NUR3002 Tutorial 6 Online activity

Instructions to students:
Respond to the discussion questions according to the cases. The discussion
forum will be closed on 26/3/2016 (Saturday) noon.

Case A (Mr. A lived in the USA)

Mr A is 70 years old but when he was in his early 60s he drew up an advance directive to
forgo artificial nutrition and hydration in end-of-life care, including tube feeding and
intravenous therapy. He was not cognitively impaired then. On admission to hospital, his wife
and the clinical staff affirmed this directive. Mr A could not recognize his wife and his ability
to speak was largely impaired. He had sensitive skin that required special care. He could not
control his bowel or bladder. He spent most of the day in a wheelchair because he could not
move by himself. He did not eat well and had lost weight over the past weeks. One day he
developed an ulcer on his ankle and reddened skin over several pressure areas. The ulcer
became worse and two new ulcers developed despite the use of pressure relieving measures.
His wife worried about the deteriorating ulcers and the quality control nurse regularly
reminded the ward staff of possible substandard care. After exhausting all the extrinsic
pressure-relieving interventions, the clinical team eventually formed a clinical opinion that
ulcers would not be controlled unless the patient’s nutritional status improved. The option
was to provide nutritional supplement through a feeding tube.

Case B (Mr. B lived in Hong Kong)

Mr B, an 89-year-old man lived with his adult son until one day he fell and broke both hips.
Once hospitalized, he was put on tube feeding and ordered conservative treatment for his
fractured hips. He was transferred to a long-term care facility after his condition had
stabilized. He could not recognize his loved ones but was responsive to them. He strongly
rejected the feeding tube and made every attempt to pull it out after reinsertion. His arms
were restrained but despite this he appeared very determined to get rid of the tube and tried
every posture in bed to release himself from the constraints. Frequent reinsertion of the
feeding tube traumatized his naso-oesophageal passage, his mobility was reduced, and
friction and sheer force were increased. His adult son questioned whether it would be better
to forgo tube feeding. The nurses worried that he would develop pressure ulcers soon.

Discussion:

What are the ethical dilemmas for these two cases?

For the Case A Mr A have drew up an advance directive to forgo artificial nutrition and
hydration in end-of-life care, however, after he lost cognitive ability his family and his health
care provider arranged the tube feeding for him. In order to help him recover.

For the Case B Mr B was fell and broke both his hips, he need to have the tube feeding
treatment. However, he strongly rejected the feeding tube, but it is a possible treatment for
him to absorb nutrients. Then, Mr B started to pull it out, however friction and sheer force
increased, it may hurt his naso-oesophageal passage. After that, nurse restrained his arms, it
reduced his mobility. Also he may have a chance to develop pressure ulcers.

What ethical theories or principles you can apply for these two cases?
For the Patient’s autonomy and non-maleficence.
First, according to the principle of autonomy patient have their autonomy to choose whether
using tube feeding or not. Also he can have a choice not being restrained. Also we should
respect patient’s decision.
Second, for the principle of non-maleficence, nurse should not do harm to their patient.
However, they need to provide the treatment to patient in order to help them recover.

Source:Davis, A. J., Tschudin, V., & De Raeve, L. (2006). Essentials of teaching and learning
in nursing ethics: perspectives and methods. Elsevier Health Sciences.