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Ethical Analysis Paper

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Running Head: Ethical Analysis Paper

When Patient Care Conflicts with Moral, Ethical, and Legal Boundaries

Ethical Analysis Paper

NURS 4080

Trends and Issues

Austin Peay State University

Gregory A. Wood

March 18, 2005

When Patient Care Conflicts with Moral, Ethical, and Legal Boundaries

There are many situations that cause ethical dilemmas in the scope of nursing practice. One such situation that is encountered repeatedly is that in which a patient has no living will or advance directive to designate when extraordinary life saving measures will be stopped and the patient will be allowed to die. This becomes a dilemma in many cases because there is so much uncertainty in outcomes for individuals. This uncertainty stems from the fact that some people recover from profound states of illness while others do not. It is in these cases in which many subjective criteria tend to be added to the equation when trying to decide on the plan of care for the patient (Oberle & Hughes, 2001)


A 78-year old man who has not had any significant health problems in his life except for a myocardial infarction (MI), which was the reason for his admittance to the hospital emergency room. After the acute issues of the MI had been resolved a battery of tests, including: cardiac catheterization, electrocardiogram, echocardiogram, and serum enzyme tests were performed to determine the extent of the damage and the best course for treatment. It was determined that there were two blockages and that the patient would be a good candidate for coronary artery by-pass graft (CABG) surgery. During surgery, the patient sustained another MI and developed ventricular fibrillation which was corrected by electro-cardioverter defibrillation and the use of anti-arrhythmic medications. After surgery the patient was taken to the post-anesthesia care unit where it was found that after the effects of the anesthesia should have dissipated, the patient was unable to sustain spontaneous respiration and his blood pressure continued to fall when trying to wean from the ventilator and vasopressor medications. This is when the patient was admitted to the surgical intensive care unit (SICU) so that the pressors could be titrated to maintain blood pressure and the ventilator could be monitored. During the 6 weeks in the SICU, the patient's status continued to decline. Several attempts were made to try and wean the ventilator and vasopressors but each attempt was unsuccessful. The patient's condition had worsened to a point that the family, including the son, daughter-in-law, and wife began questioning the nurse about trying to get an order to withdraw the life supporting measures. They began asking about the withdrawal after the third week in the SICU when the patient began developing sores on his heels and sacrum and two of his toes turned black because of the lack of circulation in the extremities caused by the vasopressors. He was experiencing renal failure as a result of the low blood pressure and his arterial blood gas values include oxygen saturation levels below 60mmHg and carbon dioxide levels above 50mmHg. The attending doctor was asked by the family on several occasions about issuing a do not resuscitate order (DNR) and to withdraw life support, but the doctor proceeded to convince the family to wait even though there were no signs of improvement. The doctor also during this time had told some of the nursing staff, who had taken care of the patient and talked to the family, to not do a "full blown code" even though there was no written DNR. The patient remained in the SICU for six weeks until he went into cardiac arrest and resuscitative efforts, with every measure available, were performed unsuccessfully.

Ethical Issues

The main ethical issue involved in this case revolves around the wishes and feelings of the patient's family and the opinion of the doctor who has the ultimate power to issue a DNR or agree with the wishes to withdraw life sustaining measures. There was also an issue with the doctor saying to only perform a partial code which was not documented by orders. This was not only an ethical issue but also a legal issue that could jeopardize a nurse's career if the verbal orders were followed.

According to the 2001 revision of the American Nurses Association Code for Nurses, there are four provisions that pertain to this situation. The main provision is Provision 1.3 that states:

"Nurses are leaders and vigilant advocates for the delivery of dignified and humane care. Nurses actively participate in assessing and assuring the responsible and appropriate interventions in order to minimize unwarranted or unwanted treatment and patient suffering. The acceptability and importance of carefully considered decisions regarding resuscitation status, withholding and withdrawing life sustaining therapies, forgoing medically provided nutrition and hydration, aggressive pain management and advance directives are increasingly evident. The nurses should provide interventions to relieve pain and other symptoms in the dying patient even when those interventions entail risks of hastening death. However, nurses may not act with the sole intent of ending a patient's life though such actions may be motivated by compassion, respect for patient autonomy, and quality of life considerations. Nurses have invaluable experience, knowledge, and insight into care at the end of life and should be actively involved in related research, education, practice, and policy development."

According to this provision, as well as provisions: 2.1, "Primacy of the patients' interests;" 2.2, "conflict of interests for nurses;" and 5.1, "moral self respect," there are many issues involving in the ethical care of this patient. These issues are all of ethical concerns, but are also legal concern according to the fact that is illegal to not completely attempt resuscitative efforts in the absence of a DNR.

The ethical principles involved in the care of this patient include beneficence, nonmaleficence, autonomy, and paternalism.

Beneficence states that "the actions one takes should promote good." This principle was used in the care given by the nurse to continue with all measures to promote the comfort of the patient



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