Ethics Midterm and Standards of Care

Categories: CareMedical ethics

Negligence

There are standards of care that patients expect to receive in a hospital. When these expectations are not met, negligence may have occurred. Negligence is defined as “any act or omission by a medical professional during a treatment of a patient that deviates from accepted norms of practice in the medical community and causes an injury to the patient” (Bal, 2008). Medical malpractice is an example of negligence and is a common citing in many negligence lawsuits in the United States.

Under the law of torts, four items must be met in order to prove that a medical professional acted with negligence. They are: a professional duty was owed to the patient; there was a breach of duty; injury was caused by the breach; the injury is proven (Kanopy, 2014). A key specification is that this breach of duty is what directly caused the injury. Something that is not always as clear is what is considered the expected behavior that a negligent person is being compared to.

To define this with more detail, a person has acted negligently if she has failed to act as a prudent reasonable person would under similar circumstances. When these cases go to trial, it is all about considering what this hypothetical reasonable person would do in order to have a standard to judge others. This hypothetical reasonable person can be different from the “average” or “typical” person. Rather, it is how the community believes a typical person should act, not how the typical person actually does act.

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Though a majority of people may act a certain way, that doesn’t establish it as the standard. For example, if most nurses do not actually turn their comatose patients every two hours overnight, this is still the standard of care they are held to. If a nurse’s patient developed ulcers because he wasn’t turned, she can be found negligent. Just because everyone else is doing something, such as only turning patients every six hours, doesn’t mean it is acceptable.

One well known example of medical negligence occurred recently at Duke University Hospital (Campion, 2013). Jessica was a 17 year old girl receiving a heart and double lung transplant. She died 15 days after the surgery because she was given organs of type A blood when she was type O. The entire complex and long procedure went perfectly besides the fact that her body rejected the organs for this obvious reason. It wasn’t just bad luck that this happened. There was negligence by countless members of the medical team involved in her case. Over a dozen people involved did not do the double check that the donor organs and the recipient blood types were compatible. The hospital hid this mistake for 11 days before making a statement and searching for a new set of organs. By that point it was too late and she was declared brain dead.

As nurses, we have a duty to our patients and the care that we give must be in line with the established standards of medical care (Goguen, 2017). Medical negligence occurs when a medical professional fails to do their duty and does not meet the standard of care. Patients deserve to receive safe and high quality care. They should have confidence that all nurses will provide this and will not harm them. Through education, training, and awareness of both state and institution guidelines of care, nurses must strive to avoid negligent behaviors and keep patients safe.

Beneficence vs. Nonmaleficence

Beneficence and nonmaleficence are arguably two of the most well-known and relevant topics in ethics. These terms are a central aspect of the nursing code of ethics and yield countless implications that guide our nursing practice.

Beneficence is a moral action and ethical principle to promote good. This means that we are only performing interventions and making recommendations that we believe are in the best interest of the patient. As nurses, beneficence is extremely valuable because it encourages critical thinking and to consider the outcomes of our care to ensure it is in the patient’s best interest. Beneficence holds us to the highest standard of practice. To put it simply, beneficence “emphasizes compassionate care and advocates for continual striving toward excellence” (Bernstein, 2017). Nurses are encouraged to always act with beneficence in mind, which should come as no surprise since the core of the profession’s goals is to promote the well-being of others. Doing no harm is directly tied to the nurse’s duty to protect the patient’s safety. Born out of the Hippocratic Oath, this principle dictates that we do not cause injury to our patients (Silva, 1999).

Examples of beneficence in nursing are numerous. One simple example is that a nurse knows it is in the best interest of a severely injured patient to receive pain medication as soon as possible when he/she arrives at the emergency room. They should receive this medication before other non-urgent aspects of their care are dealt with. In other situations, beneficence can be difficult and complex. One example that I have witnessed myself and we have discussed in class is when an Arabic mother was giving birth and would only allow female doctors in the room. The birth was traumatic and the baby needed a neonatologist immediately, but there were only male neonatologists working that day. The nurse knew that it was in the best interest of the patient to get the baby the help she needed and allowed the male doctor in the room. Another complex instance of beneficence could be when a patient denies medical care due to religion or cultural preferences and then later becomes unconscious in an emergent situation. The nurse then gave the medical care anyways in the emergency. It can be said that the nurse took away the patient’s autonomy and right to choose, but she has also acted with beneficence because the intervention saved the patient’s life.   Problems may arise between a patient’s desires when competent and the essential care that was given when they were deemed incompetent. In cases like this where a patient is unable to make decisions, medical staff is expected to act with both nonmaleficence and beneficence.

Next, there is nonmaleficence, which can be defined as a medical professional’s duty to “do no harm.” This principle must be followed closely by nurses with the best interest of the patients in mind (Timko, 2001). In many critical care situations, treatments and interventions that are done often may result in unintentional short-term or long-term harm. The decision on whether or not to perform an action is decided by weighing the risks and benefits. No action should do anything to knowingly harm patients without the action having desired equal or greater benefits. In other words, the dangers of a procedure must be understood and weighed against the prospective benefits (Pantilat, 2008). When conscious and able to make the decision, it is the patient’s right to decide if they believe the procedure is worth the risk of potential harm.

In conclusion, comprehensive and patient centered care that follows our moral code must demonstrate a balance between beneficence and nonmaleficence when weighing treatment decisions for our patients.

Informed Consent

A key principle in medicine and in research is informed consent. Informed consent was first developed and established as the protocol after an appeal during the Salgo v. Leland Stanford litigation in 1957.  Informed consent is an important procedure for safeguarding both patients in hospitals and participants involved in research studies.  Informed consent means that participants have adequate information, comprehend the information, and have the power to choose, enabling them to consent to or to decline voluntarily (Menendez, 2013).  In other words, informed consent provides the patient with “the freedom to decide what should or should not happen to his/her body and to gather information before undergoing a test/procedure/surgery” (Rao, 2008).  It is important to note that the patient cannot be coerced into acting a particular way.  It is a doctor’s job to act as a facilitator, but to not sway a patient one way or another (Rao, 2008). The patient should also be reassured that refusal to do the procedure or plan of care that the doctor proposes does not result in the withdrawal of care. Their decision will be respected and other options will be explored that better fit what the patient wants. Patients are considered competent to give their own consent if they are a coherent adult 18 years or older. The patient’s parent or legal guardian will give consent if the subject is a minor. There are of course some exceptions that nurses should be aware of in regards to age or other situations. Most notably is the Good Samaritan law and that consent is implied in emergency situations in which the patient is unable to provide it.

As can be drawn from the name, informed consent must be an informed decision preceded with sufficient information.  The information must be given in a way that the patient can easily understand and comprehend. There are many aspects that must be included, such as the condition that the patient is being treated for, the necessity and benefits of the proposed interventions, the possible consequences for not receiving treatment, the expected outcome, the required follow up care, and lastly, the estimated cost (De Bord, 2014).  Only with all of these factors can the patient have adequate information to make an informed decision. Furthermore, the patient needs to have the opportunity to ask questions and clarify anything that is unclear. The nurse has a responsibility to assess the patient’s understanding and advocate for them if they need more time to speak with the team before deciding. The overall process of informed consent must be documented, signed and dated after consent is given (Mendedez 2013). The patient is signing that the physician provided him with the information and the nurse is signing that they are watching this patient sign the consent him/herself.

In a clinical example that I wrote about for our first essay earlier in the semester, I found a case study of a man who consented to surgery for his elderly mother over the phone. He was on vacation and rushed through the phone call. The doctor did not provide him with the proper information and did not inform him of the major risks involved in his mother’s hip replacement. Upon arriving home to find his mother in a coma, he filed a lawsuit against the hospital. He eventually won the case for a few reasons. First off, the physician never should have called him because the elderly woman was completely capable and competent to provide her own consent, which she had already voiced she did not consent to surgery. Second, the consent he gave over the phone was in no way informed (Coerced Consent, 2017).

To determine the real world clinical effectiveness of informed consent, a group of nurses from many different hospitals conducted surveys. Their goal was to gather information about how informed consent was given and perceived.  The study showed that with informed consent, patients felt they were being given the opportunity to make as many decisions as possible. They felt that they were receiving proper and fair treatment. Furthermore, the nurses noticed that informed consent was providing a foundation for patient autonomy and that patients seemed to be happy with their care (Lemonidou, 2003).

Citations

  1. Bal, B. S. (2009, February). An Introduction to Medical Malpractice in the United States. Retrieved February 19, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628513/
  2. Bernstein, R. (2017, August 11). Beneficence Nursing and Ethics. Retrieved February 20, 2019, from https://online.husson.edu/beneficence-nursing-ethics/
  3. Campion, Tad. (2003). A death at Duke. The New England journal of medicine. 348. 1083-4. 10.1056/NEJMp030033.
  4. Case study: Coerced consent. (2017, September 20). Retrieved February 20, 2019, from https://www.americannursetoday.com/case-study-coerced-consent/
  5. De Bord, J. (2014, March 7). Informed Consent. Retrieved February 19, 2019, from https://depts.washington.edu/bioethx/topics/consent.html
  6. Goguen, D., JD. (2017). Medical Negligence: The Law Explained. Retrieved February 19, 2019, from http://www.alllaw.com/articles/nolo/medical-malpractice/negligence.html
  7. Kanopy. (2014). An introduction to negligence for health professionals Lemonidou, C., PhD, RN, Merkouris, A., PhD, RN, Leino-Kilpi, H., PhD, RN, Valimaki, M., PhD, RN, Dassen, T., PhD, RN, Gasull, M., RN, . . . Arndt, M., PhD, RN. (2003, June 27). A comparison of surgical patients’ and nurses’ perceptions of patients’ autonomy, privacy and informed consent in nursing interventions. Retrieved February 20, 2019, from https://www.sciencedirect.com/science/article/pii/S1361900403000712
  8. Menendez, J. B. (2013, December). Informed consent: essential legal and ethical principles for nurses. Retrieved February 20, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/ 24263229
  9. Pantilat, S., MD. (2008). Beneficence vs. Nonmaleficence. Retrieved February 20, 2019, from http://missinglink.ucsf.edu/lm/ethics/content%20pages/fast_fact_bene_nonmal.htm
  10. Rao, K. H. (2008, January). Informed Consent: An Ethical Obligation or Legal Compulsion? Retrieved February 20, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2840885/
  11. Silva, Mary Cipriano and Ludwick, Ruth (July 2, 1999). Interstate Nursing Practice and Regulation: Ethical Issues for the 21st Century. Online Journal of Issues in Nursing Vol. 4 No. 2.
  12. Timko, R. (2001). Clinical ethics: Due care and the principle of nonmaleficence. Lanham, Md.: University Press of America.

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Ethics Midterm and Standards of Care. (2021, Mar 09). Retrieved from http://studymoose.com/ethics-midterm-and-standards-of-care-essay

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