An Ethical Dilemma

BAH!
Get away!

By Jon, Jon, Jon, and Christina

NURS362

Leave me alone.

74-year old female patient was admitted to the medical-surgical floor from the
Emergency Dept. She was brought to the ER by HPD for AMS- altered mental
status. The police were called to a condominium in Waikiki by the manager with complaints of a
woman trespassing and refusing to leave the property. The woman claimed to have lived
there. According to the manager, she lived there for over 10 years, but was recently evicted
because of non-payment of rent. The patient supposedly had a trust and someone
had been paying her rent, but is no longer. She is a confirmed client of IHS- the Institute
of Human Services homeless shelter.
A

Upon arriving at the ER, she was alert to self only.

She had labs drawn, a set of vital signs taken and an

refused
subsequent labs, vital signs,
assessments and pulled out her IV.
IV started. Since then, she

She is requesting to leave the hospital and go back to

Waikiki. The patient refused to change into a hospital
gown and has remained in her street clothes. She was

starvation
ketoacidosis, hypothyroidism,
metabolic encephalopathy and has
a history of dementia. The patient
diagnosed with having

refuses to eat and only took small sips of water. Her

rationalization for not eating was that she needed to
first have a bowel movement- she

BM in 4-5 days.

hadnt had a

The patient agreed only to

walking the hallway and taking a stool softener.

A social worker at the hospital was able to get in touch

with a case manager at IHS and determined that the

patient lives in Hawaii alone,

and has

children that live on the mainland. The hospital is

provide
the patient with a surrogate and
determine her medical care and placement
working to get in touch with her children to

No.

after discharge. She was seen by a hospital psychiatrist

lack the capacity to make

reasonable decisions regarding
medical treatment and self-care.

and deemed to

Two weeks after admission, she is still hospitalized,

refusing all medications, assessments, lab draws and vital
signs. The social worker is still working to get in touch
with the patients family.

Do the doctors discharge her, not knowing

where she will go or what will happen to
her? Establishing surrogacy can take weeks
to months, keeping the patient in the
hospital. What do we do in this situation?

ANA CODE OF ETHICS: PROVISION 1:

The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.
Based on the code of ethics mentioned above, we, as nurses and part of the health care team cannot deny care to a patient
regardless of financial status, medical diagnosis, race, etc.. We respect the patients wishes (autonomy), but perform as
much care as we can as a collective according to what the patient agrees to.
For this patient in particular, we cannot discharge her based on the
fact that the psychiatrist deemed the patient unable to make reasonable
decisions regarding medical treatment and self-care. Even though the
patient denies all care from the staff, we still offer it and encourage
it and provide teaching when possible during every shift and hourly
rounding until a surrogate can step in to make the medical decisions.

Provision 1, Section 1.4- The Right to self Determination

Ana Code of Ethics

In situations in which the patient lacks the capacity to

make a decision, a designated surrogate decision maker
should be consulted. The role of the surrogate is to make
decisions as the patient would, based upon the patients
previously expressed wishes and known values. In the
absence of a designated surrogate decision-maker,
decisions should be made in the best interests of the
patient, considering the patients personal values to the
extent that they are known. The nurse supports patient
self-determination by participating in discussions with
surrogates, providing guidance and referral to other
resources as necessary, and identifying and addressing
problems in the decision-making process.

Complications of underlying medical conditions and denying care

Hypothyroidsm: goiter, weight gain, heart problems, mental health issues (depression), neuropathy,
myxedema (coma), fatigue, temperature intolerance (cold), muscle weakness, dry skin, thinning hair

malnutrition/Starvation ketoacidosis: Nausea/Vomiting, dehydration, weight loss, abdominal pain,

rapid respiration, altered mental status, coma
Metabolic encephalopathy: altered brain function/mental status due to an imbalance of water,
electrolytes, and other chemicals such as glucose (hyper/hypo) and kidney/liver waste products. Depending
on the area of the brain affected, systemic manifestations can occur such as muscle weakness/numbness,
etc.

Ethical Challenges
Optimal health care results from an exchange between patient
and provider with open communication about the patients
wants and needs and the providers judgement and advice.
The issue described involves four ethical challenges.

Veracity: Habitual truthfulness

How much of what information should be involved in patient care?

Is the patient autonomous enough to effectively communicate their needs and wants?
Does the patient have a full and clear understanding of their situation and the options for
treatment?
Should certain information be withheld?

Paternalism: The provider is knowledgeable, but not all-knowing

Does the provider overlook the patients right to autonomy in the name of beneficence?
Do we as healthcare providers believe we can make better decisions than the patient?
Are there financial or business-related motivations behind a providers decision?

Autonomy: Fully informed consent or refusal

What or who motivates the decision made by the patient involving their care?
Does the patient have a clear understanding of their situation?
Is the patients refusal or acceptance of care valid during a state of mental
confusion?

Accountability: Doing the right thing when nobody's looking

What motivated the decision we made involving the patients care?

Did we conduct ourselves professionally and responsibly?
Would we make the same decision again, and will we every time?
Did we uphold the highest standards of practice and care?

Patient choice and respect for personhood are deemed just as important as
scientific knowledge and sound health care advice:
We care for many patients, follow many trends, and predict outcomes of our many interventions.
At the same time, we have not cared for this current patient, followed their trends, nor observed their
outcomes before initiating contact.

As healthcare providers We must seek a balance between:

-being truthful, yet fastidious with information

-being knowledgeable, but not egotistical

-providing or withholding interventions

Above all else: be ACCOUNTABLE every day

Clinician Surrogates for Unrepresented Patients

There is a chance that this patient may be unrepresented by a family member as a surrogate to make
future treatment decisions. Due to the patients inability to make their own treatment decisions,
clinicians may act as surrogates. Clinicians are knowledgeable of disease processes and the
treatments involved to help patients recover. Its mentioned in an article by White, Jonsen, and
Lo (2012) that clinician surrogates should take the role of advisor rather than a sole decision
maker to avoid ethical dilemmas such as:
competing obligations
conflicting interests

lack of procedural fairness

potential criticisms

How nurses can improve surrogate decision-making

In the case of an incapacitated patient, information between the surrogate and the provider is
required for optimal health care. Nurses can improve the decision-making process of surrogacy by
implementing the Four Support Intervention to help with the burden and stress that it comes with
(White et al., 2012).
1. Emotional Support
2. Communication Support
3. Decision Support
4. Anticipatory Grief Support
Nurses spend a lot of time with their patients and having nurses implement the intervention
focuses on patient-centered care with the intent of improved decision making by their surrogates.

references
American Nurses Association. (2011). ANA Code of Ethics. Retrieved from Nursing World: http://www.
nursingworld.org/provision-1#four
Cherry, B. & Jacob, S. R., (2014). Contemporary nursing: issues, trends, & management, (6th ed.).
St. Louis: Elsevier.
Rid, A., & Wendler, D. (2010). Can we improve treatment decision-making for incapacitated
patients?. Hastings Center Report, 40(5), 36-45 10p.
White, D. B., Jonsen, A., & Lo, B. (2012). Ethical Challenge: When clinicians act as surrogates for
unrepresented patients. American Journal Of Critical Care, 21(3), 202-207 6p.
oi:10.4037/ajcc2012514
White, D. B., Martin Cua, S., Walk, R., Pollice, L., Weissfeld, L., Seoyeon, H., & ... Arnold, R.
M. (2012). Nurse-led intervention to improve surrogate decision making for patients with
advanced critical illness. American Journal Of Critical Care, 21(6), 396-409 14p.
doi:10.4037/ajcc2012223