Ethical Dilemma                  In the documentary The Invisible Patients, Jessica, a nurse practitioner for home-limited patients, is faced with several ethical dilemmas. For example, Jessica provides care for an elderly couple named Wink and Patty Sherrill. Both Patty and Wink are prescribed narcotics to manage their arthritis pain. During a routine urine drug screen, it is discovered that Patty does not have any trace of her pain medication in her system, yet she is still having her narcotic prescription refilled regularly. This obviously raises concerns for medication diversion. Patty is presumably giving her narcotics to her husband or selling her narcotics, which is a clear violation of her pain contract. She is banned from her primary care MD’s practice, which causes her great difficulty in finding another healthcare provider. Jessica feels that it is her responsibility to provide care for this couple.             This scenario raises the ethical dilemma of beneficence versus nonmaleficence. The principle of beneficence is “the duty to do good and prevent or remove harm" (Hamric, Hanson, Tracy, O'Grady, 2014, p. 337). Prescribing narcotics to those experiencing chronic pain and disability is a necessary and beneficent act of healthcare providers. The principle of nonmaleficence is “the duty not to inflict harm or evil” (Hamric et al., 2014, p.337).  Prescribing narcotics to a patient who is suspected of narcotics diversion has the potential to cause harm to the person who is taking the narcotics illicitly. Jessica must now decide which principle to follow and which principle to potentially break. Jessica decides that even though Patty is abusing her prescription, she does in fact still need her narcotics and continues to prescribe the pain medicine.  My Solution In this scenario, I would not continue to prescribe Patty narcotics. Since she is not taking her pain medications but still seeking refills, she is abusing her prescription and the trust placed in her. If she is diverting her narcotics to her husband and/or selling them on the street, this places Wink and/or the narcotic abuser at risk for health complications such as respiratory depression, constipation, drug dependence, increased tolerance, and narcotic withdrawal in the future.  I believe Wink has a legitimate need for pain medications, but he should be honest and open with Jessica about the need to increase his pain medications or try different modalities if his pain is not properly controlled. Regardless of motive, illegally diverting narcotics is a breach in contract and should not be overlooked.             If I were presented with this scenario, I would have talked with Patty and Wink about Patty’s narcotic diversion and sought an alternative solution to continuing to prescribe narcotics. If Patty were in fact giving her narcotics to her husband to help control his pain, I would adjust Wink’s medications and pain management strategy. If they were selling their excess n.

1. Ethical Dilemma
In the documentary The Invisible Patients, Jessica, a
nurse practitioner for home-limited patients, is faced with
several ethical dilemmas. For example, Jessica provides care for
an elderly couple named Wink and Patty Sherrill. Both Patty
and Wink are prescribed narcotics to manage their arthritis pain.
During a routine urine drug screen, it is discovered that Patty
does not have any trace of her pain medication in her system,
yet she is still having her narcotic prescription refilled
regularly. This obviously raises concerns for medication
diversion. Patty is presumably giving her narcotics to her
husband or selling her narcotics, which is a clear violation of
her pain contract. She is banned from her primary care MD’s
practice, which causes her great difficulty in finding another
healthcare provider. Jessica feels that it is her responsibility to
provide care for this couple.
This scenario raises the ethical dilemma of beneficence
versus nonmaleficence. The principle of beneficence is “the
duty to do good and prevent or remove harm" (Hamric, Hanson,
Tracy, O'Grady, 2014, p. 337). Prescribing narcotics to those
experiencing chronic pain and disability is a necessary and
beneficent act of healthcare providers. The principle of
nonmaleficence is “the duty not to inflict harm or evil” (Hamric
et al., 2014, p.337). Prescribing narcotics to a patient who is
suspected of narcotics diversion has the potential to cause harm
to the person who is taking the narcotics illicitly. Jessica must
now decide which principle to follow and which principle to
potentially break. Jessica decides that even though Patty is
abusing her prescription, she does in fact still need her
narcotics and continues to prescribe the pain medicine.
My

2. Solution
In this scenario, I would not continue to prescribe Patty
narcotics. Since she is not taking her pain medications but still
seeking refills, she is abusing her prescription and the trust
placed in her. If she is diverting her narcotics to her husband
and/or selling them on the street, this places Wink and/or the
narcotic abuser at risk for health complications such as
respiratory depression, constipation, drug dependence,
increased tolerance, and narcotic withdrawal in the future. I
believe Wink has a legitimate need for pain medications, but he
should be honest and open with Jessica about the need to
increase his pain medications or try different modalities if his
pain is not properly controlled. Regardless of motive, illegally
diverting narcotics is a breach in contract and should not be
overlooked.
If I were presented with this scenario, I would have
talked with Patty and Wink about Patty’s narcotic diversion and
sought an alternative solution to continuing to prescribe
narcotics. If Patty were in fact giving her narcotics to her
husband to help control his pain, I would adjust Wink’s
medications and pain management strategy. If they were selling

3. their excess narcotics on the street to help pay for their bills or
health insurance (which Patty frequently mentioned), I would
consult a social worker to help Patty and Wink manage their
finances and review insurance options. Narcotic abuse is an
epidemic in America, and nurse practitioners must use wisdom
when prescribing narcotics (CDC, 2017). Pain management is
certainly a responsibility of the nurse practitioner and should
always be considered when providing care.
Personal Beliefs and Values: Costs and Benefits
I believe that individuals should be held accountable for
their actions. Though it is sad to think that some individuals
feel they must break the law to “make ends meet”, that does not
make it right. I tend to see things as black and white, and I
realize that this is a barrier when facing ethical dilemmas.
Ethics and medicine have many grey areas, and I must be
cautious to not let my personal views affect how I care for my
patients. One may argue that Patty felt she had no other choice,
and it was a necessary means for Patty and Wink for them to
survive on such a limited income. Though I disagree with this
argument, I must still be willing to consider the opposing view
before making my final decision. By pausing and considering
the opposing viewpoint with an open mind, I can begin to
overcome my personal bias when faced with an ethical dilemma.
A potential cost to my barrier of being a dichotomist
thinker is that I may fail to see an alternative solution. There

4. are often more than just two solutions to a problem, and I need
to actively seek creative, alternate solutions before coming to a
decision. A potential benefit to my beliefs is that I do not tend
to ruminate over past decisions. Working in healthcare is often
emotionally taxing and can lead to burnout if you let it consume
your thoughts.
Disruptive Innovators
According to our text, disruptive innovators are
individuals who provide a cost effective, convenient service to a
customer who is less demanding than the typical customer
(Hamric et al., 2014). This creates competition between the
disruptive innovator and the larger corporations and often
drives down prices of the larger corporation. Nurse
practitioners, such as Jessica, can provide excellent care to
patients at a cheaper price and deliver this care conveniently at
home. Providing care to homebound patients such as those
in The Invisible Patients is an excellent example of a service
that is competitively priced and convenient for the less
demanding patient population.
ANA Code of Ethics
The ANA Code of Ethics is a grouping of morals and
values that nurses are expected to adhere to during their career
(ANA, 2015). Nurses must use this code when faced with
difficult ethical dilemmas. An example of a barrier regarding
the ANA Code of Ethics could be found with Provision 3: “The

5. nurse promotes, advocates for, and protects the rights, health,
and safety of the patient” (ANA, 2015, p.8). For example, if a
nurse is caring for a patient that confesses to elder abuse, the
nurse must now report that patient to the police and fail to
protect the patient's right to confidentiality. Most nurses would
agree that this is the correct action to take, but some may
mistakenly believe that Provision 3 prohibits reporting the
incident to the police. This is a barrier of the ANA Code of
Ethics as well as a barrier due to simply a lack of
understanding. The Code of Ethics is a great tool for nurses but
also has the potential to be a barrier in healthcare if
misunderstood.
Jessica has been a nurse practitioner for nearly two decades.
She has been providing primary care services to home bound
and home limited patients since 2013 with an organization
known as MD2U in Evansville, Indiana. In viewing the
documentary, The Invisible Patient, Jessica presented herself as
a disruptive innovator. According to Hamric, Hanson, Tracy, &
O’Grady, “disruptive innovation transforms an existing market
or creates a new market by making processes simpler and
improving access” (2014). Jessica took pride in carrying for
individuals in the community that were faced with challenges.

6. In viewing the documentary, I was able to see many of them
live in difficult situations. Some are unable to travel to see a
clinician at a doctor’s office for a lot of different reasons. They
all had multiple chronic conditions, and all faced some form of
poverty. Jessica mentioned several times that there are only a
handful of people currently reviving primary health care in their
homes. Jessica background was in renal and telemetry medicine
at Yale New Haven hospital. Prior to joining MD2U, she cared
for the adult and geriatric population with dementia. She also
spent a decade in traditional family practice prior to branching
out. If Jessica did not provide her services many of her patients
would have frequent admissions to the hospitals or require long
term or skilled rehab services. During the documentary, Jessica
displayed respect and empathy to her patients while delivering
high quality patient centered care. Per Jessica, her services are
also more cost efficient for the patients, especially since they
were on a fix income.
The ethical dilemma that stuck to to me the most while
watching the documentary was the care Jessica provided to the
34-year male Roger Brown. He was diagnosed with muscular
dystrophy at four years old. “Muscular dystrophy is a group of
diseases that cause progressive weakness and loss of muscular
mass” (“Muscular dystrophy”, 2018). According to “Muscular
dystrophy”, the genes are abnormal, and they mutate interfering
with the production of proteins needed to form healthy muscle

7. (2018). This disease is very common in young males. There is
no cure, but medications and therapy can try to help manage
symptoms and slow the course of the disease. The normal life
expectancy is approximately twenty years, Roger exceeded this.
Symptoms may include, “frequent falls, waddling gait, walking
on the toes, large calf muscles, muscle pain/stiffness and
respiratory complications” (“Muscular dystrophy”, 2018). The
ethical dilemma faced here was informed consent, “Concerns
that patients and their families have not been fully informed
about there treatment or clinical prognosis is a common ethical
concern for nurses” (“Muscular dystrophy”, 2018).
Often, patients feel more comfortable asking a nurse to
decipher what their doctor say because of comprehension,
especially with end life decision making. In one party of the
documentary Jessica is faced to discuss end of life care with
Roger and his mom due to the progression of his disease
especially impacting his respiratory status. Jessica conflict was
Rogers age. Normally treating a person of his age, you would
take aggressive measures. But regarding Rogers health, his EF
is 20%, fluid buildup, heart failure, kidney stones and
generalized pain. He had multiple co-morbidities that Jessica
knew if his heart stop beating, performing CPR to prolong his
life would cause more harm to him. At first Roger wanted to
continue aggressive measures so he could continue his life if he
could. Jessica had to find another approach to assist Roger and

8. his mother to understand the progression of his disease. She
helped him understand that he wasn’t getting better regardless
of his treatment. Aggressive measures and hospice/palliative
care services are two different treatments. Jessica had a
difficult time discussing this because she was fully aware
Rogers time was near. She did a great job explaining to Roger
and his mother what would happen once he starts to transition.
Many people are faced with difficult decision regarding code
status, hospice and palliative care services in their lifetime.
End of life should be a smooth transition, but it is often
difficult because people find it hard to accept.
One important factor that affects ethical decision
making is your personal belief system (Hamric, Hanson, Tracy,
& O’Grady, 2014). Your life experiences over a period may
change your personal values Hamric, Hanson, Tracy, &
O’Grady, 2014). My personal beliefs are inline with Jessica
with this ethical dilemma. I feel end of life patients should
have pain and symptoms management. I would also assist the
patient and family through the dying and death process, so the
anxiety and fear can be decreased like Jessica did. Advocacy
for the patient is key to me. For a person to give great end of
life care appropriately, effective communication should take
place.
Becoming an adult gerontology nurse practitioner, I will
be the spokesperson for my patient and honor their rights and

9. give them dignity. I will ensure my patients are informed on
what advance directives and living wills are in case they ever
are unable to make a sound decision and they wouldn’t want to
put that burden on there love ones. Everyone should honor a
patient wishes as it is not causing any harm. Through education
with end of life, DNR, palliative care services, hospice services
and advance directives the tales will be eliminated, and
anxiety/fear will be decreased (Hamric, Hanson, Tracy, &
O’Grady, 2014).
One mechanism to overcome barriers is recognizing a
patient needs and making
patient and families aware of additional services such as
palliative care. It is for patient with life threatening illness.
“Patient have better quality of life and live longer and cost the
health system less”, with palliative care services (Perrin &
Kazonowski, 2015). Barriers to palliative care consultation for
patients in critical care include misunderstanding. Palliative
care undermines the focus of saving the patient life is what
some feel. Providers often have difficult time determine when
critically ill patients are approaching the end of life, often
causing patients to die in pain. According to Perrin &
Kazonowski, palliative care is an approach that improves the
quality of life of patients and their families facing problems
associated with life threatening illness (2015). APN can
emphasize to families that symptom management care to the

10. patient can improve a patient outcome.
When the dying process is detected earlier, comfort
focused treatment goals are initiated sooner. When appropriate,
patients are moved to lower intensity care site (Perrin &
Kazonowski, 2015). Length of stay in the intensive care unit is
decreased (Perrin & Kazonowski, 2015). Cost of care is
reduced because realistic goals are established. Staff would
receive support for patients and families. The need for repeat
admission could be reduced because treatment goals have been
clarified. And lastly, with palliative care the patient and
families would have continuity of care with familiar faces
because they would be followed from the hospital, to
skilled/long term care or home.