In the selected hypothetical situation, the patient, Mrs. Rodent, is going through a difficult treatment, and she is often in pain. Mrs. Rodent has a daughter who visits regularly, but the patient is reluctant to share her treatment experience with her daughter. In a conversation with one of the nurses, Mrs. Rodent says that she is uncomfortable with her daughter seeing her in such a situation; the patient does not want to look fragile and vulnerable to her family members. Although Mrs. Rodent did not explicitly say to the nurse that she wanted to keep the information secret, it was clear that Mrs. Rodent did not want this information to be shared with her daughter.
In a different conversation with the same nurse, the patient confessed to having suicidal thoughts. Mrs. Rodent is 67 years old, and she is diagnosed with a terminal disease; however, the prognosis is that, upon receiving the current treatment, Mrs. Rodent will live for three to five more years; cases are known in which patients with the same diagnosis lived for more than ten years. Upon confessing, the patient not only avoided asking for psychological assistance to address her suicidal thoughts but also asked the nurse, this time explicitly, not to tell anyone about these thoughts.
The presented case involved several ethical issues from the perspective of the nurse. Primary concerns are the principles of nursing ethics and the concept of patient advocacy. The latter suggests that a nurse should act and speak to other members of the health care team on behalf of the patient and protect the patients’ interests; however, the concept is challenging, and there is no consensus among researchers and practitioners concerning the appropriate form of advocacy or the appropriate extent of it as part of nurses’ scope of practice (Cole, Wellard, & Mummery, 2014). To examine the presented case, a certain ethical perspective needs to be adopted.
Bioethical Decision-Making Model
An example of such an ethical perspective is the bioethical decision-making model. Bioethics deals with ethical issues in the areas of “medical and biological research and clinical practice…[including] issues of individual care and broader concerns such as access to health care, confidentiality, genetic testing, and resource allocation” (Husted, Scotto, Wolf, & Husted, 2015, p. x). According to Levine-Ariff and Groh (1990), the first step in the bioethical decision-making model is to define the dilemma.
In the presented case, the dilemma of the nurse is whether to tell other members of the health care delivery team about the patient’s family support issues and suicidal thoughts and thus fulfill the role of an advocate or to refrain from telling them anything and thus follow the patient’s request to keep it secret.
The medical facts relevant to the dilemma need to be identified in the model’s second step. It is a medical fact that the patient is terminally ill, and the prognosis is that the patient only has three to five years left to live, although it is known that sometimes people diagnosed with Mrs. Rodent’s disease lived ten and more years. Also, it should not be overlooked that the treatment Mrs. Rodent receives is a medical fact, too; her current treatment is rather difficult, as she receives medications that seriously affect her body, and several adverse effects occur, including fatigue, nausea, and occasional numbness; also, the patient is often in pain.
Further, non-medical facts need to be identified; a primary and relevant non-medical fact is the lack of family support. Mrs. Rodent’s daughter demonstrates a willingness to support her mother, and she talked to nurses repeatedly to ask how she could be more engaged. However, the patient is reluctant to receive support, and this reduces her comfort, which, according to Kolcaba (2015), should be ensured for her by identifying and addressing her needs properly.
However, it should be recognized that the lack of patient comfort is an assumption rather than a non-medical fact. Decision-making can often be guided by assumptions that can be misleading; to avoid this, assumptions should be tested and either confirmed or disconfirmed (Husted et al., 2015). The assumption can be tested by having a conversation with the patient to explain the benefits of family engagement and to suggest that the participation and support of her daughter can improve Mrs. Rodent’s experience of coping with her treatment. This will be the action aimed at clarifying the current situation and thus improving further decision making. However, such a conversation may be regarded as a nursing intervention.
Another component of the model is identifying external influences in the decision-making process; in the presented case, an external influence is the code of nursing ethics. The facility in which Mrs. Rodent stays adopted the standard ethical principles in its regulations of nurses’ work; this regulation—the requirement to respect patients’ own decisions particularly—will affect the decision that the nurse will eventually make.
Mrs. Rodent is often in pain, and her treatment is difficult, which is why it can be said that her decision making can be affected by the vulnerability of her state. However, she is still regarded as the decision-maker in the presented case, and there is no reason to consider her incapable of making informed and responsible decisions.
A conflict between two principles of nursing ethics is evident: autonomy and nonmaleficence. When acting as a patient’s advocate, a nurse may often face such dilemmas because the identified best interests of a patient (the interests that an advocate should serve) may conflict with the patient’s own care-related decisions, and a nurse cannot ignore those decisions according to the principle of autonomy (Cole et al., 2014). Since Mrs. Rodent asked the nurse to keep the confession about suicidal thoughts secret, refraining from telling other nurses and physicians about this will comply with the principle of autonomy. Moreover, it will not technically violate the principle of advocacy because the patient did not ask the nurse to convey her (the patient’s) concerns to other care providers.
However, there is an alternative decision. The nurse may decide that the information is too important for the treatment to be kept secret. If other care providers do not know that Mrs. Rodent has suicidal thoughts, they may fail to provide necessary additional support and assistance. The patient’s state will only deteriorate because of this. Therefore, being guided by the principle of nonmaleficence, the nurse may opt for violating the principle of autonomy and telling the truth to other nurses and physicians. The process will involve a confidential conversation with them and discussing what should be done; the question of whether Mrs. Rodent will be informed about her care providers’ awareness of her suicidal thoughts or not is to be answered upon having this conversation.
Discussion of Nurse Advocacy
The role of a nurse as an advocate remains unclear, and one of the reasons for this is that identified patient needs may be remarkably different in different cases. As Mrs. Rodent’s advocate, should the nurse convey the patient’s concerns to other care providers? If yes, the principle of autonomy will be violated; however, if no, the principle of nonmaleficence may be violated. Additional clarification is needed (such as talking to the patient) to ensure that the nurse will make an ethical decision.
Cole, C., Wellard, S., & Mummery, J. (2014). Problematising autonomy and advocacy in nursing. Nursing Ethics, 21(5), 576-582.
Husted, G. L., Scotto, C. J., Wolf, K. M., & Husted, J. H. (2015). Bioethical decision-making in nursing (5th ed.). New York, NY: Springer.
Kolcaba, K. (2015). Katharine Kolcaba’s comfort theory. In M. C. Smith & M. E. Parker (Eds.), Nursing theories and nursing practice (4th ed.) (pp. 381-391). Philadelphia, PA: F. A. Davis.
Levine-Ariff, J., & Groh, D. H. (1990). Creating an ethical environment. Nurse Managers’ Bookshelf, 2(1), 41-61.