Factors Affecting Patient Outcomes
There are numerous dynamics that affect a patient’s health care outcomes. Nurses and doctors should be aware of these factors all the times while assessing a patient’s condition. These factors include ethical theories and principles, legal aspects, assessment, analysis and intervention skills, reasoning skills and the general knowledge of medicine. Nurses should also be able to relate well with patients as well as possess quality communication skills (Bramhall, 2014). This case study seeks to outline the necessary ethical and legal issues applicable to nursing and medical health care. Ethics involve the integral and competent aspects of nursing professions. Ethics outline what nurses should do to cure patients, how and why they should do it (Epstein & Turner, 2015). Nurses need to abide to a specific code of conduct while administering treatment methods to patients. Laws are the rules that bind together people in a society, organization or certain professions. There are several rules and regulations that guide nurses in professional organizations (Barloon & Hilliard, 2016). There are some activities, if carried out by nurses, are considered to be illegal. Therefore nurses need to ensure that they adhere to the legal guidelines at their disposal. Illegal acts in the nursing profession definitely attract penalties such as imprisonment. Nurses should ensure that every activity that they undertake while treating patients is cognizant with the ethical and legal aspects of nursing profession. In this case study a medical issue regarding Jo, a 46 year old woman with upper abdominal pains, was presented at the rural accident and emergency department with her partner. Therefore an assessment relating to ethics and law within the nursing profession is the main focus of this assignment.
Jo, a 46year old female, presented herself to the emergency department complaining of upper abdominal pain. Jo was firstly triaged by the registered nurse and her vital signs and pain score were noted. Jo’s temperature was 37.2, pulse 96, respiration 16, BP 136/86 and her pain score was six. Jo had also experienced nausea and abdominal bloating. Jo had also been taking Mylanta for the indigestion in the past year. She had a urine sample tested by the registered nurse and this had no abnormalities therefore the nurse requested the doctor’s immediate attention. However, the doctor had to attend to an accident victim therefore wasn’t able to attend to Jo immediately. Jo vomited dark coffee ground fluid two hours after her admission to the emergency department. Her pulse was rising and her blood pressure falling. Jo was assessed by a more senior doctor who inserted an intravenous line, a full blood count and group and hold. Jo was prescribed Pethidine 100mg and Maxolon 10mg by the doctor for her pain and nausea. This pain relief made Jo drowsy and she vomited coffee ground fluid once again. The nurse monitored Jo’s signs consistently before she was referred to the theatre for an endoscopy procedure.
Patient Assessment and Treatment: Nursing and Legal Implications
In this situation, there are several instances where the doctor or the nurse would have taken action on the patient but they failed to do so thereby not abiding to certain laws and ethics principles. When Jo was triaged by the registered nurse (RN), key screening tests and the possibility of a menopause commencement was not checked. It is very necessary to know about the symptoms that might initiate menopause in a woman in her mid-40s (Bernstein, 2016). However, neither the nurse nor the doctor requested for a screening on Jo for a possible menopause taking effect. Even though it is not clearly stated what really caused Jo’s deterioration, there certain things that nurses can do in order to prepare for an impending patient deterioration.
Nurses can use Track and Trigger Systems such as Modified Early Warning Score to detect an imminent deterioration of a patient’s condition (van Galen, et al., 2016). However, these methods have not really been proven to be very effective. In many cases, the causes of decline in patients’ conditions are never known. The nurse assessed Jo’s vital signs and concluded that she needed immediate attention of the doctor. There had been a motor cycle accident and the driver of the motor cycle suffered serious leg and chest injuries therefore Jo had to wait due to shortage of staff in the emergency centre. The doctor and nurses had opted to attend to the patient involved in an accident over Jo. The doctor did not violate any law or ethical principle by choosing to attend to the deteriorating patient first (Australian Commission on Safety and Quality in Health Care, 2014).
When Jo’s condition began to deteriorate, all attention was turned to her just like the doctor had chosen to attend to the accident victim before. The patient whose condition is worse at the time of admission is given priority. Even though giving priority to the patient with the worst condition is right and legal, the nurse or even the doctor should have at least prescribed some pain killers to Jo to ease the pain. Having noticed that Jo required the doctor’s immediate attention, the nurse should have used her knowledge of medicine to prescribe medication to Jo as she waited for the doctor. In the emergency department, the patient is assessed by the triage nurse upon arrival and based on the assessment a triage priority number is allocated to the patient. The number ranges between one and five whereby one is for patients who need to be attended to immediately and five is for patients who need action within two hours. In this case study Jo was not allocated a priority number however, the nurse indicated that she needed immediate attention. She was forced to wait even longer than the conventional time. Shortage of staff in the emergency centre delays the administration of apt and appropriate care to patients attending the emergency department. Shortage of staff also delays the initiation of interventions and medical care to patients (Bradley, et al., 2015).
Patient Deterioration and Triage Priority Number
In line with Jo’s case study, an ethical dilemma is evident as the anaesthetist encountered difficulty maintaining Jo’s saturations in theatre during the endoscopy procedure. Ethical dilemmas comprise of situations whereby a choice must be made from the available options that can be justified as the unsurpassed choice considering the situation (Beauchamp & Childress, 2013). In this situation the anaesthetist has decided to carry on with the endoscopy procedure despite Jo’s saturations proving to be beyond control. The anaesthetist perceived that the Jo had vomited at emergency department prior to admission at the endoscopy department. However, the anaesthetist had an option of checking with the nurse to confirm about the assessment of the medical situation and need for the endoscopy.
Jo’s vital signs required immediate attention of the doctor. The code of ethics also obliges nurses to provide high quality care to the patients they handle (Zahedi, et al., 2013). Even though these codes are obligatory to patients, they guide and support nurses in their practice of medicine and helps them to avoid moral anguish. The codes also outline the relationship that nurses should maintain with their patients. In Jo’s situation, it is the nurse’s and doctor’s duty to provide quality care to the patient. Jo has upper abdominal pain, nausea, abdominal bloating and a history of indigestion. While assessing the patient the nurse did not provide a treatment plan for the symptoms evident in Jo.
Autonomy is the ability of nurses to act according to their professional knowledge while administering clinical care to patients (Kumar & McHugh, 2017). However, autonomy does not just apply to nurses. It is the ability to make informed decisions therefore patients can also find themselves in a position whereby they have to make a decision. The patients are accorded the freedom of consent which enables them to make decisions during emergency situations. Both Jo and the doctor exercised their autonomy in this situation. When Jo was taken to the theatre for an endoscopy procedure, she had to consent before the emergency procedure was carried out on her (Staunton & Chiarella, 2016). The doctor used the professional knowledge of medicine to prescribe Pethidine 100mg and Maxolon 10mg to Jo after looking at the vital signs and symptoms. This is definitely an exercise of autonomy.
Beneficence refers to the act of doing a good thing and its main intention is to carry out affirmative actions to patients. It proclaims an obligation to physicians of helping patients. In this case study, the nurse monitored Jo’s vital signs consistently. This is an act of benevolence since the patient’s deterioration is preceded by changes in vital signs. Monitoring the patient’s vital signs consistently helps in detecting an impending clinical deterioration and providing appropriate nursing intervention (Watkins, Whisman, & Booker, 2016). In Jo’s case study, the nursed assessed the patient and came up with certain vital signs before concluding that she required immediate attention of the doctor. The nurse’s actions are very right considering that the doctor was updated on the patient’s condition at the time of treatment. The anaesthetist performed an endoscopy procedure on Jo in order to find out the problem with her abdomen.
Ethical Dilemmas in Nursing
According to the principle of beneficence, a doctor has the duty of care towards a patient and he/she has to ensure that the condition of a patient is stabilized. In case of an emergency situation, the doctor does not have to seek the patient’s consent before performing a necessary intervention. However, Jo’s consent was sought before she was taken to the theatre for an emergency endoscopy. In a perilous situation, emergency treatment can be undertaken in line with the doctrine of necessity and consent is not obligatory during a life-threatening situation (Leung, 2014). Beneficence also refers to doing a good thing by valuing a patient’s decision. Therefore, if Jo had rejected the emergency endoscopy the anaesthetist would have no choice but to respect her choice even if it would mean that her condition would worsen.
Non- maleficence refers to the ability of nurses or doctors to avoid causing harm to patients. Non – maleficence also refers to not causing harm by not disclosing vital information (King, 2017). In this case, however, Jo does not make any request about any information not to being revealed to her partner. The principle of non-maleficence aims at providing the best medical care to patients as nurses strive to offer quality services in order to stabilize a patient’s condition (Beauchamp & Childress, 2013). When Jo was referred to the theatre for an emergency endoscopy procedure, the anaesthetist found it difficult to control the patient’s saturation levels. The anaesthetist did his/her best not to cause harm to Jo during the endoscopy procedure.
Duty of care is a legal responsibility to deliver rational care and not to cause harm to anyone. Healthcare providers have a duty of care towards patients. If nurses and doctors do not adhere to their duty of care towards patients by acting contrary to their expected standards, they face charges in court for negligence of duty. In Jo’s case study, there are several situations whereby the duty of care is neglected and ignored. The nurse who triaged Jo primarily did not conduct a screening test for a possible menopause kick in thus neglecting the duty of care owed to patients (Koksal, et al., 2013). When the nurse assesses Jo, she notices several vital signs. The nurse then concludes that Jo required the doctor’s immediate attention and updates the doctor the situation. The nurse therefore observed her duty of care after she updated the doctor about the patient’s situation. The doctor, however, failed to observe the duty expected of him since he did not attend to the patient immediately even though the nurse had informed him about the patient’s initially. An endoscopy procedure is a fundamental aspect of health care in assessing the patient’s condition. It is an important part since it helps when a patient is in a critical condition and an accurate test is required to assess his/her condition. Doctors prescribe endoscopy procedures during emergency situations in order to manage life threatening conditions. Jo was suffering multiple vomiting of coffee ground fluid therefore the doctor referred her to the theatre for an endoscopy procedure.
Nurses’ Duty to Provide Quality Care
Provision of justice in a healthcare system refers to the unbiased allocation of resources as well as treatment services and equal access to health services (Shahriari, Mohammadi, Abbaszadeh, & Bahrami, 2013). In Jo’s case study she is originally triaged by a registered nurse. It is not mentioned anywhere in this case study that there was a delay in the initial assessment of the patient by the nurse. It is very likely that Jo was equally assessed like the other patients. However, Jo had to wait for a while before seeing the doctor even though her condition appeared to be serious and required immediate attention. So she had to wait until the doctor had attended to an accident victim. According to the ethical principles of medicine the doctor was right to attend to the accident victim first since the motor cycle driver’s condition appeared to be more serious. This is, however, an act of social injustice considering that Jo was also in pain and her condition was also serious. The doctor attended to Jo after her condition had worsened. In this situation if justice was to be upheld, the doctor would have checked Jo’s situation first as the nurse assessed the accident victim. That would thus have been a fair allocation of resources and an act of justice.
The law of torts is a civic wrong that causes harm to a person and as a consequence the person who commits harm results to a legal liability. The deliberate torts are battery, assault and false imprisonment (Atkins, de Lacey, Ripperger, & Britton, 2017). The law of torts that applies to this case study is negligence. A negligent tort is not a deliberate act but it occurs when a responsible person fails to abide to the duty of care and causes personal injury to another person (Balkin & Davis, 2013). In Jo’s case study the injury caused is physical. When the doctor failed to care for the patient immediately after the nurse’s assessment, he is said to have been negligent of the duty of care. Jo’s health completely deteriorated due to this negligence. If the doctor had checked the patient’s condition immediately after the nurse’s assessment, her condition might not have worsened. Neglecting a patient’s condition is legal owing to the fact that doctors are tasked with the responsibility of caring for patients. Nurses and doctors are thus required to use all the resources at their disposal to ensure that patients are treated appropriately.
Autonomy and Freedom of Consent
There are two major approaches regarding ethics and law that are applicable in his case study, for instance, utilitarian and deontological approaches. Utilitarianism refers to a general outcome that brings happiness to the party concerned. In the utilitarian approach, the outcomes determine and justify the means and greatest benefit expected for the greatest number and the morality of the intervention (Mandal, Ponnambath, & Parija, 2016). This approach has its full focus and attention on the society as a whole. The decisions made by a doctor have to be to the superlative interest of the patient. In this case study the doctor prescribed Pethidine 100mg and Maxolon 10mg to Jo in order to reduce her pain and nausea. Despite the fact that the patient became drowsy and vomited coffee ground fluid again, her pain was relieved. A little bit of harm was caused even though the outcome of the intended outcome of the intervention was pain relief.
Doctors should always ensure that they maximise the good and limit the harm when prescribing medication to patients (Johnstone, 2016). On the other hand, the deontological approach gives priority to the duty and obligations of doctors and the morality of their actions. The outcome does not justify the means in this approach and whatever the consequences of a doctor’s decision, harm is totally intolerable (Mandal, Ponnambath, & Parija, 2016). The doctor and nurses are bound by duty and obligations the happiness of the greater good is not given priority. In Jo’s case study there happens to be instances where duty was neglected. The nurse should have screened Jo for a possible menopause commencement owing to the fact that the patient is in her mid-40s.
Female within the age bracket of 40 – 50 are more likely to be in the menopause stage therefore Jo should have been screened. Jo’s pain score appeared to be 6 and the nurse considered that she needed immediate attention of the doctor. However, the doctor opted to attend to an accident victim first. This caused deterioration of the patient’s condition. Leaving a patient suffering from pain just to attend to another is unethical according to the medical ethics. Jo’s assessment already indicated that she needed immediate medical attention therefore the doctor had no reasons whatsoever to leave Jo in order to attend to the accident victim. Both seemed to have been serious cases, however, Jo was brought to the emergency department first. Both patients should have been given immediate medical attention in order to avoid dire conquers as witnessed in Jo’s situation. Therefore the nurse and doctor neglected their duty of care to patients with serious conditions.
Utilitarianism is disadvantageous to the patients considering that doctor applies a medical care that is acceptable to the general public. The happiness of the greater public is prioritized before the patient’s own well-being. For instance, the greater happiness requires that the accident victim should be treated first before Jo and other patients even though Jo herself was in deep pain (Savage, 2017). Utilitarianism allows harm to be caused to a patient. This is actually unethical and illegal at the same time. Doctors and nurses should find a way to balance between the greater happiness of the society and avoiding cause of harm to other patients. Deontology on the other hand is person centred (Acosta, Gomes, de Oliveira, Gomes, & da Fonseca, 2017). It therefore avoids cause of harm to a patient at all costs. The doctor in this case study should have treated Jo first as the nurse assessed and administered nursing intervention to the accident victim. This would have prevented deterioration of Jo’s medical condition.
In conclusion, this case study intends to evaluate nurses’ and doctors’ abilities to abide by the law as well as the ethics of profession such as autonomy, beneficence, non-maleficence, duty of care, justice and law of torts as they seek to deliver quality services to patients. The utilitarian and deontological theories of ethics have also been outlined. The nurse and the doctor in this situation tried to deliver quality services to Jo but failed in some instances. However, in certain instances the nurse and doctor adhered to the ethics of medicine profession and the laws binding it. Therefore it is necessary that doctors and nurses ensure that in as much as they want to provide quality treatment, ethics and laws are also made a priority.
References
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