Nursing is meant to be a holistic profession which also includes showing caring attitude towards patient, to their family members. However, there are situations where nurses are unable to decide about ethical issues as it will be discussed in scenario later on. Furthermore, there are ethical issues which are difficult to be answered immediately.
A female patient Ms. X who is 35 years old. She came to the hospital with complain of pain and was admitted for pain management. While her stay in hospital, she was diagnosed with stage IV Breast cancer. Therefore, the health care providers decided to keep the patient on palliative treatment. Patient had no knowledge regarding her prognosis. The primary nurse initially interacted with patient's mother. Mother shared with the nurse that family knows Rani wouldn't live for long. Besides that, they did not want Rani to know about her condition as mother had fear that Rani would develop negative effects on her health. However, on the second day primary nurse meet Ms. Rani. She looked gloomy and depressed. She asked the nurse that “Will I live long? Am I dying?”
When I reflected back on my experience with Ms. Rani’s case scenario as a primary nurse, I felt very sad because when I meet Ms. Rani, she looked gloomy and depressed. I was not able as how to initiate communication with her as her facial expression showed depression, and sadness. Hence, I feel very helpless because my patient was asking about her life and death. Moreover, I was speechless at that time because of confusion in my mind whether I should go to tell patient or I should accept her family’s decision. In addition, I also feel very frustrated because it happened to me for the first time and I was not able to control the situation. I felt very shocked that I should have visited Ms. Rani on the same day, when I had interacted with her mother earlier. Apart from that, I also felt nervous as I was not able to converse patient’s feeling of fear to her family and not even to the medical team. Besides that, even now I felt very anxious as I was unable to answer to my patient. Furthermore, I felt aggressive because I couldn’t help my patient in such a challenging situation where my patient herself didn’t know about the prognosis. On the other hand, I felt very annoyed because of the conflicts between the ideas of the patient and family members that the family was not allowing to share the diagnosis and the patient was inquiring about her health condition. Moreover, I felt that family and the staff members including me were aggravating Rani’s pain by not answering her queries about her prognosis.
This incident stands out for me because I noticed that the person, who had brought up Ms. Rani didn’t inform her about her diagnosis or in other words the principle of veracity was not applied, although, patient was curious to know about her prognosis. Beside that, every member of the family was considering their own values on the patient and not allowing the patient to use her autonomy. As Ms. Rani’s mother did not want patient to know about her diagnosis because mother had a fear that it will have harmful effects on her daughter’s health. Therefore, a personal bias came in my mind that parents especially mothers are considered to be culturally sensitive and they always over protective for their children, that’s why the mother is not letting her child to know about the diagnosis. However, in the scenario family was giving false reassurance while the doctors and nurses were also not playing active part in it. Therefore, patient was confused by looking these two different behaviors of her family as well as of staff members, so to confirm those behaviors patient asked me as her primary nurse those inquiring questions.
On analyzing this challenging situation, I came across different assumptions with different perspective i.e. from mother’s perspective, cultural perspective and perspective of health care professionals. The first side of mirror talks about mother’s point of view which includes: might be the mother wanted her daughter to die peacefully. Might be mother was ignoring to share about the diagnosis with patient and family member because cancer like other diseases has a stigma in our society. Might be she was afraid of her daughter’s pain, that it would increase by disclosing the diagnosis. Might be mother was the only member of the family who was frightened of disclosing the diagnosis. Might be the mother had taken one sided decision of not sharing prognosis. On the other hand, might be the mother was fearful of the fulfillment of the last wishes of her daughter after the disclosure of the information. Furthermore, the next side of the mirror discusses about the cultural perspective which says: might be the norms and values of the family were not allowing them to discuss the information with the patient. Might be it was their traditional values that the patient should die in peace. Apart from that, might be the culture prohibited sharing because it would enhance the psychological pain of the patient which the patient was already suffering physically. Hence, the other side of mirror was about the health care personnel. Might be they were not aware of the Patient’s Bill of Rights. Might be they had a lack of communication skills. Might be they had not tried to convince the family to disclose the diagnosis. Might be they had not perceived this situation significant for them. Might be they didn’t have time to pay attention to the concerns of patient and family members.
On further analyses, I think that we should have told the truth to Ms. Rani because she had the right to know about her condition. According to Craven and Hirnle (2003), “Veracity means telling the truth, which is essential to the client-provider relation. Health care professionals are obliged to be honest with client” (p.93). Therefore, I should disclose the information to the patient because if Ms. Rani will come to know from her mother or any other source then the trusting relationship between the patient and care giver would break. Furthermore, I am accountable as a health care member to disclose the information and if I don’t accomplish my duty then I am deceiving from the patient which is ethically wrong. Ferrell and Coyle (2002) believe that the dying patient's bill of rights includes "....I have the right to have my questions answered honestly; I have the right not to be deceived...." (p.29). Hence, I can lessen the worries of my patient by answering the correct information. In addition, by disclosing true information to the patient I am giving opportunities to the patient to fulfill her end of life wishes and to decide about herself in the last days of her life. According to Hyland (2002) cited McParland (2000), “Autonomy is the ability to understand one’s own situation, to deliberate, to make plans and choices, and to pursue personal goals” (p.476). Therefore, I am responsible for my patient’s autonomy being her primary nurse, so I think, I should help Ms. Rani in making her end of life goals and the fulfillment of her end of life wishes. Moreover, as being a health team member I should know the ethical principles given in the Patient’s Bill of Rights. According to Dunn (1999), “The Patient’s Bill of Right ensures: the right to obtain complete, current information about diagnosis, proposed treatments, and prognosis; risks and benefits of treatment; and alternative treatment” (p.42). In fact, the patient in the hospital totally depends upon the health care provider that is the reason why Ms. Rani asked about her condition from me as her primary nurse.
Apart from that, I would also keep in mind the cultural preferences of my patient because culture is considered as one of the dimension which gives shape to our personally. According to Lee, “It is more important to be sensitive to the patient’s needs, desires for information and respect cultural expectations on communication in the terminally ill” (p.536). Though, it suggests that I should have a clear understanding of my patient’s cultural beliefs while communicating any information to my patient or her family members. I should also know my patient's cultural preferences in relation to death and dying issues. Moreover, it also gives me the idea that disclosing the information through correct use of communication and giving respect to individual culture, I would help my patient to cope with the situation. According to my opinion patient should be well aware of her diagnosis because it would reduce her level of anxiety that will obviously help in her treatment. Furthermore, disclosure of the information will bring compliance with the treatment that will obviously bring better results. By knowing her diagnosis and its prognosis patient will also acknowledge the efforts of health care professionals and will start cooperating with them. According to Lee (2002) the studies from the benefits of disclosure suggest, “There was no increase in perceived symptoms of anxiety, sadness, depression or fear in the group of informed patients compared to uninformed patients” (p.535). Therefore, through the process of disclosure I would help my patient in decreasing her anxiety and become compliant of the treatment offered to her. Also help my patient to actively participate in her treatment regimen.
From this situation, I learnt that we as health care professionals should tell the truth to the patient. The decision of life and death related issues like disclosure of diagnosis to the terminally ill patients should be considered as our initial step. Therefore, I would make sure that effective communication skills are used during the disclosure of the information related to the diagnosis and prognosis of the patient. It leads to the resolution of serious problems of the patient and creates a trusting relation ship, by not deceiving the patient. I also learnt that health care provider should know the patient's bill of rights, in order to protect their patient ethically and legally both. Furthermore, I learnt that the nurse should have knowledge about patient culture. If this situation happened in future, then my first step would be that I would interact with my patient and see my patient's level of understanding about her diagnosis. I would share the conflicting ideas of the patient, family and the staff members (if any). Besides this, I would also recall my previous experience with these kinds of patient. I would also recall the ethical principal and the dying patient's bill of rights, which I have applied on Ms. Rani. Hence, in future I will become more competent and will try to solve the ethical dilemma through mutual discussion between the health care providers and the family members. Moreover, I would recommend that every hospital should have ethical committees in order to solve and protect their patient ethically. Legal support should be addressed, in order to maintain safety of the patient. In addition, the health team members should have training sessions to improve their communication skills. Also there should be ongoing review of ethical principles in the wards and there should be workshops and seminars held to bring awareness regarding these topic. The staff members should be specially trained to deal with terminally ill patient and their family members. Besides that, there should be counseling sessions of family members regarding disclosure of correct information to the patient.
As a matter of fact, we can say that Ms. Rani was suffering from psychological pain along with physical pain. Her autonomy and veracity was neglected because of health team members as well as family member. By whole analysis we can also come to many other conclusions along with their intervention. Lastly, I want to say that even the laws and literature supports the patient's right to be told truth and to know about the condition but this could only be possible if we perform our duty as our responsibility.
Reference:
- Craven, R.F., & Hirnle, C.J. (2003). Ethical & legal concerns: Fundamentals of nursing: human health and function (4th ed.). p.93.
- Dunn, D. (1999). Exploring the gray area of inform consent. Nursing,29(7).41-45.
- Ferrell, B.R & Coyle, N. (2002). An overview of palliative nursing care. American Journal of Nursing,102(5).26-30.
- Hilden, H.M., & Honkasalo, M.L. (2006). Interpretations of patient autonomy in the context of end-of-life decision making. Nursing Ethics,13(1).41-49.
- Hyland, D. (2002). An exploration of the relationship between patient autonomy and patient advocacy: Implications for nursing practice. Nursing Ethics,9(5).472-481.
- Lee, A.H. (2002). Diagnosis disclosure in cancer patient-when the family say NO!. Singapore Medical Journal,43(10).533-538.
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