Nurses face ethical dilemmas on a daily basis. Ethical dilemmas present two difficult courses of actions, making nursing work more difficult. Each dilemma is unique, and nurses have to analyze the situation thoroughly while prioritizing patients. In nursing, ethical dilemmas touch on the principles of autonomy, non-maleficence, and justice. Nurses are not only concerned with making the decision but justifying the decision. The nursing code of ethics is a useful tool for ethically challenging situations. Additionally, there are ethical decision-making models that equip nurses with specific steps in making ethical decisions. The purpose of this paper is paper is to reflect on an ethical dilemma I encountered while working as a new nurse at a community health center when a patient refused treatment for kidney failure.
As a new nurse, I did not have much experience with serious ethical dilemmas. I assumed that all patients wanted to get better until I met Mr. X. He had end-stage renal failure; he was required to undergo surgery and start hemodialysis after the surgery. The patient was a 76 year old male Cambodian capale of making decisions. The doctor gave a prognosis of six months, but the patient could live longer with the surgery. The patient refused surgery citing religious beliefs. He also did not want artificial devices in his system because of his distrust for surgery and healthcare system. His wife and children insisted on him getting the surgery, but he refused. Six months later, the patient died.
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The ethical dilemma touches on two principles of health care ethics. The principle of autonomy acknowledges the patient’s right to make decisions and hold views. The patient cited his religious beliefs and his distrust for the healthcare system as the reason not to have surgery. While Buddhism is not against surgeries, the patient is still entitled to his opinion and beliefs. Alternatively, the principle of nonmaleficence is an obligation not to harm. When a patient refuses treatment, the patient is hurting himself indirectly, and it nurses have the duty to inform and advise the patient to change his decision.
Lucy J. Hood’s ethical decision-making process is made up of six steps. The first step is identifying the problem by analyzing the situation (Hood, 2013). In the case of Mr. X, the situation was more challenging because the patient wanted a different course of action against his doctor’s wishes and the family. The patient did not want to have surgery even when he knew the risks of not having the surgery. I did not agree with the patient’s decision on a personal level and professional level, which is why I attempted to change the patient’s mind. The ethical conflict affected the multidisciplinary team that was working with the patient and the family. We took it upon ourselves to talk to the patient to attempt to change his mind while remaining respectful to his religious/ personal beliefs. The healthcare professionals reminded the patient about the health implications of his decision while the family wanted the patient to change his mind so he could live longer than six months.
The second step in the ethical decision-making process is identifying the morally relevant facts. In this step, individuals involved in the dilemma examine the complete context of the issue and how the problem arose. The patient claimed that his religion is against having surgery and artificial devices in his body. Buddhism is not against surgery and other life-saving procedures. The other key players, that is, the multidisciplinary team and the patient’s family agreed that the patient should get his surgery. There are legal, administrative, and economic concerns surrounding the issue. The patient knew that it was within his legal rights to refuse treatment, and he his personal reasons and fears for doing so.
While the patient stuck to his decision, it became apparent to me that the ethical problem of refusing treatment is common among elderly patients. According to Karnik & Kanekar (2016), healthcare professionals have a responsibility to provide detailed information to the patient to help the patient understand the consequences of his decision. The patient has the autonomy to choose the course of treatment, but health care professionals have to advise the patient while being respectful of the patient’s beliefs and decisions. The principle of autonomy implies that competent patients have the final say on the treatment plan, even when the healthcare professionals and the family do not agree.
The fourth step of Hood’s ethical decision making is the identification and analysis of action alternatives. When the patient refused treatment, the team explored other options. The first alternative was to continue providing care while advising the patient to change his mind. The team and the family worked together to advise the patient but did not change his mind. The family gave the alternative of performing surgery without the patient’s consent. The second option would prolong the patient’s life, and yet it was not an option because the patient was against it. The healthcare team could have explored other therapies if the patient was not in end-stage renal failure. In the end, there were only two options, to perform the surgery and the patient lives longer or not to perform the surgery, and the patient dies after six months.
After evaluating the alternatives, the next step is to act. Since the patient refused to undergo surgery, the team continued providing care. The patient was swollen and had breathing issues from fluid build up requiring round-the-clock care. The team had to accept the patient’s wishes and provide him with the necessary care even when they did not agree with his decision. Eventually, I understood the patient’s perspective. At 76, the patient did not see the reason to have a surgery which would prolong his life only for a few years. The patient had concerns; he did not think that the surgery would have a substantial effect on the quality of his life.
The last step is the evaluation and modification of the plan. In the end, the patient died because we respected his wishes. After the patient’s death, I wondered if I could have done anything to prevent it because we have to save lives. I still do not agree that patients should refuse treatment, and the reality remains that patients are in charge. If I encounter a similar situation, I will try to understand the patient’s concerns and perspective more so that I can influence them to make the decision accept surgery/treatment.
In conclusion, Hood’s ethical decision-making process makes it easier to make ethical decisions. The model shows that ethical decisions are complex; various factors and individuals have to be considered. When a patient refuses treatment, healthcare professionals have to understand the patient’s point of view and help the patient understand the implications of the decision. Ethical models help nurses to take responsibility and accountability when making ethical decisions.
References
Hood, L. (2013). Leddy & Pepper's conceptual bases of professional nursing . Lippincott Williams & Wilkins.
Karnik, S., & Kanekar, A. (2016, June). Ethical issues surrounding end-of-life care: a narrative review. In Healthcare (Vol. 4, No. 2, p. 24). Multidisciplinary Digital Publishing Institute.
