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Nurses Struggle With Ethical Dilemmas: by Janet Boivin, RN
Nurses Struggle With Ethical Dilemmas: by Janet Boivin, RN
By Janet Boivin, RN
A surgical liaison nurse at Boston Childrens Hospital recently found herself caught between doing what
was best for her patient and his family and the rigid rules of the operating room suite. She followed the
hospitals rules, but then, together with the patients family, helped turn the old policy around by explaining
why the rule needed to change.
The ethical quandary the liaison nurse faced arose when the mother of a baby who was dying asked to be
with him in the operating room. The baby had unsuccesfully undergone heart surgery and could not be
removed from the heart-lung machine. The mother wanted to go into the OR and be with her child when
he died.
The nurse told the mother she could not go into the OR, as anyone would have, says Christine Mitchell,
RN, MS, FAAN, director of ethics at Boston Childrens Hospital and associate director of clinical ethics at
Harvard Medical School in Cambridge, Mass.
The parents were allowed to see their baby after he died and his chest had been stitched back up.
The next day the parents returned to the hospital and paged the liaison nurse. They told her they wanted
to see the baby again before returning home, Mitchell says. The nurse told the family to meet her in the
chapel. She then went to the morgue, warmed the babys body, wrapped him in a fresh blanket, put a
cap on his head, and carried him to the chapel. The parents held their babys body for about an hour,
talking about him and what had happened the previous day. Eventually they said their final goodbyes and
went home.
A few weeks later, they wrote the nurse, thanking her for what she had done for them but restating their
sorrow about not being with the baby when he died.
Still disturbed by the experience, the nurse went to see Mitchell, asking if there was anything that could
be done. Mitchell says she suggested they discuss the experience with the OR governance committee
and the ethics advisory committee. She also asked the nurse to call the babys parents and invite them to
the discussion. The parents accepted the invitation and told the nurses and physicians why she needed to
be with her baby when he died.
We now have a policy that allows parents to be with their children in the OR [in those rare instances
when a child dies in the OR and the parents want to be there], Mitchell says.
Mitchell told this story during her presentation of the Evolution of Moral Responsibility in Clinical Practice
during the Massachusetts Association of Registered Nurses annual spring conference, which focused on
ethics in nursing practice. Nurses, she told the audience, are often caught in the middle between their
many responsiblities to patients, physicians, hospitals, and their units.
This can be a difficult place from which to assess the right course of action, Mitchell says.
In the majority of cases, what patients, their families, and physicians want is the same and does not
conflict, she says. If nurses suspect an ethical issue is developing, they should talk about what they are
experiencing during clinical rounds and with team members to determine what other people think about
the situation at hand.
Is what you think ought to be done in this situation and what others think ought to be done in synch?
says Mitchell.
The trigger word for ethics is ought (or should), as in ought we be taking this particular action or ought
we be making this decision, Mitchell says.
The important thing, she says, is for nurses to listen to their inner voices and ask themselves, Are we
doing the right thing? Pay attention to that voice.
Often nurses are reluctant to openly address an ethical issue, Mitchell says. Instead they will tell the
family what questions to ask the physician or that they should request an ethical consult. This is easier
than confronting physicians directly.
Nurses are more comfortable raising ethical issues when they work in hospitals that value the input of
nurses in determining patient care, Mitchell says.
Mitchell encourages nurses to think in ethical terms and says it took her a long time to do so. I hope it
doesnt take new nurses as long as it took me to figure out what we ought to be doing.
Patient advocacy alone is not enough to do what is best for patients. When you intensify time and
relationships with patients, you get to the heart of things that patients and family are really dealing with,
she says.
Early in her nursing career, Mitchell cared for a boy with leukemia whose parents forbade the staff to tell
him about his diagnosis. As she came to know the boy better, he one day said he was glad he didnt have
a life-threatening disease such as leukemia. Wouldnt it be awful if I had something like leukemia?
Mitchell says the boy told her. I was horrified. I had no idea what to say.
What Mitchell said was something like, What makes you say that?
Mitchell calls this attempt to avoid anwering the question the nursing duck.
We used to just duck the hard, ethical questions because we were not sure what nurses responsibilities
to patients were when it came to telling and talking about their diagnosis and prognosis, she says.
Today she would respond differently. I should have replied, Are you scared and do you want to talk about
it? I had only that moment to talk to him. I could clean up the mess later.
Science and technology tend to drive the ethical issues nurses encounter in their practice, in part because
technology is often assumed to be beneficial to patients without hard evidence to prove it.
New technologies that are already causing ethical questions include ventricular assist devices and
preimplantation genetic diagnosis, Mitchell says.
Ethics involve doing good and causing no harm. But how one defines what is
ethical can vary differently from nurse to nurse. Classes on the principles of ethics
give the nurse the tools to base ethical decisions upon. However, this knowledge is
then shaped by the values, beliefs and experiences of the nurse. Consequently, very
different choices may be made involving the same dilemma.
There are many ethical issues nurses can encounter in the workplace. These include
quality versus quantity of life, pro-choice versus pro-life, freedom versus
control, truth telling versus deception, distribution of resources, and empirical
knowledge versus personal beliefs. Quantity may address how long a person lives
or perhaps how many people will be affected by the decision. Quality pertains to
how good a life a person may have and this varies depending on how a person
defines good. So how does the nurse support a patient deciding between a
therapy that will prolong life but the quality of life will be compromised? The person
may live longer, but will likely experience significant side effects from the therapy.
What should the nurses position be?
supports the family members choice and still be supportive of the patients
and familys right to this decision?
Nurses are faced daily with ethical dilemmas in which they must make a decision.
The decisions they will make will be affected by so many factors including principles
learned in school and their own personal beliefs, values and experiences. Are these
choices right or wrong?