Case Study of an Ethical Dilemma

Introduction
An ethical dilemma arises when the clients and health care providers differ in their understanding of
what is right or wrong (Narrigan, 2004). As nurses we often deal with ethical dilemmas in our
everyday clinical practice; and as professionals we have the responsibility to analyse and examine
any ethical problems that may arise. Any decision should be based on ethical principle that protects
the best interest of both the patient and the health care provider. This paper will outline a critical
incident which occurred in one of my clinical experience in intensive care unit (ICU).It presents the
clinical case, identifies the ethical dilemma, and discusses the principles that apply to this situation.
The Case
Mrs G was a 76-year old woman who was brought to emergency department (ED) after her carer
found her in respiratory distress.
The ED doctor noted that the patient was minimally responsive to verbal stimuli, afebrile,
normotensive, tachycardic to 130 bpm, and tachypneic to 30 breaths/min.A chest radiograph
revealed a right lower lobe consolidation. Based on her old notes it was found out that she had been
recently admitted for investigation of significant weight loss and it was found to be a result of
advanced bowel cancer ,with lungs, bone and brain metastases. While in ED Mrs Gs respiratory
functions deteriorated and a referral for ICU was made. She was then seen and reviewed by our
junior registrar and after discussion from the ICU consultant, Mrs G was admitted to ICU for closer
observation. I was then tasked to look after this patient for that shift. After knowing the brief history of
the patient from my team leader, I was then asking the doctor of what do we do for this coming
admission? Are we going to intubate and ventilate this patient in case she developed respiratory
failure? And what are the chances of her recovery from this critical illness? Has it been discussed to
the next of kin before the plan for ICU admission? The doctor then replied that it was his consultants
decision, and so we will just have to wait when this patient will arrive in the unit.
. Within 24 hours of being transferred to the ICU, Mrs Gs condition deteriorated rapidly and a
decision was made to talk with the family of what we should do in the event of cardiac arrest.
Relatives need to be involved in discussions about end-of life issues so that they are fully aware of
the appropriate decisions to be made; and that all parties involved understand the situation
(McDermott, 2002).The son was immediately informed about his mothers condition and it was
revealed that Mrs G had previously stated to him that she does not want any heroic measures in the
event of cardiac arrest. The conversation with Mrs Gs son over the phone resulted in the decision to
initiate a not for resuscitation (NFR) order. The purpose of the NFR order is to deliberately withhold
life-saving measures when the patients respiratory or cardiac function suddenly stops (Costello,
2002).
The next day the patients daughter arrived. During my conversation with her she mentioned that she
had a distant relation with her mother and not had been in contact with the patient over the past 3
years. But despite of all that she still wanted that everything done 27-11-116
for her mother. At this point in time I am not sure whether the daughter was aware of the condition of
the patient before admission (especially her mothers diagnosis of bowel cancer and the chance of
survival is slim knowing it has metastasised to other organs). I then told her the need to speak the
medical staff and the meeting was arranged for her later that day.
In this case, a clinical ethical dilemma has been identified. The daughters request for care conflicts
with the patients advance directive and places us in a difficult position of either honouring the
patients wishes or satisfying the daughters request. The doctor decided to call the patients son, the
health care proxy and legally appointed decision maker for the patient. He was able to reach the son
by phone and discussed to him the planned course of treatment. The son emphatically agrees with
the ICU teams plan to continue the current supportive treatment regimen. He (son) stated that his
mother would not want any aggressive measures, and he agrees to comfort care for the patient. He
said he will speak to his sister about her concerns and will join the arranged meeting later that day.
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In analysing a clinical ethical dilemma, the first step is to further characterize the situation in terms of
the underlying ethical principles that apply and the possible related ethical concepts that may be
involved for example advance directives (Alfandre, 2007). To understand the decision-making
process in this case, one must consider the ethical principles of autonomy, beneficence,
normaleficence, and justice. These principles can guide primary care physicians and nurses to
implement the care of the dying patients in general (Rousseau, 2001; Basket, 2006; Beauchamp &
Childress, 2001). The healthcare team consultation meeting held prior to the family conference
regarding Mrs Gs status provided the opportunity for healthcare team members to agree that Mrs G
was dying. Even if more treatment was attempted for his individual systems, death was the expected
outcome for Mrs G. Therefore the aim of good critical care medicine should be to establish a
meaningful tension between the aim of preserving life and making a peaceful death possible
(Callahan, 2003). At the meeting later that day, I could feel the emotional tension between the son
and daughter, and being the nurse that involved in the care of their
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dying mother I was overwhelmed with 27-11-116feelings of uncertainty. I also felt that because of
the disagreement with the plan of care, it could compromise my moral obligation which is to support
the patients wishes and respect her preference for treatment.
As we are all aware that the patients condition was failing, the conflicts of reciprocal autonomy
(cooperation in a decision or action) should be resolved (Mick, 2005).
Autonomy
It defines the freedom to make decisions of oneself without interference from others (Urden, Stacey,
& Lough, 2006).The ethical dilemma presented in this case is whether to respect the patients
autonomy or ignoring her wishes by giving in the demands of her daughter. In this situation the ICU
consultant was concerned about providing additional medical treatment that the patient may not
have wanted. Respecting patients autonomy yields satisfaction for that person ( the patient)
directly while interfering with an individuals autonomy may be experienced as a form of pain or
suffering (Ozar & Sokol, 2002). I believe that without compelling reasons to override 27-11-116