[ANSWERED 2024] Read the case study presented at the end of Chapter 8 (Guido, p. 150)

Written By: Dan Palmer, RN

Read the case study presented at the end of Chapter 8 (Guido, p. 150)

Now consider the ethical issues that such a scenario raises.  Which ethical principles is

Impact of the Law on Patient Care Issues 

Professional Development Exercises :

  • Read the case study presented at the end of Chapter 8 (Guido, p. 150)
    • Is the patient correct in asserting that he has a right to know the names and status of individuals who will be performing this procedure?
    • Does the manner in which the student introduced herself and the two other team members have relevance in this case?
    • Was the informed consent deficient to the degree that there was a lack of informed consent by the patient?
    • How would you decide this case?
  • A patient is admitted to your surgical center for a breast biopsy under local anesthesia.  The surgeon has previously informed the patient of the procedure, risks, alternatives, desired outcomes, and possible complications. You give the surgery permit form to the patient for her signature.  She readily states that she knows about the procedure and has no additional questions; she signs the form with no hesitation.

Her husband, who is visiting with her, says he is worried that something may be said during the procedure to alarm his wife.  What do you do at this point?  Do you alert the surgeon that informed consent has not been obtained?  Do you request that the surgeon revisit the patient and reinstruct her about the surgery?  Since the patient has already signed the form, is there anything more you should do?

Now consider the ethical issues that such a scenario raises.  Which ethical principles is the husband in this example most portraying?  Which ethical principles should guide the nurse in working with this patient and family member?

  • Jimmy Chang, a 20- year- old college student, is admitted to your institution for additional chemotherapy.  Jimmy was diagnosed with leukemia 5 years earlier and has had several courses of chemotherapy.  He is currently in an acute active phase of the disease, though he had enjoyed a 14- month remission phase prior to this admission.

His parents, who accompany him to the hospital, are divided as to the benefits of additional chemotherapy.  His mother is adamant that she will sign the informed consent form for this course of therapy, and his father is equally adamant that he will refuse to sign the informed consent form because “Jimmy has suffered enough.”

You are his primary nurse and must assist in somehow resolving this impasse.  What do you do about the informed consent form?  Who signs and why?  Using the MORAL model, decide the best course of action for Jimmy from an ethical perspective rather than a legal perspective.  Did you come to the same conclusion using both an ethical and a legal approach?

Expert Answer and Explanation

The Law and Patient Care Issues

Healthcare professionals, most especially nurses, come across legal and ethical issues concerning their practice at some point (Guido, 2014). The problems arise out of the lack of satisfaction about the care that has been provided to a patient. This mainly occurs in cases where the patient feels like the care provided by the nurse has been insufficient, especially when the end result of particular care is not impressive. By looking into some case studies regarding the issues that arose in the course of the provision of care to patients, this paper will establish some of the patient care issues that arise in care provision and how they relate to the law.

Case study: Chapter 8

Patient right

 The assertion by the patient regarding having a right to know the status and names of the persons that are to carry out the operation are right. Given the critical nature of surgical procedures, an approach to informed consent should be centered on the patient because the decision to proceed with the surgery should be in terms that the patient is comfortable with (Langerman, 2016).

It is, therefore, necessary that prior to the commencement of the surgery, the patient should be aware of all the aspects of the process, including being informed of the team that will carry out the procedure. It is necessary that the patient should know their names and statuses to ensure that he is able to trust the team.

Team introduction

The introduction of the team that will carry out the procedure on the patient is necessary for the purpose of enhancing the satisfaction of patients (Krishna, 2017). When a patient is aware of the team names and their ranks, their confidence in their qualifications may be enhanced with regard to the quality of care that will be provided.

The confidence of the patient will be improved in that he will be able to trust the decisions that will be made by the team while conducting the procedure.  Therefore, the way the student made an introduction of the team members and herself was relevant in establishing the confidence of the patient in the team. It is, therefore, necessary that an introduction gets made to build trust in the patient.

Deficient informed consent

The informed consent, in this case, became deficient at the moment when the student provided the incorrect information about her status (Krishna, 2017). She failed to inform the patient that she was a student, which could have played a significant part in the final decision of the patient in allowing the procedure to be carried out. It is clear that informed consent by the patient was lacking because it was based on inaccurate information.

If the student had disclosed her status, there is a high likelihood that the patient would not have approved of her being part of the surgical team on the basis that the surgery was critical. She did not have sufficient experience and knowledge to be part of the surgical team or take part in the process without supervision.

Decision

The matter would be decided based on the proof that will be presented by the patient concerning having been misinformed by the student to motivate him into allowing the procedure to take place (Krishna, 2017). The student will be held liable for the wrongful acquisition of informed consent.

The surgeon that was in charge would be held responsible for the care standards breach in the sense that be left the room before making sure that the final procedure had been done accordingly by the other team members (Foley & Christensen, 2016). He was supposed to supervise the activities of the student and the other members to ensure that the process had been done correctly.

Informed consent

Case study

What to do

When the patient’s husband expresses concerns, all a nurse can do is alert the surgeon of the concerns that have been expressed by the husband. However, it is clear that the surgeon had made the patient aware of what the surgery would entail in terms of risks, outcomes that are desired, alternatives, and complications that may arise (Wen et al., 2017).

This means that the patient had already consented to the procedure, and signing the forms meant that she was willing to go ahead with the procedure aware of everything it entails. The nurse has to respect the decision of the patient as she signed the form while fully aware of what she was about to face (Wen et al., 2017). Therefore, there is not much a nurse can do as the signature on the consent form is legally binding and indicates approval.

Alerting the surgeon

At this point, the nurse is not under any legal obligation to make an alert to the surgeon that the informed consent had not been obtained. This is because there is definite proof of the informed consent having been made by the patient when she signed the forms of consent before getting into surgery (Wen et al., 2017).

It would be assumed that she had acquired all the information regarding the operation from the information that was provided by the surgeon before that date, the surgeon had already explained everything to her, and as such, it is safe to assume that the patient may have understood everything from the surgeon’s explanation. The fact that she was not coerced into signing the form means she did it willingly, which indicates consent that was informed.

Reinstructing the patient

Patient satisfaction is a critical part of the provision of care in nursing (Lotfi et al., 2019). Due to the sensitive nature of the concerns that get raised by the patient’s husband, the bnurse would make a request to the surgeon to revisit the patient’s decision and confirm that she understands what the procedure means in terms of possible outcomes and risks(Wen et al., 2017).

He would consider going through the provisions of the consent forms once more to make sure that the patient understands and assure the patient’s husband that the patient was fully aware of everything concerning the procedure. This will help a great deal in assuring the husband that the patient is fully aware of what is happening.

What can be done after the form gets signed?

There is nothing the nurse can do after the patient has signed the consent form. This is because the signature of the patient on the form marks the conclusion and final decision of the patient in exercising her right to informed consent (Wen et al., 2017). Unless the signature was made by the patient through undue influence, it is her choice, and the nurse has no right whatsoever to interfere with the decision that has been made by the patient.

The patient signed the form because she had already talked to the surgeon who had discussed the details of the procedure to her and disclosed the various factors for the patient to consider before proceeding with the surgery.

Ethical principles

The husband was guided by the ethical principle of duty of care to the patient, which he has because of their marital status and their personal relationship (Foley & Christensen, 2016). He owes the patient a duty of care, and as such, he is obligated to air any concerns regarding the health of the patient to the healthcare providers. Also, he will be guided by the voluntary participation principle, whereby he voluntarily supports the patient through the recovery process after surgery (Stark et al., 2016).

Therefore, he has to ensure that the patient is receiving quality care and that her emotional state is in its right place before she goes ahead with the procedure in the sense that she would be prepared for any potential outcomes.

The nurse will be guided by the principle of autonomy, which means that one is self- driven (Chadwick & Gallagher, 2016). This means that she will be fully supportive of the patient and her family and offer them help whenever they need it even when they have not asked.  This principle will require the nurse to respects the privacy of the patient and family, obtain consent in an instance where she may want to intervene and protect the information that is confidential.

The nurse will also be guided by the principle of justice in which she will be required to treat the patients and their families fairly and in the same way as every other patient and family gets treated (Chadwick & Gallagher, 2016). This will help promote ethical practices in care provision.

Jimmy Chang, a 20- year- old college student, is admitted to your institution for additional chemotherapy.  Jimmy was diagnosed with leukemia 5 years earlier and has had several courses of chemotherapy

Case study

Informed consent

What the nurse can do

In an effort to resolve the issue that has arisen with regard to the signing of the forms for informed consent, the primary care nurse could take the forms and present the details to the patient so that he can make his own decision (Wen et al., 2017). However, that is conditional on whether the patient has the capacity to make his personal decision given the condition he is in.

When the patient was diagnosed, he was just a minor, and in that case, the law requires that the informed consent decision be made by a guardian to the minor representing the minor’s best interest (Lang & Paquette, 2018). The patient, in this case, is now an adult aged 20 years, and if it gets established that he has sufficient capacity to make an informed decision, then he will be allowed to make his own decision without the involvement of his parents.

Signing consent forms

The decision on who gets to sign the informed consent form will be based on who previously approved it. That would mean that the parent who signed it before would be the one responsible for making this decision again. However, if both parties signed the form, then the form will require both if their signatures for it to be valid.

His parents need to come to a common understanding as to what they think is best for their child. If they fail to agree, the hospital will have to find ways to establish whether the patient has the capacity and if he can speak, then the parents will have to let him make his own choices and decide on whether to proceed with the chemotherapy or to stop it entirely.

In most cases, however, fathers are given the authority to sign the consent forms (Alahmad et al., 2016). When this approach gets applied, then the father’s decision will be binding regardless of what the mother thinks.

Moral Model

Nurses in such situation as the one that the patient, Jimmy Chang is in are often faced with the moral dilemma of how they can ensure that the best interest of the patient gets provided when caring for a patient about who there is a conflict concerning what the next step should be (Guido, 2014)—in this case, deciding whether he should proceed with chemotherapy or not.

Applying the moral model of decision-making in an ethical way provides an opportunity for the nurse to advocate for care that is fair for their patients (Butts & Rich, 2019). In this case, the nurse can find a way to help the patients reach a decision that is fair and in the best interest of the patient.

From a perspective that is ethical, the nurse can help in the decision making process in this case by talking to the parents, having each of them explain their reasons for the decision they want to make then assess the various opinions together to make it possible for both of them to understand each other’s point of view (Vryonides et al., 2017). afterward, I will advise them on the consequences of choosing either of the choices involved with regard to how they will affect the patient.

The ethical perspective will consider the journey that the patient and how much he has had to fight; it will address the chances the patient has in both angles.  The fact that the patient is in the acute stage of the disease means his chances of making it through the chemotherapy and going back to a healthy life are closer to none.

However, he has a right to care regardless of the condition he is in, and as such, the best course of action would be to allow chemotherapy. The same conclusion would have been reached in both a legal and ethical approach in the sense that they both advocate for the preservation of the right to care and life.

Conclusion

The case scenarios presented in the case studies in the discussion above address issues of care in relation to the law. It is evident that the law has a significant impact on the issues of care of patients in the sense that most of the problems that are ethically recognized in the care of patients are similarly recognized under the law.

The issues that come up in the care of patients can get decided in courts and are punishable as crimes under the legal doctrines. Healthcare organizations are regulated by legislation provided under the law and therefore, the practice of nursing has to be legal meaning the issues that arose out of it get handles legally too.

References

Alahmad, G., Hifnawy, T., & Dierickx, K. (2016). Ethics of children’s participation in a Saudi biobank: an exploratory survey. Genetics in Medicine, 18(8), 806-813. Retrieved from https://www.nature.com/articles/gim2015164

Butts, J. B., & Rich, K. L. (2019). Nursing ethics. Jones & Bartlett Learning.

Chadwick, R., & Gallagher, A. (2016). Ethics and nursing practice. Macmillan International Higher Education.

Craig-Schapiro, R., DiBrito, S. R., Overton, H. N., Taylor, J. P., Fransman, R. B., Haut, E. R., & Sacks, B. C. (2018). Meet your surgical team: The impact of a resident-led quality improvement project on patient satisfaction. The American Journal of Surgery, 216(4), 793-799. Retrieved from https://www.sciencedirect.com/science/article/pii/S0002961018301041

Foley, M., & Christensen, M. (2016). Negligence and the Duty of Care: A Case Study Discussion. Singapore Nursing Journal, 43(1). Retrieved from http://search.ebscohost.com/login.aspx?direct=true&profile=ehost&scope=site&authtype=crawler&jrnl=02182475&AN=119422609&h=UpsN5j8gTMR%2BWZPBgvmBrIxf2dG%2F3RvjWD6iS2eEwP61a6M7KbUVvJasQKGos0laSXmH4s8RRZskk1a3re2y%2BQ%3D%3D&crl=c

Guido, G. W. (2014). Legal and ethical issues in nursing (6th ed.). Upper Saddle River, NJ: Prentice-Hall.

Krishna, A. (2017). Motivation with misinformation: Conceptualizing lacuna individuals and publics as knowledge-deficient, issue-negative activists. Journal of Public Relations Research, 29(4), 176-193. Retrieved from https://www.tandfonline.com/doi/abs/10.1080/1062726X.2017.1363047

Lang, A., & Paquette, E. T. (2018, October). Involving minors in medical decision making: understanding ethical issues in assent and refusal of care by minors. In Seminars in neurology (Vol. 38, No. 05, pp. 533-538). Thieme Medical Publishers. Retrieved from https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0038-1668078

Langerman, A. (2016). Concurrent surgery and informed consent. JAMA Surgery, 151(7), 601-602. Retrieved from https://jamanetwork.com/journals/jamasurgery/article-abstract/2504500

Lotfi, M., Zamanzadeh, V., Valizadeh, L., & Khajehgoodari, M. (2019). Assessment of nurse-patient communication and patient satisfaction from nursing care. Nursing Open, 6(3), 1189-1196. Retrieved from https://onlinelibrary.wiley.com/doi/abs/10.1002/nop2.316

Stark, Å. J., Salanterä, S., Sigurdardottir, A. K., Valkeapää, K., & Bachrach-Lindström, M. (2016). Spouse-related factors associated with quality of recovery of patients after hip or knee replacement–a Nordic perspective. International journal of orthopedic and trauma nursing, 23, 32-46. Retrieved from https://www.sciencedirect.com/science/article/pii/S1878124116300089

Vryonides, S., Merkouris, A., Charalambous, A., Andreou, P., & Papastavrou, E. (2017). The ethical dimension of nursing care rationing as it is revealed from existing qualitative research studies. Retrieved from https://ktisis.cut.ac.cy/handle/10488/10198

Wen, X., Feng, X., Ziyi, H. U., Jin, L. I., & Mei, F. R. (2017). Application of Subject-Centered Informed Consent in Nursing Research. Chinese Medical Ethics, 30(9), 1130-1132. Retrieved from http://wprim.whocc.org.cn/admin/article/articleDetail?WPRIMID=666326&articleId=666326

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FAQs

What is an example scenario of an ethical issue?

Scenario: Allocation of Scarce Resources in a Hospital Setting

Imagine a hospital facing a sudden surge in COVID-19 cases, leading to a shortage of ventilators and other critical resources. The nursing staff is confronted with the difficult task of deciding how to allocate these scarce resources among patients in need of respiratory support.

Ethical Issue:

Resource Allocation – The ethical dilemma revolves around the fair and just allocation of limited resources. Nurses must make decisions about which patients receive access to life-saving equipment like ventilators based on factors such as medical need, potential for recovery, and overall benefit.

Additional Considerations:

  1. Equity and Fairness: Nurses are tasked with ensuring that the distribution of resources is fair and equitable. They must consider factors such as the severity of the patient’s condition, the likelihood of recovery, and the potential impact on the community.
  2. Transparency and Communication: Maintaining open communication with patients and their families is crucial. Nurses should explain the challenging circumstances, the criteria used for resource allocation, and involve them in the decision-making process to the extent possible.
  3. Advocacy for Patients: Nurses must balance the duty to provide care to individual patients with the broader responsibility to allocate resources for the greater good. This may involve advocating for patients who may be at a disadvantage due to socioeconomic factors, ensuring that decisions are not discriminatory.
  4. Emotional Toll on Nurses: The ethical issue extends to the emotional well-being of nurses who are directly involved in making these difficult decisions. They may experience moral distress and burnout as a result of being in the position to decide who receives life-saving treatment and who does not.
  5. Adherence to Ethical Standards: Nurses must adhere to professional ethical standards and guidelines while navigating these challenging situations. This includes upholding the principles of beneficence, non-maleficence, and justice.

In this scenario, the ethical challenge lies in the necessity to make decisions that may have life-and-death consequences based on limited resources. Nurses must carefully navigate these decisions while upholding ethical principles, maintaining transparency, and addressing the emotional impact on both patients and healthcare providers. Ethical frameworks, interdisciplinary collaboration, and ongoing education are essential in guiding nurses through such challenging scenarios.

What are the ethical principles and ethical issues?

Ethical principles are fundamental guidelines that inform ethical behavior and decision-making across various domains. Ethical issues, on the other hand, are situations or problems that involve conflicting moral values, and they often require individuals to make choices based on ethical principles. Here are some commonly recognized ethical principles and issues:

Ethical Principles:

  1. Autonomy: Respecting individuals’ right to make their own decisions and choices regarding their lives and treatment. This principle emphasizes informed consent and the right to privacy.
  2. Beneficence: The obligation to do good and promote the well-being of individuals. This involves actions that contribute to the welfare and improvement of others.
  3. Non-maleficence: The principle of “do no harm.” Healthcare providers and individuals are obligated to avoid causing harm or minimizing potential harm in any action or decision.
  4. Justice: The fair and equitable distribution of resources, benefits, and burdens. This principle emphasizes treating individuals fairly and ensuring that everyone has access to the same opportunities.
  5. Veracity: The commitment to truthfulness and honesty. This involves providing accurate and complete information and not deceiving or misleading others.
  6. Fidelity: The principle of faithfulness and keeping promises. This involves maintaining trust and being true to one’s commitments and responsibilities.
  7. Confidentiality: Respecting the privacy and confidentiality of individuals. Healthcare providers, for example, are obligated to protect patients’ personal information.

Ethical Issues:

  1. Informed Consent: Ensuring individuals have adequate information to make informed decisions about their treatment, including potential risks and benefits.
  2. End-of-Life Care: Issues surrounding decisions about withholding or withdrawing life-sustaining treatment, advance directives, and the dignity and autonomy of individuals at the end of life.
  3. Resource Allocation: Deciding how to distribute limited resources, such as medical treatments, in a fair and just manner, especially during crises or shortages.
  4. Patient Confidentiality: Balancing the need to share patient information for healthcare purposes with the obligation to protect patient privacy and confidentiality.
  5. Health Disparities: Addressing disparities in access to healthcare and health outcomes among different populations, ensuring fair and equitable treatment for all.
  6. Research Ethics: Ensuring that research involving human subjects is conducted ethically, with informed consent, and minimizing any potential harm to participants.
  7. Professional Integrity: Maintaining honesty and integrity in professional relationships and avoiding conflicts of interest that could compromise ethical standards.

Understanding and navigating these ethical principles and issues is crucial in various fields, including healthcare, business, research, and everyday decision-making. Ethical guidelines and codes of conduct are often established to help individuals and professionals uphold these principles in their respective roles.

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