was not harmed in any way (Ecker, 2009). In Mr. A s situation, his nurse would prevent his unjustified death. She would be ensuring her client was not harmed in any way due to information given from another healthcare professional she knew to be untrue. Beneficence is another guiding principle of the nursing profession that would be applicable to Mr. A s situation. Beneficence is a practice that encourages helping others through one s own positive actions. To act on this principle, one must act unselfishly by putting the other person s best interest before one s own (Ecker, 2009). In Mr. A s case, the nurse would be helping her client through the positive action of divulging the truth to save his life. Even though going against the doctor s opinion in this case could be a risky action on her part (Negarandeh, Oskouie, Ahmadi, Nikravesh, and Hallberg, 2006), Mr. A s nurse would be putting the needs of her client above her own. Veracity is also one of the bioethical principles that underlie the nursing practice. Veracity is the principle of truth-telling. Patients and their families trust and expect their healthcare providers to tell them the truth about their care and condition (Schroeter, 2002). Therefore, Mr. A s nurse ensuring his family knows the truth about his condition would be her acting on the ethical principle of veracity. Mr. A s nurse also has the option of doing nothing and allowing the family to take Mr. A off the ventilator. By doing this, Mr. A s nurse would not be advocating for her patient and would be neglecting the ethical principles of autonomy, beneficence, and nonmaleficence (Ecker, 2009). Mr. A s nurse remaining silent also introduces ANA s Code of Ethics principle of accountability. Accountability refers to the nurse s obligation to answer for and explain her

5 Running Head: PATIENT ADVOCACY 5 actions (Ecker, 2009). If anyone witnessed Mr. A s nurse overhearing the family s conversation, she may be held accountable for not following her duty to advocate for her patient s well-being and educating the family about the incomplete test results. Possible Consequences of the Nurse Divulging the Truth Depending on the nurse s decision, there could be several possible outcomes of her actions. Some nurses have reported that advocating for the patient against a physician s opinion often results in the physician taking offense to the situation. The offended physician may act harshly toward the nurse disrupting the positive work environment (Negarandeh, 2006). In Mr. A s situation, his nurse divulging the truth to his specialists or family could cause the ICU physician to harbor negative feelings toward her leading to an uncomfortable work environment. Another possible barrier for Mr. A s nurse going above the doctor s head is the potential lack of support from her supervisor or the specialists she contacts. If her superior and/or the specialists do not provide support for her assuming the role of patient advocate, she could possibly be reprimanded and have no one to help her defend her actions (Negarandeh, et al., 2009). Despite the possible negative effects that may result from advocating for the patient, patient advocacy typically results in a more positive situation (Briggs and Colvin, 2002). Advocating for the patient s wellbeing often provides a rewarding and healthy nurse-patient relationship. The more positive the nurse-patient relationship the more the nurse will know about the patient s desires. This will better prepare the nurse to provide excellent care structured by the patient s wishes (Negarandeh, 2006). This type of nursing involvement has been found to be desired by both the patient and family (Briggs and Colvin, 2002). Thereby, if Mr. A s nurse stands up for her patient, she would be taking steps to better care for her patient through the institution of a trusting relationship with Mr. A s family.

6 Running Head: PATIENT ADVOCACY 6 In addition to building a positive nurse-patient relationship, Mr. A s nurse could positively impact the client and family in yet another way. In just a matter of days, Mr. A s wife was faced with the complicated situation of deciding her husband s fate. This overburdening of families with important multi-faceted decisions is a problem in today s healthcare communication process. Healthcare professionals can help families in situations similar to Mr. A s by helping the family identify, prioritize, and initiate goals for the patient s care. Through these actions, Mr. A s nurse could help the family members focus on what they want for their loved one and facilitate the decision making process (Gillick, 2009). Possible Consequences of the Nurse Withholding the Truth The nurse s second option in Mr. A s case is to say nothing and allow the family to take Mr. A off life support. Since no one knew that she had overheard the family s conversation, there were no witnesses or proof that she did nothing to defend her patient. The first requirement in a malpractice suit is an assessment of the nurse s duty of care and an evaluation to determine if the nurse breached those duties. Therefore, if there is no evidence Mr. A s nurse breached her ethical duty, the first requirement for a malpractice suit would be absent (Brooke, 2008). Even though there may not be sufficient evidence to charge Mr. A s nurse with negligence directly, a lawsuit against Mr. A s physicians or the hospital could potentially affect her as well. A prime example of this type of lawsuit is the 2001 case Rowe v. Sisters of Pallottine Missionary Society. A 17-year-old motorcycle accident victim almost lost his leg as a result of a poor diagnosis by a doctor. The nurses, who knew the diagnosis was not accurate, stood by and did nothing to help this young man. The patient sued the doctor for his below standard of care. He also filed a suit against the hospital for the nurses not reporting the incidence to their supervisor as hospital policy ordered. The court ruled on the side of the patient

7 Running Head: PATIENT ADVOCACY 7 (Tammelleo, 2002). The nurses in this case were in a similar ethical dilemma as Mr. A s nurse. Mr. A s family could potentially bring a lawsuit against the hospital and physicians if they disconnect life support and find out later that Mr. A s brain was still viable. Based on the case discussed above, Mr. A s nurse could be prosecuted in the lawsuit as well for not advocating for her patient as her nursing responsibility calls for her to do. The Best Choice I believe the best decision for Mr. A s nurse in this situation would be to report the situation to her superior or Mr. A s specialist. There is too much at stake in this situation to stand by and do nothing. A person whose care she is responsible for could possibly lose his life if she does not act. Personally, I would not be able to handle the guilt I would have to carry around with me knowing that I could have possibly saved someone s life but chose not to. In addition to saving someone s life, Mr. A s nurse could also be saving herself from possible legal repercussions for her inaction. What Really Happened? Mr. A s situation had a fortunate ending. Mr. A s nurse immediately contacted the primary specialist on Mr. A s case and informed him of the situation. He rushed down to the ICU to talk to the family before they had time to sign the papers to discontinue life support. He explained to them that he had no reason to doubt that Mr. A could recover. The family made the final decision not to remove life support. A week and a half later, while this particular nurse was in his room, Mr. A awoke from his coma and began his long road to recovery. Had it not been for the actions of Mr. A s nurse, he would not have lived to enjoy his remaining months with his family.

8 Running Head: PATIENT ADVOCACY 8 References Brooke, P.S. (2008). Malpractice Maladies. Nursing Management 39(7), Briggs, L. & Colvin, E. (2002). The nurse s role in end-of-life care decision making for patients and families. Geriatric Nursing, 23(6), Ecker, M. (2009). Ethics and Values. In S. Ecker & L. Huenefeld (Eds.), Fundamentals in nursing (7 th ed.)(pp ). St. Louis, MO: Mosby. Gillick, M.R. (2009). Decision making near life s end: A prescription for change. Journal of Palliative Medicine 12(2), Negarandeh, R., Oskouie, F., Ahmadi, F., Nikravesh, M., & Hallberg, I.R. (2006). Patient advocacy: Barriers and facilitators. BioMed Central Nursing, 5(3), 1-8. Schroeter, K. (2002). Ethics in perioperative practice principles and applications. AORN Journal 75(4), Tammelleo, A. D. (2002). Nurses failed to `advocate' for their patient. Nursing Law's Regan Report, 42 (8), 1.

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