Working as an RN in Washington State, I was on the outside of an unfortunate situation involving a male patient. This did not involve me, but it became such a big deal that everyone was made aware of the details over time. The patient was an older man who had recently gone through a myriad of medical conditions following a surgery. It is a common story for someone his age where an older person has a surgery which fixes the main problem, but leads to numerous other problems as a result of inactivity, poor nutrition, and depression.
The depression stemmed from the recent passing of a loved one, and was only compounded by his medical issues.
This patient was discharged and was being followed by case management, with regularly scheduled home visits by therapy and nursing staff. During one particular visit, therapy noticed a weapon near a chair and asked why it was there and the patient hinted (after an apparently long visit/discussion) that he intended to end his life at some point with it.
The therapist also reported that the patient “demanded” nobody get involved. It is a well-known fact that older males are more likely than anyone to commit suicide, but in Washington State, attempts at suicide are not a crime, and neither are indications of a possible future attempt. As a result, reporting this to authorities wouldn’t have accomplished anything except probably encouraging the patient to carry out his plan to end his life sooner than he originally intended.
The therapist reported this to the case manager who reported this to the rest of the patient’s care team. Thankfully, those involved in his care were able to “legally” help prevent his suicide through tactful discussion with him which ended with him voluntarily surrendering his weapon (to police who destroyed it). The patient also voluntarily admitted himself to an inpatient psych program on the east side of the city he lived in. I don’t know how long the patient survived after that, or whether or not he followed-through on his thoughts of suicide as I moved to St. Louis, plus this was a psych case and patient details are strictly confidential.
Immediately following the therapists reporting of the situation, we were reminded of the American Nurses Association (ANA) code of ethics and discussed our way through this dilemma as a group. The main goal of the care team was to continue to help the patient recover from his medical issues, in addition to preventing his suicide. When the therapist reported the situation to the RN case manager, the case manager was obligated to act on the information to uphold the ethical principles of beneficence, non-maleficence, and fidelity. The case manager knew the patient didn’t want anyone involved, but provision 3 of the Code of Ethics for Nurses states that “the nurse promotes, advocates for, and protects the rights, health, and safety of the patient” (ANA 2015a, pg. 9). In addition, provision 4 states that “the nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care” (ANA 2015a, pg. 15).
In her reporting this to the rest of the care team, the case manager upheld standard 5B of the Nursing Scope and Standards of Practice, 3rd edition which states that “the registered nurse employs strategies to promote health and a safe environment” (ANA 2015b, pg. 65). Her actions led to the patient surrendering his weapon and entering a psych facility to deal with his suicidal ideation and depression. The patient was acting within the law when he stated his intentions to the therapist, and had not been deemed “unfit” to make decisions by a doctor so he couldn’t be forced into being helped. He possessed the capacity, and therefore the right, to be autonomous. “Autonomy means that individuals are respected and allowed to make their own decisions about issues that affect them. It means we do not interfere if a person genuinely has the capacity to decide. (OGrady, et al., 2015, pg. 212).
The patient had the right to make his own decisions, but the case manager and therapist acted against the demands of the patient, and were allowed to share the information with his care team as they were all somehow directly involved with his care and legally allowed to share information with one another. The therapist and case manager had to decide whether or not to oblige the patient’s demand, or to do what they could to try and sway the patient towards voluntary help. Multiple meetings with nursing staff took place regarding what to do in situations like this should they arise again. As a team, we had different opinions on what could or should be done in these instances. What we all agreed on though, was that it was in all our best interests to embody what’s outlined in the ANA’s code of ethics, and really familiarize ourselves with the laws of whatever state we are working in. Working within the confines of the ANA’s code of ethics, as well as within the law, the care team was able to solve the dilemma and prevent the patient’s suicide up to the time I left for St. Louis.