Mark’s case is one among the many that healthcare providers face on numerous occasions. In this case, Mark presents at the clinic or within the ER having sustained serious injuries following a car accident. He is assessed to have significant internal bleeding and therefore in need of immediate blood transfusion to arrest the progression of the situation to a severity point. The doctor determined that three units of blood would be necessary for Mark’s situation and therefore placed the order for an immediate transfusion. At the time the transfusion was to occur, Mark was still conscious and oriented and so when the nurse informed him of the intended blood transfusion, Mark rejected this offer and provided a written and signed Refusal of Treatment document which he handed to the nurse. He noted that this process of blood transfusion was solely against his religion and he would not compromise his religious belief as a Jehovah Witness at any cost.
His friend Pam who is with Mark at the hospital begs that the nurse ignores the document and conducts the blood transfusion but Mark cannot take it since he is adamant that the process cannot be performed on him. Pam threatens that if the nurse does not ignore the document provided by Mark, she would sue the hospital and the doctor for what she terms as negligence. The nurse is placed in a position where she has to accomplish a set of contradicting demands from every person involved in Mark’s care. This paper seeks to determine the ethical and moral dilemmas in Mark’s case, the possible solutions, the roles of the nurse and the care team as well as the role of the surrogate. Ultimately, the paper will try to determine the best solution to this situation from the nurse’s perspective such that all the professional standards and the code of ethics for nurses are honored or observed while also guarding the rights to the patient (Wong, Weiland, & Jelinek, 2012).
Discussion and Analysis
There are many revolving conflicts in this case; on one hand, the nurse has received the doctor’s orders and she knows that any further delay could worsen Mark’s situation considering that he is already having significant internal bleeding. On the other hand, the nurse cannot proceed with the doctor’s demands considering that Mark has submitted a refusal document in which he clearly states that his religious stand cannot allow him to take up any blood transfusion. Further, there is a friend of Mark by the name Pam who indicates that she loves Mark and the nurse has to ignore the letter and provide treatment as ordered by the doctor.
Apparently, failure to do so, would be Pam’s perspective qualify to make the doctor and the hospital liable for negligence of a patient. This case of Mark presents the challenge of determining the autonomy of the patient and its limits. On the other hand, it presents a fight between the autonomy of the patient and the role of the surrogate (Schneider & Whitehead, 2013). Further, it presents the challenge of determining the role of the principle of autonomy and that of beneficence and to whom such beneficence is entitled, that it whether to the patient alone or to the patient and their surrogate (AHPRA, 2016). On the other hand, this case presents a conflict between the principle of nonmaleficence which calls for nurses and the healthcare providers to ensure that they inflict to harm to the patient or in the case of harm such harm should be reasonable to facilitate healing or recovery in the future (Ryan & Callaghan, 2010).
These issues all reside within the determination of the nurse and the doctor. Their decisions must be within the scope of practice and responsibilities of a care provider while at the same time meeting the demands of the patient and/or the surrogate simultaneously (Schneider & Whitehead, 2013). The major conflict here is between the role of the surrogate and the autonomy of the patient. In this case, Pam being the surrogate she has every right to sue for negligence but in the current situation, such a move would be rendered null and void based on the refusal document that was signed by Mark (AHPRA, 2016).
However, if she decides to explore the case further, Pam can determine that at the time the patient signed the document, he was not in the right frame of mind and that Mark could not make a logical decision regarding his health or any other urgent matter at the time. The fact that he had been involved in a serious accident implies that he could be in a state of trauma which in essence means that his ability to make decisions was significantly compromised (Nursing and Midwifery Board of Australia, 2016). In this situation, the matter as to whether the patient was in the right frame of mind to make the decision would be left to the discretion of the court. The doctor and the hospital would be tasked with explaining to the court what measures they utilized to determine that the patient was in the right frame of mind to make such a decision regarding his health especially after a grossly roads accident (Lamont, Jeon & Chiarella, 2013).
At the peak of the ethical principle of autonomy vests the ability of the patient to make decisions regarding their health. However, this decision making as independent as it should be, the requirement is that it is an informed decision. This implies that the nurse or the care provider has to sit down with the patient as well as their surrogate and inform them of the state of their health and the available alternatives to facilitate their recovery. The nurse and the doctor have a duty to inform the patient and the surrogate of the benefits and harms related to each of the alternatives (AHPRA, 2016).
On the other hand, in the making of such an informed decision, the nurse or the care provider has to determine that the patient is in the right state of mind or that their cognitive capabilities are within what can be described as normal levels or state. In the event that the patient meets the criteria for cognitive capability, then it is rightly so upon the patient to make a decision in regard to their health as much as it may possess any negative outcomes so long as the nurse has duly informed them of the existing alternatives, their benefits and harms (Lamont, Jeon & Chiarella, 2013). On the other hand, in the event that the patient is not in the right state of mind or that their cognitive capability is not suitable to make such decisions, then the role of decision making is transferred to the surrogate who could be a relative, spouse or the person who presents at the clinic with the patient (Lamont, Jeon & Chiarella, 2013).
In Mark’s case, Pam is the surrogate and since the decision from Mark conflicts with that from Pam, and that the nurse and the doctor have casually assessed him as oriented and conscious, then Pam may not have so much of a say from a legal perspective (Wong, Weiland, & Jelinek, 2012). However, in addressing the patient, it would be important to involve Pam so that she can have a chance to convince her friend Mark to take up the blood transfusion as the only viable solution to his health. In the case that she cannot convince the patient to accept the treatment proposed by the care team, then Pam has no role in dictating to the care team how they should manage the patient even against his own demands (Huston, 2013).
However, the Victorian Civil and Administrative Tribunal (VCAT) Act 1998 upon which the Refusal of Treatment is based on has a requirement that makes the surrogate hold some temporary authority and power that can change the course of the treatment even when the patient is said to be competent enough to make a decision (Office of the Public Advocate, 2016). In this Act, the Refusal of Treatment document must be signed by three persons; the patient, the nurse or the doctor and the other person in this case the surrogate who witnesses that the patient has been duly informed and that there is an agreement between the three parties on the next course of action. In this case, if the surrogate or the other person is not in agreement with the patient or the nurse, then their refusal to sign is regarded to trigger the authority of the VCAT (Office of the Public Advocate, 2016).
This authority allows for the temporary orders to come in force so that the VCAT can act swiftly to protect the health of the person who is in urgent need and in whom there is a conflict among the signatories (AHPRA, 2016). Therefore the VCAT will make a decision that will end the standoff in the short term and that decision is done in the best interests of the immediate needs of the patient. Such a temporary administration or guardianship is made for up to 21 days and not even the patient has the right to refuse any of the conditions imposed by VCAT until the court or the authorities involved rule otherwise (Office of the Public Advocate, 2016).
Among the issues that the VCAT would have to determine and which would be Pam’s reference point at this time is that the patient had just been invoked in a road accident which in all essence is a traumatic experience that significantly impacted on the ability of the patient to make decisions competently (Office of the Public Advocate, 2016). This would be a logical point of view especially because the law is silent on such a matter as a traumatic event and its extent of affecting the patient’s cognitive competency and therefore leaving it to the discretion of the attorneys and the VCAT to adequately establish the impact of traumatic experiences on cognitive competency. Apparently, the nurse would have easily resolved this by involving Pam which in essence would have triggered the VCAT act (Wong, Weiland, & Jelinek, 2012).
According to Standard 2 of the NMBA STANDARDS FOR PRACTICE: ENROLLED NURSES, the nurse has a professional responsibility to practice in such a manner and in ways that preserve and protect the rights, dignity, confidentiality and the respect of the patient and their surrogate (Nursing and Midwifery Board of Australia, 2016). This in essence implies that the patient retains all the rights to determine the mode and methods of treatment as long as they are in a cognitive state that is favorable and suitable to be regarded normal and the nurse has appropriately informed them of the existing alternatives and their harms and benefits (Nursing and Midwifery Board of Australia, 2016). Further, within this standard, the nurse has to determine the role of culture, beliefs, values and perceptions and ensure that they fully understand the patient’s perspective of the same. Therefore, all decisions that are taken must be within the belief or cultural system of the client so as to afford them the spiritual and psychological comfort that they need (Nursing and Midwifery Board of Australia, 2016).
Conclusion
Apparently, even as much as a therapy or process may deliver positive benefits to the patient, ultimately the question will be whether the patient feels satisfied by the care that they have been provided. Within the contemporary setting, it is apparent that the care outcomes are not just limited to the physical recovery but more importantly to the relationship between the care provider and the patient and the ability of the care process to align firmly with the client’s belief and cultural system. The nurse has to show utmost respect of the patient’s belief systems as much as they fail to agree with what may be regarded as the professional standards of care delivery (Lamont, Jeon & Chiarella, 2013).
On the other hand, the nurse has to recognize that they hold a role of nonmaleficence not only to the patient but to the family and those around the patient. This implies that the decision or action by the nurse must be balanced in such a way that it does equally prioritize that any negative outcomes for this patient would significantly affect the roles and relationships within their family and in some way impact the health of the close members and especially the surrogate (Ryan & Callaghan, 2010). It is upon the nurse to understand the legal requirements for the various documents that are used in the healthcare setting and particularly those that deal with refusals to treatment, withdrawal of life support, consent forms and others and determine the safest way to resolve the emerging conflicts (Office of the Public Advocate, 2016).
In many cases, the nurse and the parties involved may not be in position to make the decision that can be termed as favorable to all. However, in such instances there is always a temporary stay or temporary order that protects the nurse from any legal liabilities while acting in a manner that favors the patient in the short term as a permanent solution is being sought (Schneider & Whitehead, 2013). These alternatives if explored can provide best channels for resolving dilemmas in the short term without delaying the required care to the patient. On the other hand, the critical aspect for determining the cognitive competency of the patient is one that requires team work and collaboration so that the assessment can be holistic (Huston, 2013).
References
AHPRA. (2016). Australian Health Practitioner Regulation Agency - Legislation. Retrieved from http://www.ahpra.gov.au/about-ahpra/what-we-do/legislation.aspx
Huston, C. J. (2013). Professional issues in nursing: Challenges and opportunities. Lippincott Williams & Wilkins.
Lamont, S., Jeon, Y. H., & Chiarella, M. (2013). Health-care professionals’ knowledge, attitudes and behaviours relating to patient capacity to consent to treatment An integrative review. Nursing ethics, 20(6), 684-707.
Nursing and Midwifery Board of Australia. (2016). Nursing and Midwifery Board of Australia - Fact sheet: Enrolled nurse standards for practice. Retrieved from http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/FAQ/Enrolled-nurse-standards-for-practice.aspx
Office of the Public Advocate. (2016). Refusal of treatment. Retrieved from http://www.publicadvocate.vic.gov.au/medical-consent/refusal-of-treatment
Ryan, C. J., & Callaghan, S. (2010). Legal and ethical aspects of refusing medcial treatment after a suicide attempt: the Wooltorton case in the Australian context. Med J Aust, 193(4), 239-242.
Schneider, Z., & Whitehead, D. (2013). Nursing and midwifery research: methods and appraisal for evidence-based practice. Elsevier Australia.
Wong, R. E., Weiland, T. J., & Jelinek, G. A. (2012). Emergency clinicians' attitudes and decisions in patient scenarios involving advance directives.Emergency Medicine Journal, 29(9), 720-724.
