Nursing Case Analysis: 1. First define the ethical theories and principles that use to guide discussions and apply these to the case at hand. The questions will pertain to legal issues or governmental or institutional policies that are not open to discussion. For instance, when discussing legal issues such as negligence or battery there are accepted legal definitions with which students are expected to familiarize themselves. There are also issues that are open to interpretation, such as the constituent elements of consent. Here, for instance, you may take issue with the disputed component of competence, which may be treated as either an element of consent or a threshold notion. Finally, there are opaque, amorphous subjects like autonomy that have an infinite number of facets and may be discussed in different ways, depending on the context and the parties involved. 2. Answer the questions posed as fully as possible and provide adequate references and citations for any supporting sources. (APA 7) NURSING CASE ANALYSIS: Prescribed Opioids for Chronic Pain Chronic pain is a pervasive health issue in Canadian society, not only for patients who have cancer or malignant disease but also for patients who do not. The experience of pain, whatever the cause, can severely diminish quality of life and interfere with daily functioning and performance of routine activities. To address these serious problems, clinicians commonly prescribe opioids. Opioids can be very effective for pain management but they can also have serious negative effects. Indeed, the widespread use (and misuse) of opioids prescribed to address serious health issues has itself become a serious health issue in Canadian society. The Canadian Guideline for Opioid Therapy and Chronic Noncancer Pain (Busse et al., 2017) was developed by researchers at McMaster University funded by Health Canada and the Canadian Institutes of Health Research in recognition of the benefits and dangers of prescribed opioids. The Guideline notes some alarming facts about the use of opioids in Canada: • Canada has the second highest rate per capita of opioid prescription in the world when measured using defined daily doses, and the highest when defined using morphine equivalents dispensed, with more than 800 morphine equivalents per capita in 2011. • Among Ontarians receiving social assistance, 1 of every 550 patients started on chronic opioid therapy died of opioid-related causes at a median of 2.6 years from the first opioid prescription, while 1 in 32 of those receiving 200 mg morphine equivalents daily (MED) or more died of opioid-related causes. • An estimated 2,000 Canadians died from opioid-related poisonings in 2015 and initial numbers for 2016 are higher, with most deaths attributed to fentanyl. • In Ontario, admissions to publicly funded treatment programs for opioid-related problems doubled from 2004 to 2013, from 8,799 to 18,232. (p. E659) In response to these problems, the Guideline makes several recommendations, including “tapering to the lowest effective dose, potentially including discontinuation, rather than making no change in opioid therapy” for “patients with chronic noncancer pain who are currently using 90 mg morphine equivalents of opioids per day” (p. E663). The case below illustrates ethical challenges in managing the use of opioids for chronic pain and in tapering to reduce use. Joan has degenerative disc disease, a chronic condition. At the age of 60, on account of severe back pain, she could no longer work as a nurse. Her family physician referred her to the pain clinic at the hospital where she had been a respected nurse with an excellent record for 30 years. Clinic staff agreed with Joan that the cause of her back problem was occupation related and that repeated heavy lifting during her professional life resulted in her condition. With a combination of opioid medications at 120 mg and a daily exercise plan she was able to live independently for 10 years. Following the publication of the 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain, and in view of media attention to the problem of overprescribing, the clinic changed its policies to be based on best practices for pain management. The nurse practitioner informed Joan that, in her case, this would mean tapering her use of opioids. Joan agreed to a reduction of 5–10 per cent every two weeks, at least until she was taking 90 mg per day. The withdrawal was hard but she persisted. However, after four weeks she reported that she could not manage on the reduced dose. She was in bed most of the day, could not exercise, and needed help with personal care. The nurse practitioner explained to Joan that she had become addicted to prescribed opioids and needed to continue with the tapering program. Joan responded: “If you lived in my body for twenty-four hours you would know that I need the opioids for my life to be worth living. The clinic started me on these drugs and now you cannot take them away. I have this problem because I cared for patients in this hospital. At my age, I do not care if I am dependent on opioids. If you do not provide the prescription, I will have to resort to other, less safe sources for the drugs I need.” CASE QUESTIONS: 1.Some would say that Joan is an “addict.” Do you think this term is accurate or judgmental? What other terms could be used? How would you refer to her need for opioids? 2.Joan reminds the nurse practitioner that the recognized cause of her degenerative disc disease was physical demands of nursing for over 30 years. Do you think that her dedication to patient care should be considered when Joan asks for restoration of her prescription to the level that managed her pain? 3.Nurses are taught to listen to patients when they report the level and type of pain they are experiencing. Have you witnessed patients having their report of pain and need for analgesics dismissed? Present these situations and discuss the ethical issues evident when there is a disagreement about the level of pain and how to manage the pain. How would you respond to Joan’s statement that she needs to return to a higher dose for her life to be worth living? 4.Note that upon reviewing the evidence, the Guideline authors assigned the tapering guideline to the category “weak recommendation,” which they explain as follows: “With weak recommendations, clinicians should recognize that different choices will be appropriate for individual patients, and they help patients arrive at a decision consistent with their values and preferences” (p. E661). They caution that “weak guidelines should not be used as a basis for standards of practice.” In the recommendation itself, they note that “some patients are likely to have a substantial increase in pain or decrease in function that persists for more than one month after a small dose reduction; tapering may be paused and potentially abandoned in such patients” (p. E663). How would you interpret the guideline as applied to Joan’s case? How can the nurse practitioner adequately take into account Joan’s situation and her preferences and values? Joan has implied that if she does not have the prescription for the dose she needs she will buy street drugs, which could be much more unsafe. Should this consideration influence how the nurse practitioner responds to Joan’s request for the higher dose? Materials: Keatings, M. & Adams, P. (2019). Ethical & legal issues in Canadian nursing (4th ed.). Elsevier Yeo, M., Moorhouse, A., Khan, P., & Rodney, P. (2020). Concepts and cases in nursing ethics (4th ed.). Broadview Press
