Weeks 3 & 4 Content Online Assignment

Summer 2019

The learning objectives for this assignment are stated in the beginning of each chapter assigned (Textbook-Yoder-Wise, 6th edition)

Instructions:

Read the following case studies. Answer all the questions below related to each chapter assigned.

Chapter 4: Legal and Ethical Issues

Ethical and Critical Decision Making – Ethical and critical decision making requires the

ability to make distinctions between competing choices. The thinking process involved in

making such decisions can follow many formats, but in all cases, it is a deep-thinking process– sometimes called critical thinking. In complicated cases the use of ethical decision-making models can help clarify what the competing ethical principles are, and what information should be thinking about.

What goes into ethical decision making? Consider these five steps:

1. Is It an Ethical Issue? Being ethical does not always mean following the law. And just because something is possible doesn’t mean it is ethical, hence the global debates about biotechnology advances such as cloning. And ethics and religion do not always concur. This is perhaps the trickiest stage in ethical decision making, as sometimes the subtleties of the issue are above and beyond our knowledge and experience. Listen to your instincts – if it feels uncomfortable making the decision on your own, get others involved and use their collective knowledge and experience to make a more considered decision.

2. Get the Facts. What do you know, and just as importantly, what don’t you know? Who are the people affected by your decision? Have they been consulted? What are your options? Have you reviewed your options with someone you respect?

3. Evaluate Alternative Actions. There are different ethical approaches which may help you make the most ethical decision.

a. Utilitarian Approach – which action results in the most good and least harm?

b. Rights Based Approach – which action respects the rights of everyone involved?

c. Fairness or Justice Approach– which action treats people fairly?

d. Common Good Approach – which action contributes most to the quality of life of the people affected?

e. Virtue Approach – which action embodies the character strengths you value?

4. Test Your Decision. Could you comfortably explain your decision to your mother? To man in the street? On television? If not, you may have to re-think your decision before you take action.

5. Just Do It – Make a Decision and Go. Once you’ve made the decision, then don’t waste time in implementing it. Set a date to review your decision and make adjustments if necessary. Often decisions are made with the best information to hand at the time, but things change, and your decision making needs to be flexible enough to change too. Even a complete about face may be the most appropriate action further down the track.

Case Study 1

Nurse Smith has been working in the Critical Care Unit for 18 months. One evening John, a 40-year-old male patient, was admitted with a serious head injury. He has a history of mental illness and has been living with his 80-year-old parents for the last 15 years. After being on life support for 3 days his parents came to the Unit and stated they wanted everything stopped and to have him removed from life support. After taking the appropriate measures, the team began to remove the life supporting equipment. After removing his breathing tube, John opened his eyes and looked at his family. He said to them “Why are you trying to kill me?” As the nurse assigned to John, what would you do?T

DECISIONETHICAL DECISION MAKING WORKSHEET

Answer these questions:

Using the Ethical Decision-Making Framework as a guide above, think through the ethical issues in the scenario identified and determine what decision you would make.

Is It an Ethical Issue?

2. Get the Facts.

3. Evaluate Alternative Actions.

4. Test Your Decision.

5. Just Do It – Make a Decision. What did you decide and what did you learn?

Case Study 2

Mrs. M is a 75-year-old widow who lives alone in a small house that she and her husband built during the first few years of their marriage. Before his death 2 years earlier, Mrs. M had cared for him at home with the assistance of a home health aide. The community health nurse who visited her husband also taught Mrs. M how to be more independent in the management of her own chronic illnesses. Since her husband’ s death, the community health nurse and Mrs. M have remained friends, and they see each other once or twice a month.

Mrs. M was doing well until 4 months ago, when she experienced an episode of dizziness and fell. She was examined by her physician, who could find no physical injury but hospitalized her for further evaluation of the dizziness and a possible altered mental state. In the hospital, Mrs. M fell while being ambulated with the assistance of two certified nursing assistants. The fall caused both her left hip and left arm to be broken, and Mrs. M underwent surgery for a left hip replacement. Her left arm was set. She also underwent a full rehabilitation program after the hip replacement surgery and was admitted to a skilled nursing home for a short time. When Mrs. M was discharged, a referral was made to the community health nursing agency to provide services so that Mrs. M could safely remain at home.

Mrs. M has been capable and independent all her life, so she has found it difficult to acknowledge the changes that have come with aging and the increasing limitations imposed by her chronic illnesses. Since her return home, she has responded positively to nursing counseling about her functional health status and has participated actively in a plan to meet her changing daily living needs. She has developed a stronger and more therapeutic nurse-client relationship with the community health nurse, as the same nurse who had cared for Mr. M was assigned to Mrs. M’s care.

Mrs. M has also responded well to the services of a home health aide who visits weekly to provide personal care and light housekeeping. The community health nurse visits once a month. Neighbors help with shopping, occasional meal preparation, and general monitoring. Mrs. M’s sole family member is a married daughter who lives with her family in a distant state. Although they talk frequently by phone, the daughter has not visited since her father’s funeral 2 years earlier.

Recently, Mrs. M’s long-time physician retired, and she is now seeing a different physician. After Mrs. M’s second office visit with this new physician, the community health nurse received a call from the physician. The physician said he had told Mrs. M that she must sell her house and move into a nursing home permanently. He gave this advice because, “She is an old woman. Her health will not improve, and she is at risk for falling or having an acute exacerbation of her primary illnesses that will probably lead to disability or death. She should not live alone.” The physician then added, “Mrs. M became confused and emotional. She refused to listen to me. We must do what is best for her, as she is incapable of a rational decision. You need to tell her that she must go to a nursing home, as she said she would talk with you.” The primary community health nurse acknowledged that Mrs. M does have known health risks, but when she tried to describe Mrs. M’s safe-care abilities, the safe home environment, and the community services, the physician replied, “Just follow orders,” and abruptly ended the phone conversation.

Questions:

What legal and ethical issues are presented?

As a nurse manager, what advice would you give the staff nurse regarding this client?

Chapter 9: Cultural Diversity in Health Care (Please select 2 out of 3 Case Studies below)

Case Study 1

Mr. A is a 70-year-old Egyptian male who speaks only Arabic. He was diagnosed with a meningioma by means of magnetic resonance imaging (MRI) in Egypt. Mr. A and his family came to the United States for better treatment of his meningioma. A craniotomy was performed for the removal of the tumor. The surgery produced no complications, and Mr. A was moved to the surgical intensive care unit (SICU) for observation. The SICU does not have open hours for visiting. The RN assigned to Mr. A does not speak Arabic, nor does the patient’s wife speak or understand English. Mr. A’s son speaks some English and was able to translate some words. It was reported to the oncoming day shift that Mr. A had had a very restless first postoperative night. When the assigned male RN came on at 7 am, Mr. A was trying to tell him something that seemed urgent. Mr. A’s family was unable to be located in the SICU waiting room, and an Arabic translator was not available at the time.

Mr. A appeared agitated as he repeatedly pointed to his head, making a circle with his fingers. The male RN had difficulty with verbal and nonverbal communication with Mr. A. The RN did a neurological assessment and took his vital signs, which were within normal limits. The RN expressed his need to the nurse manager to have the patient’s son available to translate for Mr. A so as to determine his level of pain. However, the RN did not want to give Mr. A pain medication because of a scheduled MRI.

Questions:

What might be some nonverbal cues for assessing Mr. A’s pain?

What could Mr. A’s son and the RN staff have done to prevent communication barriers from occurring?

If the SICU does not have a policy for open visiting or a specific hospital translator, is it fair to let a family member remain at the patient’s bedside for the purpose of communication? Provide pros and cons for your answer.

What ethical values and legal principles should be considered in this situation?

Case Study 2

Mrs. C, an 87-year-old, frail, widowed, African-American female is a patient in a skilled nursing unit in a healthcare center that has a culturally diverse staff. Mrs. C has moderate multi-infarct dementia and a history of bronchiectasis. Following her breakfast and while morning care is being given, Mrs. C suddenly starts coughing and producing a moderate amount of bright red blood. The patient does not have a signed advance directive in her chart; however, there is a written do not resuscitate (DNR) order on the physician order form. Mrs. C’s only living child, a daughter, resides in another city about 1000 miles away.

Questions:

What immediate nursing action should be taken by the licensed or unlicensed nursing staff on duty?

What nursing action should be taken by the nurse manager or the licensed nurse designate?

What are your state’s laws concerning advance directives (living wills)? What are its laws concerning directions to physicians, family, and surrogates? What is to be done if none of these are in effect for a patient?

Consider this situation: What if AND (allow natural death) had been written on the patient’s chart by the physician? Does AND have the same meaning as DNR to you and other unit staff members? Discuss why or why not. Are there any cultural implications or values to be considered in caring for this patient?

Case Study 3

A neurological intensive care nurse is assigned to care for a 16-year-old married Hispanic male patient who the physician has determined is brain-dead as the result of a severe head trauma. His mother’s and stepfather’s requests are that his organs not be donated for transplantation.

Questions:

What actions should the nurse consider while taking care of this patient?

What knowledge does the licensed nurse need to have about advance directives in this situation?

What rights does the patient’s wife have in this situation?

What ethical values and legal principles should be considered in this patient’s situation?

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