5005Case StudyIntroductionEthical dilemmas are seen more nowadays bynurses during their practice, particularly when they are taking care of apatient who is at an end of life stage. The case study demonstrates an ethicaldilemma when nursing staff are taking care of an 80 year old lady who wasadmitted onto the intensive care unit, for the purpose of this essay she willbe referred to as Mrs S, verbal consent was given by the family as it wasdeemed that Mrs S did not have the capacity to give consent; this is to fullycomply with the Nursing and Midwifery Council (NMC) code of conduct (2015). Therewill also be a brief explanation of the dilemma and also a discussion onautonomy, beneficence, non-maleficence, justice, small conclusion aboutthe findings in this case study and It will also present the clinical case, identifythe ethical dilemma.ScenarioMrs S was brought up to ICU from accident andemergency after her condition deteriorated, she was originally brought intoA&E after being found on the floor; unconscious by her carers at home, she isalso found to have had significant weight loss over a short amount of time.After further tests it was discovered that Mrs S had lung cancer with multipleareas of metastases including brain, liver and bone. After this discovery therewas a discussion with the son who was the next of kin about a do notresuscitate (DNAR) order being put in place. To which he agreed and said it waswhat his mother wished for before she became ill; there was then a later discussionwith Mrs S’s daughter about the same situation to which she did not want theDNAR order to be put in place. This is the ethical dilemma that will bediscussed in this case study; The daughter’s request for care conflicts withthe patient’s and next of kin’s wishes and places the staff in a complicatedposition of either honouring the patient’s wishes or fulfilling the daughter’srequest.

EthicalPrinciplesThemain framework for ethics that is used in healthcare is call ethicalprinciplism which is based on four principles; autonomy, beneficence,non-maleficence and justice (Rich N.D). Nice Guidelines (2009) on DNAR decisionsstates that unfortunately, when applied to an ethical dilemma, the fourprinciples often conflict with each other and so they only provide a framework fordiscussion.AutonomyThe word autonomy is a derived from the Greek’autos’ (‘self’) and ‘nomos’ (‘rule, governance, or law’) (Beauchamp &Childress, 2009, p. 99).

In nursing practice autonomy isknown as the right of a competent adult to make an informed decision about theirown medical care (British Medical Association 2016). The ethical dilemma shownin this case study is whether to respect the patient’s autonomy or ignoring herwishes by giving in the demands of her daughter. In this circumstance the ICUconsultant was concerned about providing any additional medical treatment thatthe patient may not have wanted. BeneficenceThe broad definition of beneficence is an actof charity, mercy, and kindness. It connotes doing good to others and invokes alarge selection of moral obligation.

Beneficent acts can be performed from aposition of obligation in what is owed and from a supererogatory perspective,meaning more than what is owed, all professionals have the foundational moralimperative of doing right (Kinsinger 2009). In the event of cardiacarrest, the patient is in danger of dying within minutes. Any resuscitationattempt aims at prevention of death (maleficence) and saving life(beneficence). Resuscitative efforts are unsuccessful in the majority of cases.

In at least in 50% of cardiac arrests, the action of the heart cannot berestored another 30% die in hospital after successful restoration of the circulation.For these patients, resuscitation means an extension of the process of dying byhours or days, often without regaining consciousness and accompanied by the concomitantsof intensive care treatment, such as tracheal intubation and artificial respiration.This means considerable suffering for the patient and relatives, and is a heavyburden for those involved, including the hospital staff. Of those who survive,approximately 20–50% suffer from neurological disabilities, ranging from slightdisturbances of cognitive functions to the “ultimate tragedy” of resuscitation—severehypoxic brain damage (persistent vegetative state).Non-MaleficenceRich(2012) states that Non-malefinence is the injuction to ‘do no harm,” this isoften corresponding with beneficence; however there is a difference between thetwo principles. Beneficence requires taking action to benefit others, whereasnon-maleficence involves refraining from action that might harm others.  JusticeThe next principle is justice; Butts (2012) explains that the concept of justiceis quite broad in the field of ethics.

Justice refers to the fair sharing ofbenefits and burdens. In regards to principlism, justice most often refers tothe distribution of limited healthcare resources. The majority of the times,complicated resource allocation decisions are based on attempts to answerquestions regarding who has a right to health care and who will pay forhealthcare costs. The use of this principle was not implementedright at the start of this scenario. Failure to facilitate this ethicalprinciple has contributed to the conflict dilemma of this case. When Mrs S was admittedto ICU the use of high technology equipment can often have the effect ofunrealistic expectations (by family members and visitors) of what should beachieved at end-of life care. The respect for autonomy did not empower thepatient’s right at the start and this leads to a violation in the justiceprinciple.


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