Ethics case study

Ethics case study

This is an unfolding case scenario on ethics and the application of ethical principles to provision of professional nursing care.  Please provide a thorough and complete answer to each question throughout the case study. It is expected that scholarly references be used to support your answers when applicable.  Citations and references should be provided in APA format.

    AJ is a 22-year-old male, whose family has recently located to south Florida from Colombia. AJ has sustained a high-speed motorcycle crash and sustained life-threatening injuries, including multiple rib fractures, a pelvic fracture, and a severe traumatic brain injury (TBI). He had difficulty breathing at the scene and was endotracheally intubated by paramedics en route, but only after much difficulty during which he experienced a 5-minute hypoxic period. He arrived at the trauma center with a Glasgow Coma Score (GCS) of 3. He is admitted to the intensive care unit with diagnoses of respiratory distress, anemia related to bleeding from his pelvic fracture, and altered mental status from his TBI. His primary nurse is Kevin, a Caucasian male from upstate New York. Kevin has 10 years of experience as an RN in critical care, and 5 years in his current position. Kevin is keenly aware of the long and complicated hospital course that AJ will likely experience.

  1. Review the provisions found in the ANA’s Code of Ethics for Nurses (page V of posted text).  Given the information provided thus far, list which provisions you expect Kevin to apply to this scenario and describe how Kevin would apply each.  

  2. There are also five (5) ethical principles that nurses use to guide their practice- Autonomy, beneficence, justice, paternalism, maleficence, and fidelity. In providing care for AJ, which principles do you expect that Kevin will use to provide ethical care? Describe how each relates to this specific case:  

 

AJ’s family arrives at the trauma center and they are brought to the intensive care unit to see AJ for the first time. His family consists of his mother, 52, his father, 54, two younger sisters ages 12 and 14, and an uncle (his father’s brother). They speak only Spanish, as they have been in the country for only 6 months. AJ’s parents do not allow his sisters to see him, as they are afraid they may be overwhelmed and faint. His father, mother, and uncle proceed to the bedside. They are shocked by the sight of AJ, whose body is swollen and who has multiple severe skin abrasions and lacerations. Kevin greets AJ’s family and because he speaks some Spanish, he is able to communicate basic information to the family. AJ’s mother is very emotional, and unable to focus well on what Kevin is telling them. Kevin, knowing that many health care decisions will need to be made for AJ, calls both AJ’s primary physician, Dr. B, and the unit social worker in order to arrange an informational meeting and to complete paperwork to designate someone to serve as AJ’s health care surrogate (or proxy) while he is incapacitated. Kevin also calls for professional interpreter assistance.

 

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  1. Who would serve as AJ’s surrogate decision maker if his parents were not available? Please provide a reference to support your answer. 

 

  1. What cultural or social factors may affect the care decisions made by AJ’s parents? How can Kevin ensure that the family correctly understands AJ’s condition? 

 

  1. Have you or a peer experienced a patient/family care situation in which culture (either your own or that of the patient/family) may have influenced the communication/decision-making process? 

 

    Kevin, Dr. B, the social worker, an interpreter, and AJ’s mother, father, and uncle meet in the unit conference room. Dr. B, through the interpreter, describes AJ’s prognosis, multiple injuries, and what needs to be done at present. The prognosis for any functional recovery is very poor, because of anoxic brain damage. His other injuries are severe but likely survivable due to his age and prior health status.  His pelvic fracture would need surgical repair, but because of AJ’s poor neurological prognosis, Dr. B recommends against doing the surgery. He explains that this is because he does not expect that AJ will walk due to brain damage and because the surgery would be extensive. AJ’s family appears overwhelmed and tearful, and his mother is repeating prayers aloud in Spanish through her tears. Kevin provides emotional support. Dr. B, knowing that the family will need time to process the prognosis, says he must leave but schedules another meeting in 2 days. The family asks if they may bring other family members to the next meeting, and the team agrees to the request.


6a. It is not uncommon for family members to ask nurses, “What would you do?” in situations such as Kevin’s. How would you answer this question?

  1. What direction does the Code of Ethics provide for such a situation?

    Two days later, the group meets again to discuss AJ’s condition, prognosis, and goals of care. Five additional family members are present: several cousins, two aunts, and the family’s clergyman, a Catholic priest. Kevin has facilitated the logistics of this meeting because he knows how important the meeting will be to ensure that goals of care are clarified for his patient AJ. AJ’s father has been appointed his health care surrogate. Further diagnostic testing has confirmed that AJ has significant anoxic brain damage, and his prognosis for neurological recovery is very poor. 

    As the interpreter relays this message from Dr. B to the family group, many break out in tears and exclamations. AJ’s mother repeats, “No, no, no, it is not true” in Spanish while wringing her hands repeatedly. AJ’s father appears stoic but grim faced. 

    Dr. B offers two alternative plans of care: the first would be to perform a tracheostomy and gastrostomy, and seek placement for AJ in a long-term care facility; the second would be to choose comfort measures only and withdraw his ventilator support, artificial hydration and nutrition, allowing a natural death to occur. AJ’s father becomes very agitated when he hears the second option, and he loudly tells Dr. B that he will not give up on his son (in Spanish). He leaves the room and storms down the hall. Other family members are tearful and are crying, holding each other for support. Kevin and the priest provide as much support as possible. Dr. B suggests that they meet again in 24 hours so that they may consider what they have heard.

7.  If Kevin feels as if Dr. B was not acting in the patient or family’s best interests, what options does he have in order to intervene or assist  in the family’s decision making process? 

 

  1. Provision 5 in the ANA code of nursing ethics speaks to the nurse’s duty to his or her self as to others.  Explain how Kevin can ensure that he is seeing to his own health, safety, character and integrity in this scenario?

Twenty-four hours later, most of the group members meet again. Kevin and AJ’s night nurse Maria have spent significant efforts answering the family’s questions and educating them on the choices they face, trying consciously not to project their own values and opinions on the family. AJ’s father has regained his composure and he appears tense but not visibly angry. The mother relays to Kevin that the family has discussed the two alternative plans of care and has decided as a group that the family cannot give up on AJ. They will consent to a tracheostomy and gastrostomy for long-term care, and express hope that divine intervention will allow AJ to recover. Kevin and Dr. B personally disagree with the decision as they would not want that for themselves knowing the grim future for AJ and his family, but they support the family in their decision and do not voice their opinions, knowing that different values guide AJ’s family’s decision.

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9. What is moral distress? Do you think Kevin and Dr. B may experience moral distress in this case? If so, how could they deal with those feelings? What resources should be available?

 

  1. What direction does the Code of Ethics provide for such a situation?

  2. In the case of AJ, what actions did Kevin take to uphold AJ’s autonomy?

 

  1. What other actions could Nurse Kevin have taken to uphold the ethical principle of beneficence?
  2. Is it ethical to bring a discussion of the patient financial/insurance status into the care conference discussions between the multidisciplinary team and the family? Explain, using resources to support your answer.

 

This case scenario is adapted from: 

Robichaux, C. (2017). Ethical Competence in Nursing Practice: Competencies, Skills, 

Decision-Making. New York: Springer Publishing Company