Focus on Ethics - Maternal Infant Child Health Care
Focus on Ethics - Maternal Infant Child Health Care
Ethical dilemmas are unavoidable as each person has their own set of values and morals. There are many possible actions and viewpoints to be considered when reaching a decision. For this paper I will work through an ethical dilemma using a decision making model to come up with what I feel is the best decision. I will also discuss what my role is as a nurse in this ethical dilemma.
Focus on Ethics
I am a neonatal nurse taking care of a full term medically unstable baby girl. She has numerous health problems that need to be dealt with in a timely matter for the best outcome possible. The issue at hand is that her parents are refusing the treatments needed to help save the baby’s life. The medical team believes it is in this baby’s best interest to treat her. Who should decide on what should be done?
As a guide to work through this ethical problem I will use the Thompson and Thompson Ethical decision-making model (1990).
Nature of the problem
The health problems this baby is facing at present is that she is intubated on full respiratory support; she has an oomphalocele that requires surgery within the next three hours to prevent overwhelming sepsis and gastrointestinal ischemia. She has started having seizures that require anticonvulsants to help control them as well as further diagnostic testing to determine the cause of the seizures. Sepsis is also suspected and would therefore require antibiotic treatment.
There is a lot that can and should be done for this baby and it needs to be done quickly in order to obtain the best possible outcome. The parents are nowhere to be found at present as they are off speaking with their own specialist. I believe the parents do not understand the severity of the baby’s condition, the prognosis and that precious time is being wasted? Why are these parents refusing treatment? Do they have sound rationale for wanting to stop treatment? Is their decision based on religious beliefs? I would hopefully have a greater understanding of the parents’ views and wishes if they were around to discuss it.
In knowing that a full resuscitation has already been started on this baby, why would we stop treatment now when the baby has a chance at a full and healthy recovery? Unfortunately, with time not being on our side and the parents not available to discuss the options we are unable to do a thorough analysis of the situation to include the parent’s wishes.
There are numerous ethical issues to consider before determining who will make the final decision and what that decision will be. We must remember that the most important person involved in this dilemma is the baby herself. Autonomy and parental authority and are closely related in this circumstance because this baby is incapable of making decisions for herself. Traditionally the parents have been entrusted with the decision. Harms & Giordano (1990) wrote because of the stress of the situation and the crisis of having a less-than-perfect child these circumstances can affect the parent’s ability to make rational decisions for the benefit of their child. Therefore, it would probably be better for medical team as a group to decide.
For our patients’ best interests professionals are required to provide care following the principles of beneficence and nonmalificence in that we do no harm. But how do we know who truly has the baby’s best interest in mind? We should not stop treatment just for the parent’s convenience or we should not continue with treatment because we have the technology and want to look like miracle workers in doing everything we can. In this particular case I see no reason why once treated, this baby should not experience a healthy, meaningful and productive life.
Some may wonder why we would want to utilize numerous expensive resources for an infant whose parents don’t agree with the treatment. I believe this baby has every right to the resources available regardless of the cost because she has a chance of leading a normal life. How can you put a price on an innocent life? Just because her parents have given up on her does not mean the rest of us should.
In making our decision, we must keep in mind our legal obligations to the baby. If we do nothing for this baby we could be accused of negligence under the civil law Lasby & Dunki (2004) but at the same time the parents could sue us for performing a surgery on their daughter without their consent. I would rather do what I believe as right and in the best interest of the baby then not doing what I felt was morally right to avoid a lawsuit.
I became a neonatal nurse because I genuinely care for others, especially precious and innocent babies. I believe it is important to build a trusting and open relationship with the families in order to make this scary experience a little easier and be better able to deal with difficult ethical situations if one should arise. I feel great satisfaction in knowing that I am doing my best to help the babies and their families with the potential of making a positive difference in their lives.
As a practicing professional nurse I have ethical commitments, responsibilities and expectations in my work with patients and their families, other health care professionals, the public and myself. The Canadian Nurses Association (CNA) has a code of ethics made up of eight values to assist nurses in working through ethical problems like the one I am dealing with. From the CNA’s code of ethics I will describe the values and responsibilities that will be useful in assisting me work through this particular problem.
Nursing practice standards (2003), 1. Safe, competent and ethical care; I must strive for the highest quality of care achievable, and I have the ability to engage in determining and expressing my own moral choices, but I must follow current legislation, standards and policies relevant to the profession or practice setting. Morally and ethically from a personal and professional level I think it is wrong that the parents want us to stop treatment on their baby. I cannot and will not act solely based on my own beliefs. 2. Health and Well-being; it is my responsibility to provide care directed toward the health and well-being of this baby, but if the parents do get their wish of letting the baby die, I must foster comfort and well-being to alleviate suffering and support a dignified and peaceful death for the infant. 3. Choice; I am committed to building a trusting relationship with this family in order to ensure their choice is understood, expressed and advocated. I am aware they have a right to refuse or withdraw consent for care or treatment at anytime and I need to respect how and why the decision was made, however, I am allowed to advocate for the infant if her well-being is compromised by the family due to their decisions. 4. Justice; I am aware that neonates consume a significant portion of the health services resources, but it is only fair for this baby to be treated as an equal and receive the resources proportionate to her needs. 5. Accountability; I respect and practice the values outlined by the CNA in order to be the best nurse that I can be. The key to working through this ethical dilemma is to discuss it with other health team members and the family.
I strongly believe due to our time constraints and the baby’s deteriorating condition that the medical team should have the final decision at this point. The parents have just not been around enough to properly discuss the situation with them. I believe they are too overwhelmed by the situation to be rushed into making a decision as important as their child’s life. It is in my opinion that these parents have already distanced themselves from this baby, and are making decisions not in the baby’s best interest. According to Lasby & Dunki (2004) parents are considered to be competent decision makers if they are able to make a decision in the child’s best and regardless of the hardship that may be imposed on the family. I am reading mixed signals from the parents in that their actions are different from their expressed wishes. I don’t understand why these parents who used the assistance of a fertility clinic to get pregnant, then carry through with the pregnancy, arrive at the hospital to deliver the baby and all of a sudden not want anything further done for the child. My greatest fear for these parents would be for them to regret the decision they made, and accuse us of not intervening.
Possible Actions and Outcomes
1. Do everything possible to save the baby’s life. In doing that we would be ignoring the parents wishes and infants quality of life. The equipment and technology is available and should be used to save this child. The potential outcomes of this action are; A) best case scenario save the baby’s life with no damage done and babe is able to lead a healthy and normal life, be it with her parents or with an adoptive family. B) worst case scenario baby lives but suffers with numerous health problems and will be totally dependent her entire life, physically, mentally and financially to her family and or society. The only justification for this action would be the sanctity of life.
2. Get a court order to apprehend the baby in order to start her on antibiotics, anticonvulsants, do the diagnostic tests needed to determine the focal point of the seizures and go ahead with the surgery to correct her oomphalocele. Once these treatments are completed and the baby is hopefully more stable, we will have a better idea of prognosis. As well as having more time to discuss and work through the situation with the parents and hopefully agree on a plan that is in the baby’s best interest. The potential outcomes of this action are A) best-case scenario baby makes a full recovery with no damage done and is able to lead a healthy and normal life. The parents are thankful for us taking over the decision and the three of them will be a happy family together. B) worst case scenario baby suffers unnecessarily, and eventually dies from complications. The parents are mad because we did not listen to them and we used valuable resources in terms of the legal proceedings as well as the medical team and equipment. The justification for this action would be beneficence, as the medical team truly believed that it was in the baby’s best interest to continue on with the necessary treatment.
For action 1 & 2 another ethical dilemma occurs in that we are inflicting pain while providing care. Lasby & Dunki (2004) refer to this as a double effect in that pain in an unavoidable and unfortunate product of necessary treatment.
3. Leave babe on ventilator and provide comfort measures only. The outcome would be babe would die peacefully and we would have diminished harm and promoted good. Justification would be that it is a utilitarian approach, and autonomy of the parent’s wishes.
4. Take babe off ventilator, provide comfort measures and let nature take its course. The outcome would be a quicker death for the baby. The justification would be deontological in that we are doing no harm, if prognosis was determined to be poor then quality of life doctrine would apply as well as autonomy of parents and futile use of resources.
The action that I would take in this circumstance would be to apprehend the baby and give the medications necessary as well as the surgery. We would then hopefully be able to re-discuss the situation with the parents and if need be, repeat the ethical decision making process.
I chose this action because I believe that it is in the baby’s best interest and we need to give the baby a chance to live. The treatments mentioned above are not considered heroic measures, in my opinion, just necessary to prevent death. In trying to help this baby regardless of outcome I do not feel that we inappropriately used scarce and expensive resources. She has just as much right to them as you or I do.
I would not honor the parents’ wishes at this time because I believe they are too overwhelmed and selfish to make a decision in the baby’s best interest. I have never experienced, in my practice, a family refusing lifesaving treatment for their child. It has generally been the opposite where the medical team is suggesting stopping treatment and the parents wanting anything and everything done for that slight chance that it may save the baby. Which in itself is not a good thing either, but at least these parents have hope.
As with any treatment there is always the risk of things going wrong and sadly causing further damage, harm or potentially even death. If this were to occur then we would have another ethical dilemma as well as potential legal issues. We knew that if nothing were done for the baby then death would be inevitable. So in our trying at least we were giving the baby a greater chance at life.
This action follows closest to my own personal values as I am a practicing Catholic and believe in the sanctity of life to a certain extent. In saying that I should also state that I have a great appreciation for quality of life, and just because we have the technology to save/prolong life does not mean that we should always use it.
The Code of Ethics for nursing would support me in my choice of action, in that I acted in the baby’s best interest, her dignity was maintained as well as I conducted myself with honesty and kept my professional integrity intact.
Role of the Nurse
The nurse is an essential member of the ethical decision-making process. Lasby & Dunki (2004), have outlined the nurses rights to participate in decision-making as we have; a responsibility for care, valuable knowledge to share, a greater understanding of the patient as well as having the ability to share a continuous, trusting relationship with the parents.
An important role the nurse has prior to any situation is to anticipate and prepare for potential ethical dilemmas. Due to the fact that the neonatal nurses are rarely involved with the pregnant women we would not have much opportunity to discuss potential dilemmas with them but it would be important for nurses working with these women and families (especially the high risk ones) to discuss their wishes. If a situation should arise, then it would be imperative to pass the information on to others involved in these families care. As important as preparing is, one can never be certain what they would actually do unless they are in that situation. For example when I found out that I was pregnant I said if I delivered before 25 weeks I would not want to do anything for the baby. As I approached the 22-25 week mark, I truly felt if I were to have delivered I would have wanted a full resuscitation on the baby, even knowing what I know as a neonatal nurse.
During the ethical decision-making process it is essential for the nurse to encourage and obtain a trusting parent-professional relationship with open and effective communication. In doing so we must understand and appreciate the family’s interpretation, beliefs and views of the current situation (Lasby & Dunki, 2004).
Nurses need to be readily available to the family during problem solving and decision making to help parents explore available options, potential decisions and probable outcomes. As well as facilitate parental access to physicians (Miya, Boardman, Keene, Spielman and Harr, 1995).
After a decision is made and carried through, it is important for nurses to evaluate and review the decision as well as resultant consequences. This reflection will aid in future decision-making. It is imperative to follow up with the family involved to ensure congruence in future situations (Lasby & Dunki, 2004).
Ethical decision-making will always be a part of nursing, the more involved we become the easier it will be to work through the process. We will also be in a position to better aid others involved, especially the patients’ and their families. The ideal goal in ethical decision-making is to attain a consensus between the parents and professionals (Lasby & Dunki, 2004).
Harms, D., & Giordan, J. (1990). Ethical issues in high-risk infant care. Issues in Comprehensive Pediatric Nursing, 13, 1-14.
Lasby, K., & Dunki, (2004). Issues in Maternal Infant Child Nursing. Mount Royal College.
Miya, P., Boardman, K., Keene, A., Spielman, M., & Harr, K., (1992). Ethical perceptions of parents and nurses in NICU: the case of baby Micheal. American Journal of Nursing, 24,(2), 125-130.
Nursing Practice Standards, (2003). Alberta Association of Registered Nurses. Thompson, J., & Thompson, H., (1990), Applying the decision-making model: case study Neonatal Network, 9,(3),75-77.