Contoh Kasus :

Jean W. is a labor and delivery room nurse in a small community hospital that serves both private
clients and clinical clients. Jean has always felt that certain members of the obstetrics-gynecology
medical staff have treated these two groups of clients differently. On this particular morning Jean is
caring for a woman who is scheduled for an elective cesarean delivery. The woman (who is a clinic
client) has made it very clear that she wants to be awake for the delivery and has requested
epidural or spinal anesthesia. Jean is dismayed when the anesthesiologist enters the delivery room
because the anesthesiologist’s success rate with epidural anesthesia is poor. The anesthesiologist
unsuccessfully attempts to perform an epidural block. After waiting 20 minutes for results, the
obstetrician is growing impatient and instructs the anesthesiologist to put the client to sleep. After
waiting 20 minutes for results, the obstetrician is growing impatient and instructs the
anesthesiologist to put the client to sleep. Jean feels the right of this client are being violated but is
unsure of what her response should be.

Step 1: Asses the situation (gather data)

Describe the situation that gives rise to the problem: main people involved (their views and
interests; client’s overall nursing, medical, and social situation; relevant legal, administrative, and
staff considerations)
The client is in stable medical condition (elective SC,not an emergency) and has made it very clear
that she wishes to be awake for the delivery The client is not a private paying client of the
Obstetrician. The nurse believes her role is to promote/protect the client’s interest; she knows of no
reason in this case why the client’s preferences should be disregarded. The anesthesiologist has a
poor success record with epidural anesthesia.
The obstetrician seems to want to complete delivery quickly. In the past, he has seemed to give
more weight to following wishes of private clients as opposed to clinic clients. He is the head of the
OBY dept. He believes nurses should obey physicians unquestioningly.Nurses have in the past
expressed dissatisfaction with the different levels of care being provided to private and clinic client,
but no one to date has formally addressed the concern.

Step 2: Diagnose (identify) the ethical problem

State the problem clearly; unsure of ethical issue; two or more moral principles are in conflict; object
to proposed course of action. Identify your relationship to the decision. Identify time parameter.
Jean W. objects to the obstetrician’s intent to disregard the client’s wish to be awake for her
delivery; she is aware of no good reasons justifying this course of action. The nurse will be a
participant in carrying out the decision. The decision for this care must be made immediately; it
would be helpful to plan to avoid situations like this in the future.

Step 3: Plan
a. Identify options
Identify all the possible courses of action open to you and weigh the outcomes of each;
Consider immediate consequences to the people involved as well as long-term consequences
to the institution and society
 The nurse can say nothing to the obstetrician and help with the delivery. If asked by the client
later why she needed to be put to sleep the nurse can (1) tell the truth; (2) refer her to the
obstetrician; (3) express sympathy that she could not be awake, or (4) say nothing.
Outcome: the client’s wishes are disregard
Delivery occurs in record time and the obstetrician is happy The nurse fulfills obligation to
physician and hospital but feelsshe has betrayed the client’s trust. Long-term outcome: there is
a good probability the same problem will happen again.
OR...
The nurse can remind the obstetrician that the client was adamant about wanting to be awake
and suggest that a different anesthesiologist be called in. If the obstetrician agrees, the client
may get her wish and everyone is satisfied with the outcome (the nurse must still decide how to
prevent recurrence of this dilemma). If the obstetrician refuses and insists that the client be
put to sleep, the nurse can (1) refuse to participate (if another nurse is unavailable or unwilling
to replace her,the nurse has abandoned the client and harm may e to see how to ensue); or (2)
participate and proceed as above or resolve to speak to the obstetrician in a ‘cool moment’ after
the delivery to see how to avoid this problem in the future.
If the nurse does not get satisfaction with the obstetrician, then she must decide whether to
move through the proper administrative channels. Depending on the institution and people
involved, the nurse may be affirmed or censored for this move. Long-term outcome: future client
may be helped by the nurse following through with her concerns.
OR
The nurse can say nothing and assist with this delivery, believing it to be the wisest course of
action for the time being, but resolve to take the steps above to correct the perceived injustice.
Outcome: there is no benefit for the present client but potential benefit to future clients.

b. Thinking the Ethical Problem Through

See if conventional principles of professional ethics address and resolve the problem; if not,
see if broader ethical principles and theories clarify and resolve the problem. Rely on those
principles you judge most important and of which you feel most sure.
Basic moral principles: the good of clients (beneficence)
should be the nurse’s primary concern; this strongly suggests that the nurse should do act, but it
does not address the nurse’s obligation to do so if she feels it would jeopardize her own good
(job security).
Respect for persons would suggest that client’s autonomy (right to self-determination) should
be respected unless there is strong justification for not doing so.
Justice would suggest that whether a client pays the obstetrician privately should have no
bearing on the quality of care received.
Care-based ethics would obligate Jean to serve as an effective advocate for her client,
respecting the nurse’s commitment to be faithful to the nurse-patient relationship.

c. Making Decision
Choose a course of action that best reflects your considered judgment; consultation with an
institutional ethics committee or other staff may be helpful.
 Jean W. feels from past interactions with this obstetrician that her speaking up will not
influence his decision to have the client put to sleep. She decides to speak with the obstetrician
after the delivery and follow up with whatever approach is necessary to avoid recurrence.

Step 4-5:
Implement and Evaluate Your Decision
Act and compare the actual outcome with what you considered and hoped for in advance.
How can you improve the decision process next time?
Jean W. will never know if speaking up would have resulted in the client’s wishes being
respected.
Although she is dissatisfied with the outcome of this case, she hopes to prevent this from
happening to other clinic clients in the future. In this instance, a hospital committee was formed
to study the problem and make recommendations.
If Jean W. had been told to ‘mind her own business’ unless she wanted trouble, she would have
to make a decision weighing client benefit on one hand with potential personal risk or harm on
the other.

Purpose

The nurse’s role includes assisting patients, families, surrogate decision-makers, and health
care team members in the process of making informed
choices regarding do-not-resuscitate orders. It is important to note that considerations for
do-not-resuscitate orders can happen at any time in the course of a patient’s care, not only at
the end of life.
Practice guidelines exist regarding effective cardiopulmonary resuscitation.
Performing resuscitation that is inconsistent with this evidence-informed practice risks
challenges to professional integrity as well as potential harm to patients.
In addition, there still exists confusion regarding do-not-resuscitate orders and related
terminology.
This statement provides ethical guidance for nurses in the do-not-resuscitate decision-making
process and makes recommendations for clinical and policy change.

Statement of ANA Position

Nurses advocate for and play an active role in initiating discussions about resuscitation with
patients, families, and members of the health care team.
Care for patients with do-not-resuscitate orders is no different from care for any other patient,
including respect and advocacy for the patients’preferences and values, promotion of
well-being, and alleviation of suffering.
Patients with do-not-resuscitate orders must not be abandoned, nor should these orders lead
to any diminishment in quality of care.
Nurses’ holistic view of patient and family care prepares them to collaborate with the patient,
family, and health care team to promote informed decisions when do-not-resuscitate decisions
are made.
Selengkapnya lihat di dokumen
Position statement (ANA, 2020)