06P01)
CASE STUDY – CRITICALLY ANALYSING CULTURAL, ETHICAL, MORAL AND LEGAL PRINCIPLES ON CLINICAL PRACTICE
Introduction
In this assignment the author endeavours to critically analyse an incident that happened in a critical care setting, taking cognisance of the cultural, ethical, moral, and legal principles, human rights, patient autonomy and its bearing to clinical practice. According to the Nursing and Midwifery Council (NMC) (2008) section 5.3, “As a nurse, midwife, or nursing associate, you owe a duty of confidentiality to all those who are receiving care. This includes making sure that they are informed about their care and that information about them is shared appropriately”. In this case study, a pseudonym James will be used in adherence to confidentiality. Focus will be on culture, competence, consent, right to treatment/refusal to treatment, confidentiality, and continuity of care in relation to the four main ethical principles, Autonomy, Beneficence, Justice, and Non-maleficence. In conclusion the writer summarises on the findings on the impact of seeing ethical principles.
A paediatric patient, James, has been admitted in a Paediatric Intensive care Unit (PICU), was diagnosed with terminal cancer previously and had been experiencing acute vomiting and pain. The primary was adenoids, then developed into metastasises. A junior doctor on duty decides that he needs to have a Ryle’s tube, Naso-gastric tube inserted without paying attention to the patient’s history. The patient was reluctant to agree to this, but the doctor persuaded him that this would alleviate his symptoms. The hospital team had been made aware that James’s Dad was away from UK on business and would like to be involved in the care of his son. James is well known to the staff nurse present with the doctor as he has had many admissions previously and that passing an NG tube would have needed (Ear Nose and Throat) ENT doctors or an experienced nurse, of which was not known by this doctor neither the patient. This nurse was fully acquainted to James and that he had the capability to consent, but she had failed to inform this present doctor prior to this intervention. She began to ask the doctor to stop the intervention after realising that James was in agony and the doctor had performed three unsuccessful attempts, but, however, the doctor eventually passes the tube successfully. James was left in agony and distress. The intervention traumatised him.
The relevant fact of the situation includes James’s condition and mental ability; the role of the nurse; and contextual features such as the role of the family. James is described as a terminally ill child and his treatment was likely to be palliative. It was unclear whether the doctor’s rationale for the NG tube was justified, compared to the benefits of the intervention. Careful consideration was to have been made whether this intervention outweighs the harm and distress that it may cause than benefits to be reached. It was at least questionable if the doctors’ inability to pass the NG tube three times was due to his inexperience or due to a medical reason. It seems likely that James has mental ability to decide about this intervention. The staff nurse in this situation did not express a view to the doctor about his approach to James but rather supported him to do what he could to alleviate James’ distress by holding down James arms. The contextual features include the fact that James’s father was away from the seriousness of his child’s condition and had expressed the wish to see him before he dies.
In this situation it seemed that this junior doctor had not consulted his Seniors who were known to the patient or the staff nurse. He had just arrived and decided unilaterally to insert the NG tube. It is possible that he was aware of the father’s wish to see his son. The options available in relation to the patient included not to pass the NG tube, having the NG tube passed by a more experienced practitioner or introducing other palliative measures that would alleviate the distress and promote comfort.
The main person who should have been consulted in this scenario was of course the patient. It is unclear if the doctor or staff nurse discussed the intervention options with James and what discussions had been held with the family. The nurse felt that the patient’s views were not heard, and their views were not invited or volunteered. The four principles (autonomy, beneficence, non-maleficence, and justice) illuminate most of the main ethical issues here. The virtues of professional wisdom and courage seem particularly relevant here but had been ignored.
