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ETHICAL CASE STUDY PRESENTATION
- 1. ETHICAL CASE STUDY PRESENTATION: HEALTHCARE PROFESSIONALS NEED TO USE THERAPEUTIC LIES FOR PROVIDING MENTALAND PSYCHOLOGICAL SUPPORT TO THE ELDERLY SERVICE USERS
- 2. INTRODUCTION Providing effective healthcare to elderly people is a challenging task as it often creates complex ethical dilemmas. In many cases, the clinical condition of the elderly people deteriorate periodically and the healthcare professionals need to use therapeutic lies for providing mental and psychological support to the elderly service users. However, the use of therapeutic lies often leads to ethical dilemmas. The study aims at discussing the ethical consideration in providing nursing care to elderly health service users. In this context, the study also considers practical case studies related to elderly health care.
- 3. 1. PRESENTATION OF THE ETHICAL DILEMMA USING AN ETHICAL FRAMEWORK MODEL Mrs M, a 77-year-old woman has been diagnosed with pancreatic cancer which is very common in elderly people. Usually, a patient of pancreatic cancer has a life span of almost 1 year. However, the clinical condition of the old woman was deteriorating periodically and she was admitted to St. Christopher's hospice for controlling the cancer symptoms. Enquiry of the whole situation Availability of options Views of people involved Identification of relevanty principles and legislation Clarification of key issues and meaning Selection of course of action
- 4. CONT… The family members of a service user, the service user, the hospital staff and the management authority of the hospital need to be involved in the decision-making process regarding healthcare. In this context, the service user wanted to die and she was not competent to take any decision regarding her. Therefore, it was not possible for the hospital staff to involve the patient in the decision-making process.
- 5. CONT… However, in this case, the hospice did not involve the family members of the service user also in the decision-making process. They suggested that the lady need to be transferred to a nursing home as there is no point of keeping her in a hospice as she needs only nursing care after the symptoms of pancreatic cancer have been controlled. There is no specific care provision for the cancer patients in the hospital and it is not possible to cure the patient properly. Therefore, the decision of the hospital staff was wise to transfer the old lady to a nursing home for her general healthcare. However, the concern of the family member of Mrs M is also valuable as the nursing home cannot provide effective clinical care as it is possible in a hospice.
- 6. CONT… In such a situation, there were two options available for avoiding the ethical dilemma. Either the patient should be kept in the hospice for better treatment or she should be transferred to a nursing home for reducing the cost of healthcare as costly healthcare is not a permanent solution to a patient of pancreatic cancer. kept in the hospice for better treatment she should be transferr ed to a nursing home for reducin g the cost
- 7. CONT… In this case, the patient wants to die and she has lost hope of getting recovery. The life expectancy of the patient is also less. However, considering the moral aspects of the situation, the patient can be kept in the hospice if her family members do not have any issue in paying the bills of the hospice.
- 8. CONT… According to the Health Act 1956 also the aged patient has the right to high- quality care and accommodation. Therefore, it can be said that Mrs M can be kept in the hospice and she has the right to avail the high-quality service of the hospice even if she expecting death to be inevitable (libguides.library.usyd.edu.au, 2019). In this context, the best interest of the family member of the service user is the well-being of Mrs M. Health Act 1956 the best interest of the family member respecting the concern of the daughter
- 9. CONT… According to the health safety policies of the St. Christopher's hospice, all patients need to be provided with effective healthcare services. In this context, the daughter of Mrs M is concerned about the well being of her mother and does not want to shift her mother to a nursing home as the care methods of a nursing home are not of the standard of a hospice. The hospice needed to support the decision of the family member as per this policy.
- 10. CONT… However, this decision cannot be accepted from the ethical consideration of the situation. Legally also the old woman has the right to get extensive care in a hospice (Aitamaa et al. 2016). Therefore, if the family member and the patient decide to live in the hospice for getting better healthcare services, the hospice authority cannot deny keeping the patient in the hospice (Milliken & Grace, 2017).
- 11. 2. EVIDENCE FOR CRITICALANALYSIS OF THE SITUATION FROM DIFFERENT PERSPECTIVES a. Description of the whole situation from different perspectives As St. Christopher’s hospice does not have specific care methods for curing a patient of pancreatic cancer, they took the decision for transferring Mrs M to another nursing home after her cancer symptoms are controlled. From the perspective of the hospital authority, it is not wise to keep such a patient in a costly hospice if there are no chances of recovery (Hopia, Lottes & Kanne, 2016). hospice does not have specific care methods curing a patient of pancreatic cancer took the decision for transferring perspective of the hospital authority not wise to keep such a patient in a costly hospice no chances of recovery
- 12. CONT… b. Considering if the situation can be avoided The main ethical dilemma is caused by the lies that the hospital staff told the old lady so that she accepts their decision. This ethical dilemma could be avoided if the hospital staff discussed with the family members of the old lady before taking the major decision regarding her transfer to a nursing home (Rainer et al. 2018).
- 13. CONT… c. Literature review for supporting own decision As per the philosophical principles of elderly care (De Vries & Plaskota 2017), it is necessary to be empathetic with a cancer patient so that the patient cannot lose hopes of recovery. When the patient loses hopes of recovery, it becomes more difficult to get positive outcomes from the medication. However, in this case, the hospital authority of St. Christopher's hospice motivated the negative feeling of death within the old women which cannot be supported ethically (Ku, 2017).
- 14. CONT… According to The Health of Older People Strategy 2002, the elderly patients and the family members of the patients have the right to choose options that they think wise for the well-being of the patients (health.govt.nz, 2019). In this context, the daughter of Mrs M is concerned about the well being of her mother and does not want to shift her mother to a nursing home as the care methods of a nursing home are not of the standard of a hospice. The hospice needed to support the decision of the family member as per this policy. According to the rules of the nursing council and NZNO codes, nursing care must be safe and secure for all service users (nursingcouncil.org.nz, 2019).
- 15. CONT… According to the health safety policies of the St. Christopher's hospice, all patients need to be provided with effective healthcare services. The hospice cannot deny services to any patient. However, as in this case, a specific treatment method is not there, the hospital authority suggested a transfer. However, as there is a chance of further deterioration of the clinical condition of the patient, the transfer needs to be postponed. hospice cannot deny services to any patient a specific treatment method is not there there is a chance of further deterioration
- 16. 3. OWN REFLECTIVE COMMENTS According to me, this is a critical situation that might occur in any health care organisation. The decision of the hospital staff to transfer Mrs M was not totally unwise as they do not have proper cure methods for ensuring recovery to a patient of pancreatic cancer. The clinical condition of the patient was also fluctuating periodically and the reputation of the hospital might be affected if the condition deteriorated further. This is the reason that the hospital authority did not want to keep the patient in the hospice.
- 17. CONT… According to Moncur & Lovell (2018), therapeutic lies can be effective for influencing the behaviour of the patient. However, this has negative consequences also. Especially when the patient understands that he has been told lies for some reason, the patient becomes more depressed and loses his faith in healthcare staffs. In this context, the healthcare staff encouraged the negative feeling of death in Mrs M which is not ethical. However, from the legal and ethical perspective, the act of telling lies to the patients for taking her consent for her transfer to a nursing home was unethical.
- 18. CONCLUSION The main aim of the study was to analyse the impact of ethical dilemmas in healthcare. In this context, a case study has been discussed in the study for exploring different aspects of ethical dilemma in elderly care. The dilemma has been discussed using an ethical framework model and has been critically analysed using contemporary research literature based on nursing ethics. The study reveals that an ethical dilemma can be avoided by a proper discussion of the ethical consideration of a situation with all involved persons. In this case, also, the ethical dilemma caused by the therapeutic lies of the hospital staff could be avoided by a proper discussion with the family members before taking any major decision.
- 19. REFERENCES Aitamaa, E., Leino-Kilpi, H., Iltanen, S., & Suhonen, R. (2016). Ethical problems in nursing management: the views of nurse managers. Nursing ethics, 23(6), 646-658. https://www.researchgate.net/profile/Elina_Aitamaa/publication/275362767_Ethical_problems_in_nursing_management_The_views_of_nurse_managers/links/554f474008ae128 08b377c7d/Ethical-problems-in-nursing-management-The-views-of-nurse-managers.pdf De Vries, K., & Plaskota, M. (2017). Ethical dilemmas faced by hospice nurses when administering palliative sedation to patients with terminal cancer. Palliative & supportive care, 15(2), 148-157. Retrieved on 15th august 2019 from http://eprints.brighton.ac.uk/15663/1/de%20Vries%20Plaskota%20Ethical%20dilemmas%20April%2016.pdf Ganz, F. D., Wagner, N., & Toren, O. (2015). Nurse middle manager ethical dilemmas and moral distress. Nursing Ethics, 22(1), 43-51. Retrieved on 18th august 2019 from https://journals.sagepub.com/doi/abs/10.1177/0969733013515490 Gallagher, A., & Sykes, N. (2008). A little bit of heaven for a few? A case analysis. Ethics and Social Welfare, 2(3), 299-307. Retrieved on 17th august 2019 from https://www.tandfonline.com/doi/abs/10.1080/17496530802481607?journalCode=resw20 Hopia, H., Lottes, I., & Kanne, M. (2016). Ethical concerns and dilemmas of Finnish and Dutch health professionals. Nursing ethics, 23(6), 659-673. Retrieved on 15th august 2019 from http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.920.759&rep=rep1&type=pdf James, I. A. (2015). The use of CBT in dementia care: a rationale for Communication and Interaction Therapy (CAIT) and therapeutic lies. The Cognitive Behaviour Therapist, 8. Retrieved on 15th august 2019 from https://www.researchgate.net/profile/Ian_James3/publication/276429884_The_use_of_CBT_in_dementia_care_A_rationale_for_Communication_and_Interaction_Therapy_CAI T_and_therapeutic_lies/links/5a5f0d15aca272d4a3e0c1bf/The-use-of-CBT-in-dementia-care-A-rationale-for-Communication-and-Interaction-Therapy-CAIT-and-therapeutic- lies.pdf Milliken, A., & Grace, P. (2017). Nurse ethical awareness: Understanding the nature of everyday practice. Nursing ethics, 24(5), 517-524. Retrieved on 15th august 2019 from https://journals.sagepub.com/doi/abs/10.1177/0969733015615172 Moncur, T., & Lovell, A. (2018). The Therapeutic Lie: A reflective account illustrating the potential benefits when nursing an elderly confused patient. Australian Nursing and Midwifery Journal, 25(7), 37. Retrieved on 15th august 2019 from https://search.informit.com.au/documentSummary;dn=354112376797553;res=IELHEA Rainer, J., Schneider, J. K., & Lorenz, R. A. (2018). Ethical dilemmas in nursing: An integrative review. Journal of clinical nursing, 27(19-20), 3446-3461. Retrieved on 18th august 2019 from https://onlinelibrary.wiley.com/doi/pdf/10.1111/jocn.14542 Robison, J. G., & Smith, C. L. (2016). Therapeutic Massage During Chemotherapy and/or Biotherapy Infusions: Patient Perceptions of Pain, Fatigue, Nausea, Anxiety, and Satisfaction. Clinical journal of oncology nursing, 20(2). Retrieved on 14th august 2019 from https://web.a.ebscohost.com/abstract?direct=true&profile=ehost&scope=site&authtype=crawler&jrnl=10921095&AN=113877379&h=imr754ACybDBds4zGG9QyX2kAg%2fd 9P%2b%2fEfZgHlcXOfBAjJOCdUkVlvbTS%2b1CnYkPcPmA%2fqtwAF5LUzQQUVEo9g%3d%3d&crl=c&resultNs=AdminWebAuth&resultLocal=ErrCrlNotAuth&crlhash url=login.aspx%3fdirect%3dtrue%26profile%3dehost%26scope%3dsite%26authtype%3dcrawler%26jrnl%3d10921095%26AN%3d113877379 Ku, Y. L. (2017). Literature review on spiritual care in nursing. Journal of Nursing and Health Studies, 2(1), 1-4. . Retrieved on 12th august 2019 from https://pdfs.semanticscholar.org/e2ee/0280025149508ad38d1fea7d1bc69e1a8826.pdf Shirley, N., & Phan, L. T. M. (2019). Therapeutic Communication Skills of Nurses Towards People With Dementia. Retrieved on 12th august 2019 from https://www.theseus.fi/bitstream/handle/10024/227487/Thesis_therapeutic_comm_dementia.pdf?sequence=2&isAllowed=y legislation.govt.nz (2019) Health care laws of New Zealand Retrieved on 11th august 2019 from http://www.legislation.govt.nz/act/public/1956/0065/121.0/DLM305840.html health.govt.nz (2019) Overview of The health of older people strategy https://www.health.govt.nz/publication/health-older-people-strategy-2002 nursingcouncil.org.nz (2019) Competencies of nursing council https://www.nursingcouncil.org.nz/Public/concerns/NCNZ/Concerns.aspx?hkey=c46089c0-0808-4297-8efe- 43e46bfa0faa
Editor's Notes
- Providing effective healthcare to elderly people is a challenging task as it often creates complex ethical dilemmas. In many cases, the clinical condition of the elderly people deteriorate periodically and the healthcare professionals need to use therapeutic lies for providing mental and psychological support to the elderly service users. However, the use of therapeutic lies often leads to ethical dilemmas. The study aims at discussing the ethical consideration in providing nursing care to elderly health service users. In this context, the study also considers practical case studies related to elderly health care.
- According to the prognosis report, the old women had a life expectancy of a few weeks she was depressed and repeatedly expressed her desire for death (Gallagher & Sykes, 2008). However, after a certain period, when the symptoms like nausea and abdominal pain were controlled, a decision was taken to transfer her to a nursing home as she needed nursing care more than palliative care of the hospice. The hospital staff lied to the old lady that if she goes to a nursing home she would die sooner so that the lady agrees to go to the nursing home. However, her daughter was not agreed to this decision as she thought that the care quality of the nursing will not be of the standard of that of the hospice (Gallagher & Sykes, 2008).
- The family members of a service user, the service user, the hospital staff and the management authority of the hospital need to be involved in the decision-making process regarding healthcare. In this context, the service user wanted to die and she was not competent to take any decision regarding her. Therefore, it was not possible for the hospital staff to involve the patient in the decision-making process.
- However, in this case, the hospice did not involve the family members of the service user also in the decision-making process. They suggested that the lady need to be transferred to a nursing home as there is no point of keeping her in a hospice as she needs only nursing care after the symptoms of pancreatic cancer have been controlled. There is no specific care provision for the cancer patients in the hospital and it is not possible to cure the patient properly. Therefore, the decision of the hospital staff was wise to transfer the old lady to a nursing home for her general healthcare. However, the concern of the family member of Mrs M is also valuable as the nursing home cannot provide effective clinical care as it is possible in a hospice.
- In such a situation, there were two options available for avoiding the ethical dilemma. Either the patient should be kept in the hospice for better treatment or she should be transferred to a nursing home for reducing the cost of healthcare as costly healthcare is not a permanent solution to a patient of pancreatic cancer.
- In this case, the patient wants to die and she has lost hope of getting recovery. The life expectancy of the patient is also less. However, considering the moral aspects of the situation, the patient can be kept in the hospice if her family members do not have any issue in paying the bills of the hospice. The hospice needs to clear the fact to the family members of the service user that palliative care is not a permanent solution to this disease and death is inevitable (Shirley & Phan, 2019). However, even after knowing that if the family members want to avail the services of the hospice, the hospice needs to keep the patient (Ku, 2017).
- Therefore, it can be said that for respecting the concern of the daughter of the service user, the management authority of the hospital needs to agree for postponing the transfer of Mrs M to a nursing home. The hospice needs to clear the fact to the family members of the service user that palliative care is not a permanent solution to this disease and death is inevitable (Shirley & Phan, 2019). However, even after knowing that if the family members want to avail the services of the hospice, the hospice needs to keep the patient (Ku, 2017). However, the contradictory argument of the hospital staff is that there is no point of keeping her in a costly hospice as they do not have effective treatment method for providing quick recovery to a patient of pancreatic cancer (Robison & Smith, 2016).
- According to the rules of the nursing council and NZNO codes, nursing care must be safe and secure for all service users (nursingcouncil.org.nz, 2019). In this case, there remains a chance that the clinical condition of Mrs M might deteriorate even she is transferred to a nursing home from the reputed hospice as the services of the nursing home care of lower quality than that of the hospice. Therefore, the decision of the family member to keep the patient in the hospice is wise.
- However, in actuality, the hospital staff lied to the patient that she can die soon if she is transferred to the nursing home so that the patient can not oppose the decision of her transfer. This is unethical.
- The patient also lost her hope for recovery and wanted to die and therefore, the hospital staff lied to the patient that she can get rid of her pains if she is transmitted to the nursing home. From the perspective of the old lady, the decision can be wise if it helps her to get rid of her pain. However, from the perspective of the family member of the service user, the nursing home cannot provide standard healthcare service like a hospice and therefore, the lady needs to be kept in the hospice for her better care even if it is a costly procedure. The viewpoint of the daughter of the old lady is also correct from the legal and ethical perspective also (Ganz, Wagner & Toren, 2015).
- b. Considering if the situation can be avoided The main ethical dilemma is caused by the lies that the hospital staff told the old lady so that she accepts their decision. This ethical dilemma could be avoided if the hospital staff discussed with the family members of the old lady before taking the major decision regarding her transfer to a nursing home (Rainer et al. 2018). The situation can be avoided by patient centered care also.
- c. Literature review for supporting own decision As per the philosophical principles of elderly care (De Vries & Plaskota 2017), it is necessary to be empathetic with a cancer patient so that the patient cannot lose hopes of recovery. When the patient loses hopes of recovery, it becomes more difficult to get positive outcomes from the medication. However, in this case, the hospital authority of St. Christopher's hospice motivated the negative feeling of death within the old women which cannot be supported ethically (Ku, 2017).
- In this case, there remains a chance that the clinical condition of Mrs M might deteriorate even she is transferred to a nursing home from the reputed hospice as the services of the nursing home care of lower quality than that of the hospice. Therefore, the decision of the family member to keep the patient in the hospice is wise.
- According to the health safety policies of the St. Christopher's hospice, all patients need to be provided with effective healthcare services. The hospice cannot deny services to any patient. However, as in this case, a specific treatment method is not there, the hospital authority suggested a transfer. However, as there is a chance of further deterioration of the clinical condition of the patient, the transfer needs to be postponed.
- According to me, this is a critical situation that might occur in any health care organisation. The decision of the hospital staff to transfer Mrs M was not totally unwise as they do not have proper cure methods for ensuring recovery to a patient of pancreatic cancer. The clinical condition of the patient was also fluctuating periodically and the reputation of the hospital might be affected if the condition deteriorated further. This is the reason that the hospital authority did not want to keep the patient in the hospice. However, from the legal and ethical perspective, the act of telling lies to the patients for taking her consent for her transfer to a nursing home was unethical.
- According to Moncur & Lovell (2018), therapeutic lies can be effective for influencing the behaviour of the patient. However, this has negative consequences also. Especially when the patient understands that he has been told lies for some reason, the patient becomes more depressed and loses his faith in healthcare staffs However, from the legal and ethical perspective, the act of telling lies to the patients for taking her consent for her transfer to a nursing home was unethical.
- The main aim of the study was to analyse the impact of ethical dilemmas in healthcare. In this context, a case study has been discussed in the study for exploring different aspects of ethical dilemma in elderly care. The dilemma has been discussed using an ethical framework model and has been critically analysed using contemporary research literature based on nursing ethics. The study reveals that an ethical dilemma can be avoided by a proper discussion of the ethical consideration of a situation with all involved persons. In this case, also, the ethical dilemma caused by the therapeutic lies of the hospital staff could be avoided by a proper discussion with the family members before taking any major decision.