Content check — Fundamentals of Nursing, Chapter 16: Legal and Ethical Considerations

Case Study 16.2.1 §16.2 source ↗

The nurse is caring for a 58-year-old female with metastatic lung cancer who is a patient on the oncology unit of the hospital. The patient’s health has been deteriorating for the last few months, and she has expressed an interest in discussing palliative care options.

Past Medical History

Patient has been receiving chemotherapy intermittently over the last two years. She reports one brief period of remission six months ago; however, the cancer returned shortly after.
Medical history: Chronic obstructive lung disease, one pack/day smoker for over thirty years, gastroesophageal reflux disease.
Social history: Three adult children, no known medical conditions. Husband of thirty-five years passed away five years ago in a car accident.
Family history: Both parents deceased from natural causes.
No current medications and no known allergies. Last chemotherapy round ended two months ago.

Nursing Notes

0900: Assessment
Patient reports she does not wish to receive another round of chemotherapy and is ready to discuss palliative care options. Consult placed to palliative care team who plans to round on her this afternoon. When asked about family, patient reports: “They will want to keep me alive and change my mind about chemo, but I just can’t do it anymore. Please don’t contact them. I don’t want them to know about this.”

Recognize cues: What cues does the nurse recognize as being the highest priority at this time?

Answer

The highest priority concern at this time is that the patient is requesting to discuss palliative care options. It is important for the nurse to ensure the patient has all the resources she needs to make an informed decision about her medical care.

Case Study 16.2.2 §16.2 source ↗

The nurse is caring for a 58-year-old female with metastatic lung cancer who is a patient on the oncology unit of the hospital. The patient’s health has been deteriorating for the last few months, and she has expressed an interest in discussing palliative care options.

Past Medical History

Patient has been receiving chemotherapy intermittently over the last two years. She reports one brief period of remission six months ago; however, the cancer returned shortly after.
Medical history: Chronic obstructive lung disease, one pack/day smoker for over thirty years, gastroesophageal reflux disease.
Social history: Three adult children, no known medical conditions. Husband of thirty-five years passed away five years ago in a car accident.
Family history: Both parents deceased from natural causes.
No current medications and no known allergies. Last chemotherapy round ended two months ago.

Nursing Notes

0900: Assessment
Patient reports she does not wish to receive another round of chemotherapy and is ready to discuss palliative care options. Consult placed to palliative care team who plans to round on her this afternoon. When asked about family, patient reports: “They will want to keep me alive and change my mind about chemo, but I just can’t do it anymore. Please don’t contact them. I don’t want them to know about this.”

Analyze cues: Which ethical principle is most relevant to the patient’s current situation?

Answer

Autonomy is the most relevant ethical principle to the patient’s current condition. Autonomy refers to the patient’s right to make their own care decisions, and in this case, the patient is advocating for herself to make the decision to pursue palliative care.

Case Study 16.2.3 §16.2 source ↗

The nurse is caring for a 58-year-old female with metastatic lung cancer who is a patient on the oncology unit of the hospital. The patient’s health has been deteriorating for the last few months, and she has expressed an interest in discussing palliative care options.

Past Medical History

Patient has been receiving chemotherapy intermittently over the last two years. She reports one brief period of remission six months ago; however, the cancer returned shortly after.
Medical history: Chronic obstructive lung disease, one pack/day smoker for over thirty years, gastroesophageal reflux disease.
Social history: Three adult children, no known medical conditions. Husband of thirty-five years passed away five years ago in a car accident.
Family history: Both parents deceased from natural causes.
No current medications and no known allergies. Last chemotherapy round ended two months ago.

Nursing Notes

0900: Assessment
Patient reports she does not wish to receive another round of chemotherapy and is ready to discuss palliative care options. Consult placed to palliative care team who plans to round on her this afternoon. When asked about family, patient reports: “They will want to keep me alive and change my mind about chemo, but I just can’t do it anymore. Please don’t contact them. I don’t want them to know about this.”

Prioritize hypotheses: Why do you think the patient is requesting for her family to not be contacted regarding her decision to pursue palliative care? Does this request require follow-up or intervention by the nurse?

Answer

There are many reasons why the patient may not want her family to know about her decision to receive palliative care. She may not be close with her children or may not want them to feel sad about her condition, especially since they lost their father in a car accident only a few years ago. Ultimately, because she is of sound mind, she can make this decision for herself, and the nurse should respect her autonomy. However, the nurse could have a conversation with the patient about contacting her children to make sure that’s really what she wants. The nurse must have this conversation in a nonjudgmental way, allowing for the patient’s concerns to be expressed and then following her wishes as expressed.

Case Study 16.2.4 §16.2 source ↗

Refer back to Unfolding Case Study #3: Part 1 for a review of the patient data. The nurse is experiencing moral distress about the patient’s situation. The nurse is concerned because she has previously interacted with the patient’s children before and knows they will be upset if they are not updated on their mother’s condition and decision to pursue palliative care. But on the other hand, the nurse knows she must respect the patient’s autonomy and her wishes not to contact her family. The following conversation takes place between the nurse and patient:

Nurse: Are you sure you don’t want to contact your children about the palliative care decision? It might be nice to have them here with you when the team comes to discuss your options. This is a hard decision to make on your own.

Patient: No, I don’t want them involved. I love my kids, but I know them well. They will want me to keep fighting, and I just don’t have it in me. I don’t want to tell them no and let them down.

Nurse: I understand your concerns. I’m not trying to pressure you or change your mind, but I just want to make sure you are certain about what you want.

Generate solutions: Thinking about the “O” of the MORAL model of ethical decision-making, what options does the nurse have at this time?

Answer

The nurse has three options: The first option is to leave the situation alone and respect the patient’s wishes to not contact her family. The second option is to go ahead and contact the family since the nurse knows they will want to know about her condition. The third option is to continue to discuss the situation with the patient and hope she changes her mind about contacting her family.

Case Study 16.2.5 §16.2 source ↗

Refer back to Unfolding Case Study #3: Part 1 for a review of the patient data. The nurse is experiencing moral distress about the patient’s situation. The nurse is concerned because she has previously interacted with the patient’s children before and knows they will be upset if they are not updated on their mother’s condition and decision to pursue palliative care. But on the other hand, the nurse knows she must respect the patient’s autonomy and her wishes not to contact her family. The following conversation takes place between the nurse and patient:

Nurse: Are you sure you don’t want to contact your children about the palliative care decision? It might be nice to have them here with you when the team comes to discuss your options. This is a hard decision to make on your own.

Patient: No, I don’t want them involved. I love my kids, but I know them well. They will want me to keep fighting, and I just don’t have it in me. I don’t want to tell them no and let them down.

Nurse: I understand your concerns. I’m not trying to pressure you or change your mind, but I just want to make sure you are certain about what you want.

Take action: Of the options identified in the previous question, which is the best action for the nurse to take at this time?

Answer

The nurse is obligated to honor the patient’s autonomy, which means that contacting the family without the patient’s consent would be inappropriate. This action would violate boundaries and disregard the patient’s wishes, demonstrating a lack of respect for their autonomy. The nurse should maintain an open dialogue with the patient about contacting her family but should do so in a nonjudgmental way without trying to coerce the patient to do it. If the nurse is unable to have these kinds of conversations without patronizing the patient, it would be best for the nurse to proceed with option one, which is to respect the patient’s wishes and leave the situation as is.

Case Study 16.2.6 §16.2 source ↗

Refer back to Unfolding Case Study #3: Part 1 for a review of the patient data. The nurse is experiencing moral distress about the patient’s situation. The nurse is concerned because she has previously interacted with the patient’s children before and knows they will be upset if they are not updated on their mother’s condition and decision to pursue palliative care. But on the other hand, the nurse knows she must respect the patient’s autonomy and her wishes not to contact her family. The following conversation takes place between the nurse and patient:

Nurse: Are you sure you don’t want to contact your children about the palliative care decision? It might be nice to have them here with you when the team comes to discuss your options. This is a hard decision to make on your own.

Patient: No, I don’t want them involved. I love my kids, but I know them well. They will want me to keep fighting, and I just don’t have it in me. I don’t want to tell them no and let them down.

Nurse: I understand your concerns. I’m not trying to pressure you or change your mind, but I just want to make sure you are certain about what you want.

Evaluate outcomes: What findings would indicate the nurse’s moral distress has improved? What findings would indicate that it has worsened?

Answer

Moral distress in nurses often manifests as physical symptoms including headaches, gastrointestinal upset, and depression. If the nurse’s distress has improved, these symptoms should be improved or resolved altogether. If the nurse is experiencing these symptoms or has feelings of dread or anxiety when caring for the patient, the distress is likely still present. If that is the case, it is important for the nurse to reflect on their feelings and values and actively find ways to resolve the internal distress.