Abstract
Members of the health care profession have a responsibility to identify and regulate their practice to protect consumers and assure the delivery of quality service. In this case study in which a patient wakes up during surgery, the nurse's code of ethics, standards of care, and ethical decision-making models provide guidance toward the resolution of this clinical dilemma. Such resolution requires sound nursing knowledge, knowledge of the facts of the situation, knowledge of the law, and application of critical thinking skills to facilitate positive outcomes for all parties involved. © 2001 by American Society of PeriAnesthesia Nurses.
TODAY'S NURSE IS challenged to deliver quality care in a dynamically changing health care environment. This constant change often creates ethical dilemmas resulting from the combination of increasing patient acuity, advanced technology, and limited resources. The nurse's unique relationship with the patient enables her to provide the “watchful vigilance” or close observation required to identify both clinical crises and ethical dilemmas. Management of these issues requires a combination of clinical expertise and skill in moral judgment. The American Nurses Association (ANA) Code for Nurses
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is a guide to the moral foundation of nursing. It not only provides a framework and theories for the nurse to use in ethical decision making, but it also provides society with a set of expectations for professional nursing behavior.- American Nurses Association
Code for Nurses.
American Nurses Association,
Washington, DC1995
www.nursingworld.org/readroom/position/ethics/etcode.html
Date: August 1999
Case study
The incident to be examined under an ethical decision-making framework is outlined as follows: On entering the OR, the perianesthesia nurse identified immediately that the safety of the surgical patient was compromised. Monitor alarms chimed, bringing the nurse's attention to the patient's airway and the oxygen saturation reading that was below 90%. Immediate assessment of the situation revealed that the patient was awake, extubated, and shaking his head from side to side, trying to free himself from under the surgical drapes. It was 45 minutes into the thyroidectomy procedure, and the surgical incision was exposed. The nurse immediately stepped forward to assist the anesthesiologist by providing 100% oxygen with a face mask. The patient was very vulnerable at this time because of emergence excitement, depressed central respiratory drive, inadequate mechanics of ventilation (from residual muscle relaxation), and aspiration. The nurse questioned the standard of care asking why the patient was awake and not intubated. The anesthesiologist responded with, “I have a cuff leak and want to replace the tube.” The nurse acknowledged the response but further questioned the anesthesiologist about the situation and the patient's safety. Angrily, the anesthesiologist responded, “Don't say anything the patient will remember.” After what seemed like hours, the patient was reoxygenated and reintubated. The surgical procedure recommenced, and the nurse was thanked for her assistance by the surgeon. In the stress of the aftermath, however, the anesthesiologist's behavior was defensive, exhibiting avoidance of the fact that the incident actually happened. (This is a fictional incident and is not intended to reflect any real people or incidents.)
Deontological decision-making model
A professional ethic is based on 3 elements: (1) a professional code of ethics, (2) the profession's purpose, and (3) the standards of practice of the profession. Ethical nursing practice is not only concerned with nursing duties, but also with the consequences of decisions on patients, colleagues, society, and the nursing profession. The previously mentioned case study shows a setting in which the patient was most vulnerable—when the intrusion of anesthesia and surgery had a significant impact on motor and sensory functions, rendering the patient insensible to his surroundings and unable to protect himself from injury. The nurse, therefore, must serve in an advocacy role, providing active advocacy for the individual while reflecting the nurse's innate responsibility and obligation to the patient. When advocating for the patient, the nurse's personal and professional values and standards are incorporated.
A deontological approach to the incident in question would focus on the rightness or wrongness of the action. Deontology is an ethical philosophy describing actions that apply principles and rules. In other words, the rules are to be followed by all individuals at all times. Deontology is supported by the ethical principles of beneficence, nonmaleficence, autonomy, and justice.
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A nurse operating from a deontological approach would consider an incident and its effect on the client and all professionals involved by analyzing the incident within the context of these principles.Beneficence
The principle of beneficence requires that one prevents harm to competent persons, removes harmful conditions, and does good for the benefit of others.
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When applying this principle to the case study, it implies that the nurse not only must not harm the patient, but the nurse must also try to benefit the patient. Beneficence is the underlying principle in all medicine, health care, and research whereby physicians and nurses are primarily guided by a professional code of ethics. The ANA Code For Nurses states that “the nurse acts to safeguard the patient and the public when health care and safety are affected by the incompetent, unethical, or illegal practice of any person.”1
- American Nurses Association
Code for Nurses.
American Nurses Association,
Washington, DC1995
www.nursingworld.org/readroom/position/ethics/etcode.html
Date: August 1999
Nonmaleficence
Nonmaleficence is defined as freedom from harm. Harm may be classified as physical, emotional, social, or potential risks to the client. Within the health care setting, physicians and nurses must be aware of possible complications, particularly those that risk permanent damage. Strategies should be in place to manage adverse events within this setting.
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Nonmaleficence, applied to the case study, assumes that no harm should come to the patient as a result of the surgical procedure. Potential risks to the patient must be reviewed by both the physician and the patient and informed consent obtained. Care must be taken to avoid risks and complications whenever possible.Autonomy
Nursing practice must truly respect patients as dignified human beings who are capable of deciding what is in their own best interest. The ANA Code For Nurses
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states the following: The fundamental principle of nursing practice is respect for the inherent dignity and worth of every client. Nurses are morally obligated to respect human existence and the individuality of all persons who are the recipients of nursing actions. Nurses therefore must take all reasonable means to protect and preserve human life.- American Nurses Association
Code for Nurses.
American Nurses Association,
Washington, DC1995
www.nursingworld.org/readroom/position/ethics/etcode.html
Date: August 1999
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The case study showed a patient under the effects of anesthesia and thus unable to act autonomously. It was the nurse's responsibility, therefore, to protect the autonomy of the patient.
Justice
The ethical principle of justice requires that medical care be fair to all participants. The mere fact that someone is a patient renders him or her vulnerable. All patients have the right to quality care, and any breach of this standard of care by the physician or nurse violates the patient's right to justice.
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It was the nurse's responsibility in the case study to assure that an appropriate standard of care was maintained.Ethically analyzing a situation
Frameworks for ethical decision making are helpful in examining a clinical situation or action to determine if the situation involves ethical issues. Curtin's 6-step model of ethical decision making recommends the following steps: (1) Perception of the Problem, (2) Identification of Ethical Components, (3) Clarification of Persons Involved, (4) Exploration of Options, (5) Application of Ethical Theory, and (6) Resolution/Evaluation.
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Perception of the problem
The first step in ethical analysis is to establish the perception of the problem. This is accomplished by gathering background information or conducting an assessment to gather data. Relevant questions to be asked at this stage include the following:
- •Does an ethical dilemma exist?
- •What information is known?
- •What information is needed?
- •What is the context of the dilemma?
The ethical dilemma facing the nurse professional in the case study was whether to report the event or to remain silent as if the event had not occurred. What is known is that the patient woke up during the surgical procedure. Information that is needed is why the patient woke up and whether or not this constitutes professional negligence. The nurse, in choosing to be a patient advocate, must act for the patient. In doing so, it is the nurse's duty to report the incident. Thus, the value of beneficence (patient care) is preferred by the nurse over that of justice (loyalty to a colleague). This decision, however, predisposes the nurse to a fear of retaliation by the physician. The nurse may also be placed in the position of having to deal with other unpleasant work environment issues that may be of consequence.
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Identifying the ethical components
The second step in ethical analysis is to identify ethical components. Relevant questions to be asked at this stage are the following:
- •What is the underlying issue/problem?
- •Who (patient, nurse, doctor, family, institution) is affected by this dilemma?
The underlying issue or dilemma in this case is the concept of inappropriate or questionable practice by the anesthesiologist. This issue created a conflict between the nurse's primary commitment to the health, welfare, and safety of the patient and the nurse's professional working relationship with colleagues. The primary parties affected by the dilemma of whether to report the incident or not include the nurse, physician, and all others present in the OR at the time of the incident. The incident itself could have repercussions for the nurse, physician, other health care providers, the institution, patient, and the patient's family.
Upholding a duty to report the incident resides from personal values regarding patient advocacy and standards of nursing practice, in which identifying unsafe practice may initiate an area of growth for the anesthesiologist in question. The duty that the anesthesiologist owes to the patients under his care is to adhere to the standards of care within his own profession.
Clarification of the people involved
Clarification of the people involved is the third step in the process of ethical analysis. This is similar to the planning stage of the nursing process. Relevant questions to be asked at this stage are the following:
- •What are the rights of people/person involved?
- •What are the obligations of each person involved?
- •Who should be involved in decision making?
- •For whom is the decision being made?
- •What degree of patient consent is needed?
The patient has the right to safe and quality care that is delivered according to professional standards. The nurse has the right to question the care delivered and to receive an adequate explanation. The anesthesiologist has a right to due process. The anesthesiologist has the obligation to explain his actions and to report them if inappropriate. The nurse has the obligation to assure that appropriate actions are taken to prevent future occurrences of such events.
The primary person involved in the decision-making process should be the nurse, in consultation with his/her immediate supervisor. Other parties that may be involved or consulted include those in the OR at the time of the incident. If the anesthesiologist was in agreement that an incident or sentinel event occurred, then he/she should ideally be involved in any decisions. In this case, the anesthesiologist did not perceive that there was a problem, and therefore the head of the anesthesia department would need to be involved in whatever decisions are made. The decision to report is ultimately being made for the patient and for the protection of future patients, although the patient would not need to give his/her consent for the nurse to report this type of incident.
Exploration of the options
The fourth step of ethical analysis is the exploration of the options. Relevant questions to be asked at this stage include the following:
- •What alternatives exist?
- •What is the purpose or intent of each alternative?
- •What are the potential consequences of each alternative?
The only alternative to the duty of reporting (disclosure) the incident was to overlook it or implement the “code of silence.” The nurse may have maintained a code of silence and chosen justice (loyalty to colleagues) over beneficence (patient care) with the intent of remaining on the same team as her peers. The purpose of disclosure, however, was to advocate nurse-patient integrity and to maintain the standards of care of the health professionals involved and, thus, the institution. Consequences of the alternative were the moral dilemma of mixed loyalties for the nurses and the potential for compromise of the individual's integrity as professional and personal conflicts arose. Such conflicts have been shown to affect nurses to the point of resignation.
Application of ethical theories
Application of ethical theories is the fifth step of ethical analysis. The application of ethical theories in situational analysis strengthens the final decision and prevents subjective quandary. A relevant question at this stage is, which ethical theory should be used?
When nurses are resolving ethical dilemmas in clinical situations, they are obliged to consider their social role; professional standards of care; legal obligations; professional codes of ethics; patient, family, and other health team members involved; and documentation issues. A deontological approach to this situation determines that only one course of action, the duty to report, is consistent with the deontological theory that “actions are independently assessed for their own value, and the consequences are not part of the decision.” Therefore, the consequences to the nurse should not be considered as part of the decision to report.
Resolution—resolution into action
The sixth and final step is the requirement to decide on a resolution—resolution into action. Relevant questions to be addressed here are the following:
- •What are the social and legal constraints and ramifications?
- •What is the goal of one's decision?
- •How can the resulting choice be implemented? (Is it the best for the patient, family, nurse, and all concerned?)
- •How can the resulting ethical choice be evaluated?
In this case study, the anesthesiologist and the nurse have a duty to adhere to professional standards of care. These standards are determined from published guidelines of his/her professions, societal expectations, and written policy of the hospital and department. The resolution assures that incompetent or unethical practice on the part of any health care professional is corrected within the employment setting to minimize risk and maximize the quality of care and safety provided for all patients.
Documentation and reporting. From a professional perspective, not telling the truth undermines the principle of respect for autonomy, in which the patients' autonomy is infringed if they are deceived. Therefore, the nurse is morally obligated to document and report the incident using the chain of command. A typical chain of command found in many institutions and described in the context of the case study is noted as follows: The incident was reported to the team leader of the department, whereby an accurate, factual incident report was completed that focused on the patient and the outcome. This written incident report was forwarded to risk management, the ethics committee, and the anesthesia practice committee. In addition, the nurse gave a verbal report to the anesthesia department administrator and nurse manager.
Evaluation. The duty owed to the patient began when a relationship with the anesthesiologist was established. A breach of duty occurred with the noncompliance to the accepted professional standard of care. Within the context of this case study, the anesthesiologist had established a duty to the patient with the consent to administer anesthesia and failed to fulfill this obligation (thus a breach of duty) when the patient was subjected to a substandard quality of care. An appropriate route of evaluation would be the following: The incident was evaluated on different levels of accountability by intrahospital patient advocacy committees (such as risk management and ethics committees). In addition, the incident was brought to the attention of the monthly anesthesia committee, whereby examination of the incident revealed a compromise of standards that was not in the best interest of the patient's safety. Appropriate and confidential disciplinary action was taken to avoid practice that may jeopardize the welfare and safety of future patients.
The standards of care involved in the evaluation of the incident arose from the physician's medical profession and peers, as well as from societal guidelines, department and hospital policies, and past precedence.
Conclusion
A dilemma or ethical issue often involves being caught between a rock and a hard place, a situation involving a choice between equally unsatisfactory alternatives. The situation may seem unsolvable, but can be resolved if ethical principles and approaches are used. There are a number of moral issues that face the health care profession as a whole. As a result, adverse outcomes are an inevitable part of medical practice. However, standards of care must be upheld in all professions to provide advocacy and protection for patients in vulnerable positions. Nurses need to take steps to minimize risk and improve the quality of care in these increasingly complex times of change. Following nursing standards and codes of ethics improves communication with colleagues while protecting and advocating for the patient and quality care.
References
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Article info
Publication history
Address correspondence to Jacqueline Wood, RN, BSN, CPAN, PO Box 1516, Frisco, CO 80443.
Identification
Copyright
© 2001 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.
