Personal Values And Beliefs

Isaac Livingston had led a good life. He had worked as a pharmaceutical salesman for 45 years
before retiring 6 years before his most critical medical problems began. Now, at 72, he was
hospitalized for what the nursing staff suspected might be his last time. He was suffering from
carcinoma of the prostate that had metastasized to the bone and sapped his strength. His current
hospital admission was triggered by several episodes of fainting, undoubtedly related to a serious
drop in blood pressure. The pain of the tumor, the side effects of the medication (Dilaudid, 4 mg
q 3–4 hours as necessary and chlorpromazine 10 mg qid as needed for nausea from the
chemotherapy), and his lethargy combined to make him somewhat groggy. Moreover, Mr.
Livingston often desired to get up and leave his room “to get some air” as he put it. To make
matters worse, Mr. Livingston suffered from a partial paralysis of the left leg of some 15 years’
duration, apparently caused by spinal cord damage related to pressure from a spinal disc. All of
these facts led the nursing team to be concerned about potential injury should Mr. Livingston fall
getting out of bed.
To protect him from such injury, Mr. Livingston was placed in a room across from the nurses’
station. His bed was lowered as close to the floor as possible, he was observed closely, his bed
rails were raised at night, and he was instructed to press his call button to summon the nurse or
nurse’s aide whenever he wanted to get out of bed. Despite these precautions, however, the
nurses frequently found Mr. Livingston trying to get out of bed by himself without help. His
safety became a serious issue the night Ms. Howard found Mr.Livingston on the floor at 1:00
A.M. Apparently, he had slipped to the floor while trying to get out of his bed. He was not
injured, but he could easily have suffered some injury. To€ prevent this from happening
again, Ms. Howard told Mr. Livingston that he absolutely could not leave his bed without
someone else being present, left a light on in his room at all times, and moved his bed so that he
could not get out of it without observation by the nurses. During the next day, Mr. Livingston
vociferously objected to having to wait for a nurse or aide in order to get out of bed, use the
toilet, or walk in the hallway—something he wanted to do quite frequently. Although he
understood that these precautions were intended for his own good and that the nurses thought it
was dangerous for him not to have someone accompany him when he was out of bed, Mr.
Livingston intensely disliked all the constraints to his freedom. That evening, Ms. Howard was
approached at the nurses’ station by Mr. Livingston’s son during visiting hours. The son
explained that Mr. Livingston had been trapped in a burning building when he was a child and
since then had been severely afraid of suffocating or being enclosed or otherwise confined in
small rooms. He needed to be able to get out of bed and leave his room whenever he felt
confined. Were the nurses’ constraints on his freedom absolutely necessary?
This explained some of Mr. Livingston’s behavior, but Ms. Howard was still seriously concerned
about the danger to a 72-year-old man, groggy with medication and partially paralyzed, falling as
he attempted to get out of bed. It was her judgment that continued use of the protective measures
were indicated for good nursing practice and Mr. Livingston’s safety. Ms. Howard explored her
options. She could follow Mr. Livingston’s urgent request that he be allowed to get out of bed
without assistance whenever he felt like it. Or she could insist that, in her clinical judgment,
good and safe nursing care required nursing assistance and close observation. Then again, she
could ask for guidance from the resident on call or ask that Mr. Livingston’s physician be
consulted in the morning for an increase in the patient’s sedation, which would make it unlikely
that Mr. Livingston would try to get out of bed for any reason.

1. During treatment, explain the physical and mental evaluation of the patient that must be
carried out by the nurse (Explain based on the data in the case)
2. Describe the history of events that underlie the formation of Mr Livingston's values and
behaviors
3. Describe the intervention against Mr Livingston's wishes
4. Explain the aspects of autonomy that exist in the case