Professional nurses need to be able to recognize the regulations and scope under which they practice and apply ethical principles in decision making.
As a staff nurse in an intensive care unit you accompany Dr. K to assess the condition of a patient Mr. E currently in the emergency department. The nursing home where Mr. E resides has brought him to the hospital because of lung congestion. The medical notes indicate that Mr. E is a 67-year-old white male with diabetes high blood pressure poor vision and hearing difficulties and is mildly developmentally delayed.
After assessing Mr. Es condition Dr. K determines that Mr. E has pneumonia secondary to aspiration. Mr. E is dyspneic on exertion and is running a fever of 101o F. He has a blood oxygen saturation level (SpO2) of 88% on room air. Dr. K determines that Mr. E will need to be placed on a ventilator and admitted to the intensive care unit. When Dr. K explains the situation Mr. E shakes his head and says Go away! No! No! Take me home. Knowing that Mr. E is developmentally delayed and hypoxic Dr. K is concerned that Mr. E does not understand the situation.
Dr. K notes that without the ventilator Mr. E will continue to aspirate and likely die. Dr. K asks you to look at Mr. Es file to determine whether there is anyone else who might have responsibility for Mr. E. The chart indicates that seven years ago Mr. E checked himself into the local nursing home. When he entered the nursing home a patient advocate helped him fill out an advance directive which stated Mr. Es medical wishes. Mr. E clearly indicated that he did not want a ventilator or cardiopulmonary resuscitation. No family member signed the advance directive and it is unclear if any family members were involved. Mr. E has also filled out a medical power of attorney which states Mr. E wants his younger brother Mr. Y to make medical decisions for him in the event he is no longer able to do so.
Dr. K asks you to call the brother and explain the entire situation. You call Mr. Y and tell him his brother is in the hospital with serious pneumonia. You explain that if Mr. E is not treated soon he will most likely die within a few days. You tell Mr. Y that his brother is refusing the ventilator. You also explain to Mr. Y that his brothers low oxygen saturation and fever may be preventing him from thinking clearly. Mr. Y asks if he can think about it and let you know the following day. Because Dr. K feels it is an urgent situation and that the decision needs to be made right away you tell Mr. Y that it cannot wait. You do not mention the advance directive.
Finally Mr. Y agrees to drive to the hospital see his brother and make a decision. Immediately after hanging up the phone Mr. Y decides to call his niece Ms. H hoping she might know what to do. His niece does not answer the phone so he leaves her a message about the situation stating he would like her advice on what to do.
Ms. H receives the phone message within the hour. She immediately calls Mr. Y back but he is no longer home. Ms. H calls her boyfriend and asks him to drive her to the hospital. When she gets there she does not find Mr. Y but she is directed to the intensive care unit where you are still on duty. Ms. H arrives with her boyfriend at her side.
You greet Ms. H just as Dr. K walks into the waiting room. Upon hearing who Ms. H is Dr. K begins to explain Mr. Es condition. The boyfriend is standing next to Ms. H and there are several other people sitting in the waiting room. Dr. K emphasizes the need for someone to provide consent for the ventilator. He does not mention Mr. Es advance directive. Ms. H quickly provides verbal consent and tells Dr. K she will talk with her uncle Mr. Y and convince him to sign the necessary paperwork since he is the one with the medical power of attorney. Dr. K plans to proceed with the intubation while Ms. H and her boyfriend wait for Mr. Ys arrival.
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