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Friday, 11 November 2011

Nursing Case Study – Ethical Conflict

She has been in the hospital for 10 days and she is finally scheduled to be discharged today. She is very excited to go home. She was admitted in the hospital due to bowel obstruction which was spontaneously resolved.


 


I accidentally walk past her bedroom today and heard her vomiting. When she saw me, she begged me not to tell anyone because she really feels all right and she just don’t want that to stop her from going home. For one moment, I hesitated.


 


I was trained to serve for the best health interest of my patients. The dilemma begins when their interests aren’t really the best for their health. Though I, as a person, completely understand that they have their reasons for whatever their interests are, we, medical practitioners often find ourselves in crossroads between following the policies or believing the patients who feel themselves better.


 


 


Bowel Obstruction


 


According to the book “Small-bowel obstruction: optimizing radiologic investigation and nonsurgical management”, Bowel obstruction is a mechanical or functional obstruction of the intestines, preventing the normal transit of the products of digestion. It can occur at any level distal to the duodenum of the small intestine and is a medical emergency. Although many cases are not treated surgically, it is a surgical problem.


Symptoms of bowel obstruction depends on the intensity of the obstruction. It might trigger the patients abdominal pain, abdominal distension, vomiting, fecal vomiting, and constipation.


It may be present within the bowel lumen, within the walls of the bowel, or outside the bowel (such as compression, entrapment or volvulus). (Maglinte et al., 2001)


Moreover, bowel obstruction may also be accompanied with dehydration and electrolyte abnormalities due to vomiting; respiratory compromise from pressure on the diaphragm by a distended abdomen, or aspiration of vomitus; bowel ischaemia or perforation from prolonged distension or pressure from a foreign body. (Maglinte et al., 2001)


The book also sited the difference of the small bowel obstruction and large bowel obstruction. In small bowel obstruction the pain tends to be colicky (cramping and intermittent) in nature, with spasms lasting a few minutes. The pain tends to be central and mid-abdominal. Vomiting occurs before constipation. While in large bowel obstruction the pain is felt lower in the abdomen and the spasms last longer. Constipation occurs earlier and vomiting may be less prominent. Proximal obstruction of the large bowel may present as small bowel obstruction.


There are couple of ways to diagnose this illness. It is normally confirmed through blood tests, X-rays of the abdomen, CT scanning and/or ultrasound. If a presence of mass inside the abdomen is identified, biopsy is also one of the most common ways to measure the nature of the mass.


Radiological signs of bowel obstruction include bowel distension and the presence of multiple (more than six) gas-fluid levels on supine and erect abdominal radiographs. (Maglinte et al., 2001)


Contrast enema or small bowel series or CT scan can be used to define the level of obstruction, whether the obstruction is partial or complete, and to help define the cause of the obstruction.


According to a meta-analysis of prospective studies by the Cochrane Collaboration, the appearance of water-soluble contrast in the cecum on an abdominal radiograph within 24 hours of oral administration predicts resolution of an adhesive small bowel obstruction with a pooled sensitivity of 96% and specificity of 96%. (Maglinte et al., 2001)


Other diagnostic operations are colonoscopy, small bowel investigation with ingested camera or push endoscopy, and laparoscopy.


Most cases of Bowel obstruction require operative treatments. Maglinte sited in his book that frequently, the surgical intervention and the treatment of the causative lesion are required. In malignant large bowel obstruction, endoscopically placed self-expanding metal stents may be used to temporarily relieve the obstruction as a bridge to surgery, or as palliation.


However, there are some causes of the illness that resolve spontaneously.


Patient’s condition


She has been under medication for ten days. The illness was proven to resolve spontaneously, which, apparently, is the reason of her early discharge from the hospital. There has been no treatment which was mentioned to have been applied to the patient the whole time she was confined to the hospital. It is clear, that the bowel obstruction subsided on its own.


However, the vomiting is, as mentioned earlier, a sign or a symptom that the illness have not resolved yet. Although, in most cased the patient itself claims to feel all right and well, a nurse, or a medical practitioner should always check the appropriate symptoms based on how he or she was trained as a medical practitioner, before yielding to whatever the patient wishes or says.


The patients’ health is not his or her sole responsibility. It is a shared responsibility of the government and the medical practitioners.


In a book written by Fleming, Health Promotion: Principles and Practice in the Australian Context, she defined public health in the Australian Context.


“The Australian Public Health Association (1997) defines public health in a similar way to last as:


… a combination of science, practical skills, and beliefs that is directed to the maintenance and improvement of the health of all people. It is one of the efforts organized by society to protect, promote and restore the people’s health through collective or social actions.” (Fleming and Parker, 2001)


The Australian Health Administration Act 1982 sec 22 or Disclosure of Information states that:


If a person discloses any information obtained in connection with the administration or execution of this Act or any other Act conferring or imposing responsibilities or functions on the Minister, Department, Director-General, Corporation or Foundation and the disclosure is not made:


(a) with the consent of the person from whom the information was obtained,


(b) in connection with the administration or execution of this Act or any such other Act,


(c) for the purposes of any legal proceedings arising out of this Act or any such other Act or of any report of any such proceedings,


(d) with other lawful excuse, or


(e) in any other prescribed circumstances,


that person is guilty of an offence against this Act and, on conviction by a court of summary jurisdiction, liable to a penalty not exceeding 10 penalty units or to imprisonment for a term not exceeding 6 months.


 


In this case, concealing of information such as a symptom which is present on the patient for discharge is an act against the health department.


 


‘Act always in such a manner as to promote and safeguard the interests and well-being of patients and clients’ is the first and central statement of the nurse’s Code of Professional Conduct and at first sight seems to embody what every nurse firmly believes in. (Hunt, 1994)


 


Let’s examine the possible outcome of this scenario if information such as this are concealed. Patients will go home untreated. Later on, complexities will arise. More or severe illness will follow, and in worst cases, death may even be the result of tolerating secrecy between patients and attending medical practitioners. The impact will both be devastating to the health department and to the patient’s or family’s patients as well.


 


As a medical practitioner, it is a duty to report every important detail of either the recovery or worsening of their patients.


 


This act will sure halt the scheduled discharge of the patient. However, decision may always be in favor of the patient’s health, but not might not sound as pleasing to them as it should be.


 


Ethical Concerns


 


The patient asked for a disclosure of the symptoms. The patient would like to keep that particular piece of detail, since according to her, that wouldn’t be a big problem nor would create a problem because she feels good to go.


 


 


The choice between right or wrong is always a tough one. Right and wrong is not a natural knowledge which we biologically inherited when we were born. It is mandated by the culture, and by the society we are brought up in.


 


“–cases that can be paradigms of either right or wrong conduct. In either instance, the case represents very strong and widely accepted judgments to the effect that this particular conduct in these particular circumstances is right or wrong. The idea here is that our notions of right or wrong grows out of actual experiences of exemplary conduct, and thus are not the result of theoretical speculations about the nature of ‘the good’ and ‘the right.’ While the paradigm case serves, then, as the objective source of our substantive notions of right or wrong, the judgment that the case elicits represents the moral sensibility that guides the professional casuist.” (Blake, 1992)


 


 


Utilitarianism can also be the grounds of deciphering the right act from the wrong. Most countries in the west were adapting utilitarianism, which is prescribed as “the greatest good for the greatest number”.


 


Since this would not apply to this situation, because the only interest we have is the patient and there is no “common good” given in the situation, let’s dig deeper to other kinds of utilitarianism. Because of the absence of the “common good”, we can now use the law of “lesser evil” or Negative utilitarianism (NU) requires us to promote the least amount of evil or harm, or to prevent the greatest amount of suffering for the greatest number.


 


Conclusion


 


Non-disclosure of the information will give the patient what she wishes. A time well-spent in the family. However, a few days later, the patient might still go through the same symptoms. Vomiting, constipation, abdominal pains and all the she would probably don’t want to feel again.


 


On the other hand, disclosure of the information will, the same way, add an amount of suffering for staying a few more days inside the hospital, and probably having to go through a more painful operation and dialysis in order to be treated. However, this would end the illness and will never let the patient have to go through all these again.


 


Both ways will inflict pain and suffering. Both will have to have the patient to be confined in the hospital. The only difference is time. The patient might be discharged today and will come back at a later time for the same reason, or the patient will not be discharged today but won’t come back in the later time.


 


But time is an important element in recovery. If the patient will not be treated today, possible complexities will arise. That will cause more suffering and pain to the patient. Therefore, it is best to disclose the information to the attending physician so he or she can decide the best way to cure the patient. It is at the same time what was mandated by law.


 


Physicians have special competence in many areas of social importance, from abortion and drug addiction to the psychiatric effects of military combat. The increasing tendency to view competent medical practice as necessarily dealing with the whole person, not simply with his damaged liver, heart, eyes, spleen, stomach, or kidneys, means that physicians must deal with ethical problems in relation to social situations. (Visscher, 1972)


Books:


Visscher, M.B. (1972) Humanistic Perspectives in Medical Ethics. New York: Prometheus Books.


 


Maglinte, D.D., Kelvin, F.M., Rowe, M.G., Bender, G.N. and Rouch, D.M. (2001). “Small-bowel obstruction: optimizing radiologic investigation and nonsurgical management”. [Electronic Version] Radiology 218 (1): 39-46.


 


The Cochrane Collaboration. The Cochrane Manual Issue 1, 2008, section 2.2.5.4 COCHRANE LIBRARY FEEDBACK HOUSE RULES [updated 15 November 2007]. (http://www.cochrane.org/admin/manual.htm) (accessed 12th December 2007])


 


Hunt, Geoffrey. (1994) Ethical Issues in Nursing.  London and New York: Routledge.


 


Journal:


Blake, D.C. (1992) The Hospital Ethics Committee: Health Care’s Moral Conscience or White Elephant? The Hastings Center Report, Vol. 22.


 


Websites: www.austlii.edu.au/forms/search1.html



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