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CASE STUDIES IN NURSING ETHICS (3RD ED.)

Editor(s): Maloni, Judith A.

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reviewed by Elizabeth G. Johnson, RN, DSN, associate professor, University of Southern Indiana, Evansville

case study in nursing ethics

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Case Studies in Nursing Ethics 2nd Edition

  • ISBN-10 0763713333
  • ISBN-13 978-0763713331
  • Edition 2nd
  • Publisher Jones & Bartlett Learning
  • Publication date April 15, 2000
  • Language English
  • Dimensions 6 x 0.75 x 9 inches
  • Print length 402 pages
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  • Publisher ‏ : ‎ Jones & Bartlett Learning; 2nd edition (April 15, 2000)
  • Language ‏ : ‎ English
  • Paperback ‏ : ‎ 402 pages
  • ISBN-10 ‏ : ‎ 0763713333
  • ISBN-13 ‏ : ‎ 978-0763713331
  • Item Weight ‏ : ‎ 1.2 pounds
  • Dimensions ‏ : ‎ 6 x 0.75 x 9 inches
  • #1,042 in Medical Ethics (Books)
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case study in nursing ethics

case study in nursing ethics

Ethics case study: ‘Just watch them die…’

According to the Associated Press, a Brookdale Senior Residence facility* worker who identified herself as a nurse, refused to administer cardiopulmonary resuscitation (CPR) to Lorraine Bayless, an 87-year-old woman who collapsed in the facility’s dining hall because “It was against company policy.” Although the nurse called 911, and the dispatcher urged her to start CPR or to find someone who was willing to do so, the nurse refused. The press reports that there was no Do Not Resuscitate (DNR) directive in place. Shortly after this report, Brookdale Senior Living issued a statement saying the employee’s failure to heed to a 911 dispatcher’s directions was a mistaken interpretation of the policy. Fortunately for this company, Bayless family members said she did not want life-prolonging treatment.

Believe it or not, this case study is not about whether or not an 87-year-old person should receive CPR: it is, after all is said and done, a matter of personal choice for the patient. A 2012 study showed that only about 2% of adults who collapse on the street and receive CPR recover fully. Another from 2009 showed that anywhere from 4% to 16% of patients who received bystander CPR were eventually discharged from the hospital. And only about 18% of seniors who receive CPR at the hospital survive to be discharged, according to a study from Ehlenbach and colleagues. So, enough on this subject.

The points at issue are:

1. Did the nurse have a duty of care to this person — even if she had only passed her by on the street? 2. Does company policy trump ethical or legal obligations? 3. Does age or place of residence (a senior living facility) exclude one from the rights accorded to other citizens? 4. Does this “policy of noninterference” (other than to call 911) in a medical emergency extend to other kinds of emergencies? The woman collapsed in the dining hall, so it is not inconceivable that she could have slipped with her knife and cut an artery. Would the nurse simply watch her exsanguinate while 911 is on its way? If she slipped and fell and hit her head, would she be ignored until the emergency squad arrived?

As Carolyn Rosenblatt, a nurse attorney writing in Forbes commented, “I was not surprised to learn that there was ‘company policy’ about a nurse in an independent seniors’ residence not giving nursing care…However, the horrible image of a nurse standing by refusing to permit anyone else there to get emergency instructions from the 911 dispatcher is most disturbing, no matter what kind of a home this was.”

In response to the points at issue:

Points 1 and 2: In the face of a company policy that refuses intervention in an emergency situation, the nurse still has a duty of care to a resident even though this facility does not provide skilled nursing care. Although the patient was living in an assisted living facility and not a nursing home, the American Nurses Association Code of Ethics for Nurses is clear: “The nurse’s primary commitment is to the patient, whether an individual, family, group or population.” This is clear, but just in case there is a possibility of misinterpreting it, the statement means that a facility’s policies do not supersede a nurse’s obligation to a patient, resident, or, for that matter, a passerby.

Point 3: Let’s put this another way: Is there such a thing as equal rights for the elderly? If one joins a senior living facility, is one’s right to life abrogated by its policies? I think not. One of the most important characteristics about policies is that they should be clear. Apparently Brookdale’s policy to call 911 in an emergency is clear; however, Brookdale’s policies on the emergency care of its residents until 911 gets there apparently is not clear. Why would the company have its employees call 911 if they are not to follow the instructions given to them by the 911 dispatcher?

Point 4: Certainly the elderly woman in question has a right to refuse treatment – and can do so by executing an advance directive. The fact that she did not do so is both salient and unsurprising. Most of us do not — and all of us should do so. A person or someone who holds his or her healthcare power of attorney may refuse treatment for that person. A nurse, administrator, institution, or company may not — through their policies or any other means. Can you imagine an organization with a policy that forbids employees from helping to save the life of its clients (or of other employees) in an emergency?

A duty to care

To put the matter succinctly, the nurse, if she was a nurse as she told the 911 operator (we know it was a she because copies of the 911 call were shared with the public), had a duty of care to this resident regardless of policies or her own uncertainties. This is a professional and ethical obligation. I am not a lawyer so I cannot say that she had a legal obligation to so. However, Good Samaritan laws offer legal protection to people who give reasonable assistance to those who are injured, ill, in peril, or otherwise incapacitated, especially to doctors and nurses. Good Samaritan laws provide a defense against torts arising from the attempted rescue.

I don’t think such laws don’t constitute a legal duty to rescue. But just as certainly, we don’t expect to see nurses on the phone with a 911 dispatcher refusing to even hand the phone to a passerby so the dispatcher can instruct someone else to administer CPR. And do what? Even though CPR is at best marginally effective in such circumstances, what is the alternative? Just watch them die?

*According to its website ( www.brookdale.com ) Brookdale is a national company that operates approximately 1,150 communities, with 80,000 associates serving about 100,000 residents every day.

Selected references Ehlenbach WJ, Barnatao AE, Curtis JR, et al. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. N Engl J Med . 2009;361:22-31. www.ucdenver.edu/academics/colleges/medicalschool/departments/medicine/intmed/imrp/CURRICULUM/Documents/Ehlenbach%20WJ–In-hosp%20CPR%20epidemiology%202009.pdf

Hagihara A, Hasegawa M, Abe T, et al. Prehospital epinephrine use and survival in patient with out-of-hospital cardiac arrest. JAMA . 2012;307(11). 1161-8. http://www.acc.org/latest-in-cardiology/articles/2014/07/18/17/33/prehospital-epinephrine-use

Rosenblatt C. Nurse refuses to give CPR, senior dies: Ethical problem or legal issue? Forbes . March 8, 2013. www.forbes.com/sites/carolynrosenblatt/2013/03/08/nurse-refuses-to-give-cpr-senior-dies-ethical-problem-or-legal-issue/

Sasson C, Rogers MAM, Dahl J, Kellerman AL. Predictors of survival from out-of-hospital cardiac arrest: A systematic review. Circulation . 2010;3:63-81 (published online November 10, 2009). www.firstaidcorps.org/wp-content/Predictors-of-Survival-From-Out-of-Hospital-Cardiac-Arrest-A-Systematic-Review-Meta-Analysis.pdf

Leah Curtin is Executive Editor, Professional Outreach for American Nurse Today

3 Comments .

It’s awful.

To the editors: Thank you for quoting my article on Forbes.com. When one is not acting in the capacity of a nurse, there is no legal duty to render care. The CA Board of Nursing did examine this nurse’s conduct and did not discipline her. She was acting as a coordinator, not as an RN in her job. However, her actions created an uproar and a PR problem for Brookdale, which quickly changed its policy to clarify that an RN in its facility can indeed act to summon 911 in such a matter. What the case did do was remind everyone that we all need to have an Advance Healthcare Directive on hand especially in a non-nursing facility such as assisted living. Staff are helped by knowing what a resident wants in emergencies. In the absence of a directive, 911 will normally be called.

Hello May I use this article for a case study on nursing ethics for a BSN pre-licensure nursing? Thank you for your consideration, Dr. Judith Elkins

Comments are closed.

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Ethical Decision Making

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Learning Tools - Case Studies

Nurse P is a staff nurse in the coronary care unit of a large medical center. One morning he is informed that a patient from the recovery room will soon be admitted to the coronary care unit and assigned to him. The patient, a white man, 67 years of age, with known history of myocardial infarction, also has cancer of the prostate. The initial hospital admission was for a transurethral resection, which had been aborted in the operating room when the patient developed cardiac changes following spinal anesthesia. The patient had been transported to the recovery room with the diagnosis of possible myocardial infarction and was to be transferred to the coronary care unit for management and evaluation.

Nurse P heads to the recovery room with a bed to pick up the patient. When he arrives, the patient is being coded. He had apparently gone into ventricular tachycardia/ventricular fibrillation in the recovery room and had required countershock, cardiopulmonary resuscitation (CPR), intubation, lidocaine, and vasopressors to maintain his blood pressure. A Swan-Ganz catheter was put in place. Recovery rhythm was sinus bradycardia to sinus tachycardia with occasional pauses. The patient was acidotic, in pulmonary edema by chest x-ray with an alveolar oxygen partial pressure (PaO 2 ) of 50–60 mm Hg, a fraction of inspired oxygen (FIO 2 ) of 100%.

During the events of the code, an attending cardiologist (Dr. D) passed by, observed the code, and made the following statement to the recovery room staff and coronary care unit resident: "Say, that's Mr. S. I know him from his last hospitalization of 1 month ago when I was attending in coronary care unit. I believe he has a living will." While the patient is stabilized, Dr. D calls the patient's relative, who happens to work in another part of the medical center. The relative also expresses the belief that Mr. S has a living will and does not want to receive extraordinary support measures. Dr. D relays this information to the other physicians, and there is general agreement that conservative measures to ensure support are indicated while the living will is located.

The coronary care unit resident and Nurse P transport Mr. S to the coronary care unit. When admitted, the patient's systolic blood pressure is 70 mm Hg while on dobutamine 8 mcg/kg and dopamine 26 mcg/kg. The patient occasionally responds to verbal commands, opens his eyes, grips Nurse P's hands, and responds to pain in the upper extremities (his lower extremities are still under the effects of the spinal anesthesia). Cardiac monitoring shows that the patient is still having sinus tachycardia.

At this point, the coronary care unit resident and an intern approach Nurse P and inform him that they believe that the present treatment of the patient is cruel. Upon locating old medical records, they learned that the patient had been designated "do not resuscitate" (DNR) on his last admission, and the patient is supposed to have a living will, although it has still not yet been located. They order Nurse P to slowly turn off the intravenous (IV) drip of dopamine and dobutamine. Nurse P is faced with an ethical dilemma.

Rationale and Comments

The treatment modalities in Mr. S's treatment plan were basic: IV therapy, medication, and oxygen support. Some people might say the hospital team missed its chance when it failed to act decisively when it might have omitted the resuscitation of this patient. The IV, medication, and oxygen support may have been seen as obligatory for the patient and as supportive care.

Two reasons for this position might be offered. First, it might be argued that aggressive resuscitation is extraordinary, whereas an IV drip is ordinary. Another question might be whether the patient saw the IV as serving a purpose any more than the CPR served. Second, the difference between the CPR omission and stopping the IV drip is that one is an omission and the other would be a withdrawal. This raises the question of whether there is a difference between the two. Maintaining such a distinction might incline caregivers to be reluctant to start treatments such as an IV drip. Defenders of the view that there is no legitimate moral difference, believe that it is better to start a treatment when there is doubt about the correctness of the course and then withdraw if the time comes when it is clear that the patient would not have wanted the treatment to continue.

Here, however, Nurse P is being told by a resident and intern to turn off the IV drip on the basis of an unconfirmed belief that the patient has a living will and the fact that he reportedly had been designated for nonresuscitation on his last hospital admission. Nurse P must face the question of whether that is sufficient reason to stop the treatment even with the apparent approval of Mr. S's relative.

It is likely that the next of kin's judgment would be sufficient in the case where the patient's wishes cannot be determined, but that does not seem to lead to a clear answer here. First, we are not sure if the relative is Mr. S's next of kin. Moreover, even if it is, it seems possible that Mr. S has expressed his own wishes, and those wishes would surely take precedence. While the assumption is that he has a living will, no one seems to know exactly what it says. Some living wills are written for the purpose of insisting that treatment continue. The other possibility is that the living will could have been changed or voided by the patient between hospitalizations. Therefore, any action based on assumptions is taking considerable liberty. Also, any previous DNR order during another hospitalization would not be in effect for the present hospitalization. Again, there is the danger of paternal decision making by physicians and others for the patient [33] .

More prudent action here must be considered in the light of the PSDA. Because a living will is thought to exist and a relative was found, no withdrawal in the treatment of Mr. S should occur. The following would be a reasonable and prudent decision making process on behalf of the patient, Mr. S: (1) the living will document should be obtained (there should have been a copy from the last hospitalization, or perhaps in the possession of other family members or with the primary care physician's office); (2) relatives should be notified, and those, by law and policy of the hospital, could consent for continuation or removal of treatment modalities in the absence of an advance directive; and (3) consideration of the patient's wishes and witnessed comments and conversations in the past regarding healthcare decisions to be made for him under specific circumstances should be ascertained, in the absence of an advance directive.

Every situation that presents itself may be different, but ethical decision making based on a framework of ethical theories can provide the nurse with useful means for resolving ethical dilemmas in patient care.

What happens when, for example, patients are unable to make decisions for any reason? A blending of theoretical ethical systems and principles and a practical framework on which the healthcare professional can help patients and their families make healthcare choices is our next area for discussion.

Patient M, a woman, 34 years of age, is in critical condition and is scheduled for emergency surgery following a severe motor vehicle accident. You have been informed that her two children have been killed in the crash. She is almost hysterical and is asking you repeatedly about the condition of her children as you prepare her for emergency surgery. Do you tell the mother the truth about her children at this time or wait until after the surgery?

The ethical principles involved are beneficence and veracity (i.e., doing what is in your patient's best interest and telling the truth) and to a certain extent non-maleficence. This is an emotional issue, as most ethical dilemmas are, so be careful not to get into the "what if" trap (e.g., "What if Patient M were not in a critical condition, but was still facing surgery," or, "What if this woman was a close friend or family member?"). Remain as objective as possible when gathering facts and assessing the information and do not let emotions cause altered behavior.

Other considerations are personal values. Telling the truth is a concept that varies substantially between individuals. Personal views on absolute versus situational ethical reasoning will also affect the decision-making process and, perhaps, the definition of and decision-making use of the veracity principle. It is also very important to remember that there are other healthcare professionals to assist in the dilemma and help make a collaborative decision.

The other major consideration is knowing your hospital's policies in regard to deciding ethical issues. The groundwork should be there for you, and you should be familiar with it. If your workplace does not have policies that address making ethical decisions, you may want to refer to the suggested Guidelines for Ethical Decision Making in Patient Care, included later in this course. It may be helpful for your use and can be adapted to fit your institution.

CASE STUDY 1: AN INTOXICATED PATIENT

Patient J, a man 35 years of age, was involved in a fight and sustained a large laceration to the center of his forehead. The patient presents to the emergency department alert and oriented without significant findings other than the 10-cm laceration. However, his speech is slurred, and he readily admits to drinking 10 beers during the last few hours. The emergency department is very busy with more urgent cases, and the patient becomes impatient because of the wait. Patient J wishes to leave but is urged by the ED staff to wait and is told that he should not drive. He is clearly lucid and states that he will not wait any longer and intends to drive himself home.

Using the acronym R.O.L.E. as their framework, note that the authors identify the same decision-making issues as the framework and algorithm examples discussed in this course.

R: Risks of medical treatment . In this case the proposed treatment bears little risk to the patient. Few people have life-threatening complications from laceration repair; therefore, the chance of the patient experiencing untoward harm from the procedure is remote.

O: Opinion of the patient . Why does the patient want to leave the emergency department? Does he understand the risks and benefits of the procedure? Is he competent to make this decision in his intoxicated state?

L: Life quality . Will not having the laceration repaired significantly affect the patient's quality of life? Would an unsutured wound healing for an extended period affect the patient in his profession and render him unable to earn a living? For example, would he be unable to wear required safety equipment, such as a helmet or goggles, because of the laceration? Is the patient involved in a profession, such as acting, where a potentially disfiguring scar could affect his career?

E: External factors . Is there any obligation on the part of the healthcare team to third parties (i.e., those who may be traveling at the same time as the patient and who may be endangered from a safety standpoint)?

The conflict in this case is between the patient's right to autonomy and self-determination and the staff's concern for his well-being and the safety of others. From both a legal and ethical standpoint, competent adults have the right to decide whether they will accept medical treatment. This right relates to the ethical principle of autonomy and the legal doctrine of informed consent.

In their professional education, nurses and physicians are frequently taught to apply very strict standards in the determination of patient capacity or the ability to make decisions. There is not allowance for medicated patients to sign consent forms, and frequently, it is assumed that developmentally disabled, intoxicated, and critically ill patients lack the capacity for decision making. In the emergency setting, in particular, there is a bias toward intervention and treatment if there is any doubt about patient capacity.

However, none of the above conditions negates the patient's ability to make responsible healthcare decisions. From an ethical standpoint, the patient is a capable decision maker if:

The patient can understand information relevant to the decision at hand.

The patient can interact and communicate with caregivers about the decision.

The patient can weigh the possible alternatives.

Given these guidelines, Patient J was clearly capable of refusing medical treatment, despite the feelings of the ED staff about the necessity of suturing the wound.

But what about the third parties who may be affected by Patient J's decision to drive while intoxicated? Do the healthcare professionals have a duty to prevent him from driving? In instances such as these, care providers must remember that their first duty is to the patient. A decision to violate patient confidentiality or to detain the patient against his will automatically places the caregivers in a position that may require justification of actions. If the patient is clearly too intoxicated to drive, a prudent course of action would be to document that the patient was asked to stay and that he was advised that if he chose to leave, his license plate number would be given to the police. Always check the policies and procedures, guidelines, and protocols in your facility to see what resources and assistance you have in these situations.

CASE STUDY 2: A SUSPECTED CASE OF CHILD ABUSE

(From the book Leadership Roles and Management Functions in Nursing: Theory and Application , in a chapter entitled "Ethical Issues" [45] .)

You are a nurse on a pediatric unit. One of your patients is a girl, 15 months of age, with a diagnosis of failure to thrive. The mother has stated that the child appears emotional, cries a lot, and does not like to be held. You have been taking care of the infant for the two days since her admission, and she has smiled and laughed and held out her arms to everyone. She has eaten well.

There is something about the child's reaction to the mother's boyfriend that bothers you. The child appears to draw away from him when he visits. The mother is very young and seems to be rather immature but appears to care for the child.

This is the second hospital admission for this child. Although you were not on duty for the first admission six weeks ago, you check the records and see that the child was admitted with the same diagnosis. While you are on duty today, the child's father calls and inquires about her condition. He lives several hundred miles away and requests that the child be hospitalized until the weekend (it is Wednesday) so that he can "check things out." He tells you that he feels the child is mistreated. He says he is also concerned about his ex-wife's four-year-old child from another marriage and is attempting to gain custody of that child in addition to his own child. From what little the father said, you are aware that the divorce was very bitter and that the mother has full custody.

You talk with the physician at length. He says that after the last hospitalization he requested that the community health agency call on the family. Their subsequent report to him was that the 4-year-old appeared happy and well and that the 15-month-old appeared clean, although underweight. There was no evidence to suggest child abuse. However, the community health agency plans to continue following the children. He says the mother has been good about keeping doctor appointments and has kept the children's immunizations up to date.

The pediatrician proceeds to write an order for discharge. He says that although he also feels somewhat uneasy, continued hospitalization is not justified and the state medical aid will not pay for the additional days.

When the mother and her boyfriend come to pick her up, the baby clings to you and refuses to go to the boyfriend. She is also very reluctant to go to the mother. All during the discharge you are extremely uneasy. When you see the car drive away, you feel very sad. What should you do?

Upon returning to the unit, you talk with your supervisor, who listens carefully and questions you at length. Finally, she says, "It seems as if you have nothing concrete to act upon and are only experiencing feelings. I think you would be risking a lot of trouble for yourself and the hospital if you acted rashly at this time. Accusing people with no evidence and making them go through a traumatic experience is something I would hesitate to do."

You leave the supervisor's office still troubled. She did not tell you that you must do nothing, but you feel she would disapprove of further action on your part. The doctor also felt strongly that there was no reason to do more than was already being done. The child will be followed by community health nurses. Perhaps the disgruntled ex-husband was just trying to make trouble for his ex-wife and her new boyfriend. You would certainly not want anyone to have reported you or created problems regarding your own children. You remember how often your 5-year-old bruised himself when he was that age. He often looked like an abused child. You go about your duties and try to shake off your feeling.

If the pediatrician had not yet alerted the community health nurses or another child welfare agency, this option might have been taken by the nurse. She had reasonable suspicion given the child's reaction, underweight condition and ex-husband's concern. A call would not have been inappropriate. However, this action had already been taken. The child had no other signs that she was an abused child or that she was in danger of being abused. The nurse in this situation was going on strong feelings, but little evidence.

CASE STUDY 3: THE STUDENT NURSE PERFORMING UNSAFE PRACTICE

From the Journal of Nursing Administration , we find a case to study regarding the public and professional responsibility of hospitals [46] . Hospitals throughout the country are held in high esteem within their communities for public service. They earn the public's trust by providing safe, good quality patient care. Many community hospitals serve as teaching sites for students' practicum programs, as did the hospital in this case study. Health facilities also have an obligation to share the responsibility for the quality of the nursing program by providing practice sites and nursing role models. In the case presented, the hospital should have been more proactive in addressing the quality of this practice issue.

MW is a senior nursing student at a local university. The university's nursing program requires a 200-hour practicum be completed six weeks before graduation. MW chose the intensive care unit (ICU) at a community hospital for her practicum site. MW contracted with one of the ICU staff nurses to serve as her preceptor for the six-week time period. The nurse preceptor is responsible for assisting MW to meet the course objectives. MW, the nurse preceptor, and the nursing instructor met before the practicum to discuss course objectives and expectations.

During the six weeks, MW was assigned to work the same schedule as the nurse preceptor, which was the night shift. Within the first week, the nurse preceptor reported to the ICU nurse manager that MW had displayed some inappropriate behaviors. These behaviors included inappropriate dress for work, an arrogant attitude toward the staff nurses, and considerable discussion about the amount of money MW would make as a nurse. The nurse manager and nurse preceptor discussed these issues with MW, and the behaviors improved somewhat.

By the end of the second week, the nurse preceptor reported another disturbing incident to the nurse manager. During the previous shift, MW and the nurse preceptor cared for a peritoneal dialysis patient. The nurse had explained the dialysis process to MW, and MW assisted with some of the procedure. After one of the dialysis exchanges, MW was instructed to empty and measure the dialysate output. Under the nurse preceptor's supervision, MW completed this procedure. MW and the nurse preceptor concurred that the amount of fluid removed from the patient was 1,400 cc. MW was given the responsibility of recording the amount on the dialysis flow record.

At the end of the shift, when intake and output was being calculated, the nurse preceptor noticed that the amount of dialysate fluid recorded by MW was 1,000 cc. When questioned about the discrepancy, MW responded that the recorded 1,000 cc amount was similar to the amounts recorded by other nurses. The nurse preceptor explained that the dialysate had been changed for the purpose of removing more fluid; thus, a greater amount of dialysate output was desired and expected from this dialysis exchange. MW stated that she did not want her recorded amount to be dramatically different from other recorded amounts. The nurse preceptor reinforced the reasoning behind the dialysis orders and that the actual amount removed is what needed to be recorded. When MW did not correct the dialysis flow record, the nurse preceptor recorded the actual dialysate output.

The nurse manager documented the incident and contacted the nursing instructor. The nurse manager informed the nursing instructor that MW's practicum in the ICU was terminated, and she would not be allowed to return to the ICU. The nurse manager requested that the incident be reviewed by the university's nursing program before MW continued the program.

The nursing instructor discussed the incident with MW. Later, the nursing instructor told the ICU nurse manager: "The incident does not appear to be serious. MW is completing her practicum requirement at another hospital and is doing great. She will be graduating with her class." Following this conversation, the ICU nurse manager discussed the incident with the hospital's director of nursing and sent a letter to the dean of nursing at the university documenting her concerns about MW's performance. The nurse manager never received a response to this letter. MW went on to another ICU clinical site to continue her practicum. When the nurse manager at the new facility was alerted to the previous incident, she monitored MW closely. She and the charge nurse of the ICU unit found similar inaccuracies in documentation. Further, documentation was made for vital signs by MW. However, she was observed during one shift to have not taken a blood pressure cuff or thermometer into any of her patient rooms. When the charge nurse took her own vital signs on the patients, none matched the documentation of MW.

When approached, MW indicated that "vital signs don't change much in four hours and probably don't need to be monitored that often." When questioned about the vital signs she had recorded, MW stated, "I don't want my charting to stand out and be different. None of my patients have been harmed, so I don't see what the problem is." MW was terminated from this practicum site as well and told she could not apply for a position there after graduation.

The ethical decision-making model outlined in this course can be helpful.

First, name the dilemma. The nurse is violating several ethical principles in this situation: beneficence, the duty to do good; non-maleficence, the duty to cause no harm; veracity, the duty to tell the truth; and respect for persons, the duty to honor the responsibilities of her position and to care for patients without bias, in this case, without regard for how she imagines she will be perceived.

Second, sort the issues. MW is displaying both unethical and illegal behaviors. She is falsifying patient information and potentially endangering her patients while disregarding her responsibilities. The nurse has shown that she values fitting-in over gathering accurate patient information.

Third, solve the problem. Ethical considerations and recommendations would include the reporting by the hospital to the school of nursing. The hospital should formally address concerns to the division director, dean of the school of nursing, and/or the governing board and request a written follow-up on the findings and actions of the investigation. The hospital should also investigate its State Nursing Practice Act and regulations relative to the governance of a student nurse's role. The hospital should obtain an understanding of the responsibility and accountability of the nursing faculty as well as the hospital's and staff nurse's role in this incident. The hospital should then seek and follow the advice of the State Board of Nurse Examiners. Specific actions to withhold the student's prospective licensure should not be sought unless required by the State Nursing Practice Act.

Fourth, take action. The hospital has an ethical responsibility to review the case in whatever forum its policy specifies. In many organizations, the hospital nursing leadership group is the forum. After the problem has been identified and reviewed with the individual, a probationary period should be given for the student's performance to improve. In this case, MW was counseled by the nurse preceptor in the first ICU practicum site. The school should have used the second practicum site as the probationary review. This was not done. Only the clinical nurses were aware of MW's move to another unit, and they began to evaluate her performance there. The school should have been a part of the process. Because this practice standard violation involved a student, a member of the school's faculty was included in the review. During the practice review process, the name of the individual must be disclosed and a determination made whether the practice violation is serious enough to warrant the student's suspension from clinical practice pending a complete investigation. Whatever the outcome, the contractual agreement between the hospital and the school should be reviewed to clarify guidelines. The decision makers must choose which course of action they feel best meets the particular situation and implement. Given the circumstances in this instance, termination of employment was deemed to be the most appropriate course of action.

Fifth, evaluate and reflect on the action. Time must be taken in re-evaluating with all parties involved how the decision-making process was handled. One question to be asked by the reviewers is: "Given what we know now, would we make the same decision today that we made then?" In this particular case scenario, and in any similar to it, as professionals, nurses have an obligation to act truthfully and to protect the patients (veracity and beneficence). Nurse leaders have an obligation to investigate practice concern and take the appropriate steps to correct practice problems of any nursing employee or student. This decision is absolutely justifiable.

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20 Common Examples of Ethical Dilemmas in Nursing + How to Deal With Them

case study in nursing ethics

If you are a nurse, chances are you have faced situations where you had to make decisions based on your belief of whether something is right or wrong, safe or unsafe. This type of decision is based upon a system of ethical behavior. It is essential that all nurses develop and implement ethical values into nursing practice. If this sounds familiar, you may be asking, "What are the common examples of ethical dilemmas in nursing?" There are many things that could be considered an ethical dilemma in nursing, and it is important for nurses to know how to address them when they occur. In this article, I will share the 20 most common examples of ethical dilemmas in nursing and offer some insight into handling them.

What is an Ethical Dilemma in Nursing?

5 main reasons why nurses face with ethical dilemmas in nursing.

1. Patients or their loved ones must make life or death decisions 2. The patient refuses treatment 3. Nursing assignments may contradict cultural or religious beliefs 4. Nursing peers demonstrate incompetence 5. Inadequate staffing

How to Identify Ethical Dilemmas in Nursing?

What are the common examples of ethical dilemmas in nursing, example #1: pro-life vs. pro-choice, ethical dilemma:, how to deal with this ethical dilemma:, example #2: protecting the adolescent’s right to privacy, example #3: empirical knowledge vs. religious beliefs, example #4: parent refuses to vaccinate child, example #5: personal and professional boundaries related to social media, example #6: nurse is instructed to have patient with low literacy level to sign consent for treatment, example #7: end-of-life decision-making, example #8: inadequate resources to provide care, example #9: former patients - to date or not to date, example #10: informed consent, example #11: inadequate staffing, example #12: spirituality vs. science, example #13: patient addicted to prescription pain medication, example #14: duty and compassion do not align with facility safety protocols, example #15: patient does not have an advanced directive, example #16: incompetence among nursing peers, example #17: disclosing the seriousness of medical conditions, example #18: questioning physician orders, example #19: asked to work in a department without training, example #20: beneficence vs. autonomy, 4 consequences of avoiding ethical dilemmas in nursing, 1. nurses can quickly experience burnout., 2. avoiding ethical dilemmas in nursing can lead to legal issues., 3. nurses who avoid ethical dilemmas could lose their jobs., 4. loss of licensure:, my final thoughts.

case study in nursing ethics

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A Case-Centered Approach to Nursing Ethics Education: A Qualitative Study

Affiliations.

  • 1 Department of Nursing, Chung-Ang University, Seoul 06974, Korea.
  • 2 Department of Medical Humanities and Social Sciences, Yonsei University College of Medicine, Seoul 06974, Korea.
  • 3 Department of Family Health Nursing, College of Nursing, The Catholic University of Korea, Seoul 06974, Korea.
  • PMID: 33113978
  • PMCID: PMC7660290
  • DOI: 10.3390/ijerph17217748

Nurses deal with ethical decisions as they protect patients' rights, but a consensus on effective approaches to nursing ethics education is lacking. The "four topics" method can facilitate decision-making when nurses experience ethical dilemmas in practice. This study aimed to describe nursing students' perspectives on and experiences of a case-centered approach to nursing ethics education using the four topics method. This qualitative study consisted of two phases. First, we delivered case-centered nursing ethics education sessions to nursing students using the four topics method. Then, we conducted two focus group discussions that explored students' perspectives on and experiences of nursing ethics education. Data were analyzed using conventional content analysis. Four themes were identified: the importance of ethics education as perceived by nursing students, problems in current nursing ethics education, the experience of case-centered nursing ethics education using the four topics approach, and suggestions for improving nursing ethics education. The case-centered approach using the four topics method is effective in enhancing nursing students' nursing ethics ability. It is crucial to understand that nursing students would like to set up their own ethical standards and philosophy. Continuous efforts to encourage students' participation and to provide ethical reflection opportunities during clinical practice are needed to better connect theory with clinical practice.

Keywords: four topics approach; nursing education; nursing ethics; nursing student; qualitative research.

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Conflict of interest statement

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

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Nursing Case Study Examples and Solutions

NursingStudy.org is your ultimate resource for nursing case study examples and solutions. Whether you’re a nursing student, a seasoned nurse looking to enhance your skills, or a healthcare professional seeking in-depth case studies, our comprehensive collection has got you covered. Explore our extensive category of nursing case study examples and solutions to gain valuable insights, improve your critical thinking abilities, and enhance your overall clinical knowledge.

Comprehensive Nursing Case Studies

Discover a wide range of comprehensive nursing case study examples and solutions that cover various medical specialties and scenarios. These meticulously crafted case studies offer real-life patient scenarios, providing you with a deeper understanding of nursing practices and clinical decision-making processes. Each case study presents a unique set of challenges and opportunities for learning, making them an invaluable resource for nursing education and professional development.

  • Nursing Case Study Analysis [10 Examples & How-To Guides] What is a case study analysis? A case study analysis is a detailed examination of a specific real-world situation or event. It is typically used in business or nursing school to help students learn how to analyze complex problems and make decisions based on limited information.
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Pediatric Nursing Case Studies

Nursing Case Study Examples

In this section, delve into the world of pediatric nursing through our engaging and informative case studies. Gain valuable insights into caring for infants, children, and adolescents, as you explore the complexities of pediatric healthcare. Our pediatric nursing case studies highlight common pediatric conditions, ethical dilemmas, and evidence-based interventions, enabling you to enhance your pediatric nursing skills and deliver optimal care to young patients.

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Mental Health Nursing Case Study Examples 

Mental health nursing plays a crucial role in promoting emotional well-being and providing care for individuals with mental health conditions. Immerse yourself in our mental health nursing case studies, which encompass a wide range of psychiatric disorders, therapeutic approaches, and psychosocial interventions. These case studies offer a holistic view of mental health nursing, equipping you with the knowledge and skills to support individuals on their journey to recovery.

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Nursing leadership is essential for driving positive change and ensuring high-quality patient care. Our nursing leadership case studies examine effective leadership strategies, change management initiatives, and interprofessional collaboration in healthcare settings. Gain insights into the qualities of successful nurse leaders, explore innovative approaches to leadership, and learn how to inspire and motivate your team to achieve excellence in nursing practice.

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Remember, success in nursing begins with knowledge and continues with lifelong learning. Explore our nursing case study examples and solutions today and embark on a journey of professional growth and excellence.

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Case Studies in Nursing Ethics

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The Nine Code of Ethics for Nurses: Guiding Principles for Professional Practice

A nurse in blue scrubs holds the hand of a patient, providing compassionate care.

In healthcare, nurses stand as guardians of compassion, advocates for patients, and pillars of ethical practice. Rooted in a commitment to delivering quality care with integrity, nurses adhere to a set of guiding principles encapsulated in the Code of Ethics for Nurses . These principles serve as a compass, navigating the complexities of healthcare delivery while upholding the highest standards of professionalism. 

Within the code of ethics, there are nine provisions. Let’s explore the meanings behind each of these nine provisions and how that can be applied practically in care settings. 

1. Practicing with compassion and respect

In a practical care setting, this provision entails treating each patient with empathy, kindness, and understanding . Nurses take the time to listen attentively to patients' concerns, validate their feelings, and address their needs with sensitivity. By recognizing and honoring the inherent dignity and worth of every person, nurses foster a therapeutic relationship built on trust and respect.

2. Primary commitment to the patient

Nurses prioritize the well-being and interests of their patients above all else. In a practical care setting, this commitment manifests through attentive and individualized care that addresses patients' physical, emotional, and spiritual needs. Nurses advocate for patients' rights, preferences, and autonomy, ensuring that they are actively involved in decision-making regarding their care and treatment.

3. Promoting and protecting patient rights

Nurses play a crucial role in promoting, advocating for, and protecting patients' rights to receive safe, quality healthcare. In practice, this involves respecting patients' autonomy, maintaining confidentiality of personal information, and ensuring informed consent for all interventions. Nurses also advocate for equitable access to healthcare services and strive to eliminate discrimination and disparities in healthcare delivery.

4. Authority, accountability, and responsibility in practice

Nurses exercise authority in making decisions and taking actions that promote health and provide optimal care to patients. In practical terms, this means utilizing their clinical judgment, evidence-based knowledge, and critical thinking skills to assess patient needs, develop individualized care plans , and implement appropriate interventions. Nurses are accountable for their practice, ensuring that their actions align with professional standards, institutional policies, and ethical principles.

5. Duty to self and others

Nurses recognize their duty to promote their own health and well-being , as well as that of their patients and colleagues. Practically, this involves practicing self-care, maintaining physical and emotional resilience, and seeking support when needed. By prioritizing personal and professional growth, nurses ensure they can continue to provide high-quality care and contribute positively to the healthcare team.

6. Creating an ethical work environment

Nurses contribute to establishing and maintaining an ethical work environment that supports safe, quality healthcare delivery. In practice, this involves fostering open communication, mutual respect, and collaboration among healthcare team members. Nurses advocate for ethical decision-making processes, address ethical dilemmas proactively, and promote a culture of transparency and accountability.

7. Advancing the profession

Nurses actively engage in research, scholarly inquiry, and professional development to advance the nursing profession. In practical terms, this may involve participating in research studies, staying informed about current evidence-based practices , and contributing to the development of clinical guidelines and professional standards. Nurses also advocate for policies that promote nursing excellence and support the profession's growth and recognition.

8. Collaboration for human rights and health equity

Nurses collaborate with other healthcare professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities . In practice, this involves working collaboratively with interdisciplinary teams to address social determinants of health, advocate for vulnerable populations, and promote health equity and access to care for all individuals.

9. Integration of nursing values and social justice

The nursing profession collectively upholds nursing values and integrates principles of social justice into nursing and health policy. In practical terms, this may involve participating in professional organizations, advocating for policies that address healthcare inequities, and promoting diversity and inclusivity within the profession. Nurses advocate for policies and practices that uphold the dignity, rights, and well-being of all individuals, regardless of background or circumstances.

Guiding principles for professional practice

The Nine Code of Ethics for Nurses encapsulates the foundational principles that guide ethical nursing practice. By embracing these codes, nurses uphold the profession's integrity, promote patient-centered care, and advocate for the well-being of individuals and communities. As stewards of healthcare ethics, nurses play a pivotal role in shaping a compassionate, equitable, and patient-centered healthcare system.

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The Terri Schiavo Case: a Comprehensive Summary and its Ethical Implications

This essay about the Terri Schiavo case explores a deeply divisive and complex episode in American medical and legal history. It covers the prolonged legal battle between Terri’s husband, who wished to remove her feeding tube, and her parents, who wanted to keep her alive. The case raises important questions about patient autonomy, medical ethics, government intervention, and the sanctity of life. The essay also discusses the broader implications of the case on end-of-life care legislation and the necessity of clear healthcare directives.

How it works

The Terri Schiavo case stands as a deeply polarizing and complex chapter in the annals of American medical and legal history. In 1990, Terri Schiavo, a young woman from Florida, suffered irreversible brain damage due to cardiac arrest, plunging her into a persistent vegetative state. This tragic event sparked a protracted legal battle that would span over a decade, captivating the nation and igniting fierce debates on issues ranging from patient autonomy and medical ethics to the role of government and the sanctity of life.

Central to the controversy was the stark disagreement between Terri’s husband, Michael Schiavo, and her parents, Bob and Mary Schindler. Michael argued fervently in court that Terri would not have wanted to be kept alive in a vegetative state and sought the removal of her feeding tube, which was keeping her alive artificially. In contrast, the Schindlers passionately opposed this stance, clinging to hope and asserting that their daughter showed signs of responsiveness and could potentially recover. Their viewpoint was underpinned by religious convictions that opposed euthanasia and the withdrawal of life-sustaining treatment.

The legal saga unfolded through multiple appeals and interventions, including legislative actions that further complicated the already contentious landscape. At one pivotal moment, the Florida legislature, backed by then-Governor Jeb Bush, passed “Terri’s Law,” aimed at keeping her alive against court rulings favoring Michael’s decision. This legislative maneuver underscored the delicate balance between legislative authority and judicial oversight in matters that profoundly impact individual rights and medical ethics.

Ethically, the case raised profound questions about the boundaries of medical intervention, the rights of incapacitated patients, and the moral obligations of caregivers. Advocates supporting Michael Schiavo emphasized the importance of honoring Terri’s presumed wishes and allowing her to die with dignity, arguing that continued life support would only prolong her suffering without realistic hope of improvement. Conversely, opponents, including disability rights advocates and religious groups, contended that withdrawing life-sustaining treatment could set a dangerous precedent, potentially devaluing the lives of individuals with disabilities and undermining the sanctity of life itself.

The medical community itself was divided over Terri’s prognosis, with conflicting expert opinions adding complexity to an already emotionally charged debate. Some experts suggested the possibility of minimal consciousness or improvement over time, while others maintained that her condition was irreversible, leaving her in a permanent state of unconsciousness.

The media coverage and public reaction to the case were intense, reflecting deep-seated societal divisions and ethical dilemmas. It became a focal point for national debates on advance directives, end-of-life care, and the complexities surrounding surrogate decision-making in cases where patients cannot express their own wishes.

Ultimately, after years of legal battles, appeals, and emotional turmoil, Michael Schiavo prevailed, and Terri’s feeding tube was removed in 2005. She passed away peacefully, marking the end of a protracted legal and ethical ordeal that had gripped the nation for more than a decade.

The legacy of the Terri Schiavo case continues to reverberate in legal, ethical, and medical discussions. It has influenced legislation and policies concerning end-of-life care and advance directives across various states, prompting ongoing conversations about patient autonomy, informed consent, and the responsibilities of caregivers and healthcare providers. Moreover, it serves as a poignant reminder of the importance of clear and documented healthcare directives and the complexities inherent in navigating highly sensitive medical decisions amidst deeply held familial beliefs and societal expectations.

In conclusion, the Terri Schiavo case remains a powerful and thought-provoking example of the intricate intersections between law, ethics, medicine, and personal convictions in matters of life and death. It underscores the enduring relevance of ensuring that individual wishes regarding end-of-life care are respected and legally upheld, while also highlighting the profound challenges and ethical dilemmas that arise when navigating such deeply sensitive and contentious issues within a legal and medical framework.

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