Ethical Dilemmas in Nursing
Ethical Dilemmas in Nursing
Case 3 (JUSTICE)
Takes place in a busy general intensive care unit, where the Charge Nurse and other health team members debate their reasons for choosing to give more or less nursing care to particular patients – and for deciding which patients to keep or to transfer – in circumstances where there are neither enough nurses nor enough beds and equipment to give all patients ideal care.
Description of the Case
The scene opens with the Charge Nurse, Frances, discussing the unit’s bed situation with the attending physician. She says she can bring in a nurse who is on call, but “we can’t really accommodate two more people (patients) tonight.” Nurse-ethicist Anne Davis comments that when there are more patients than facilities available, nurses’ decisions are based on the principle of justice. We then see an ambulance pulling up to the hospital emergency entrance with a cardiac emergency case who will need immediate care, but we hear Frances on the phone saying that there is no bed available.
As we view some of the activities of the unit, including two new admissions and an elderly patient being sent out of the ICU to another unit in the hospital, we hear nurses express a variety of views about the criteria they use in making such decisions: One comments that prognosis is important – you should give care to the patient who will benefit most. Another notes that viability, an aspect of prognosis, may also be a factor in allocating ICU beds and nursing care, for example when “non-viable” patients are occupying beds needed by potentially “viable” new admissions.
Another nurse is heard to comment that the social and economic status of patients may sometimes result in their getting better care. A social worker comments that quality of life is an important factor, and goes on to question the mind-set (sometimes referred to as “ageism”) that values the life of a young person over that of an older patient.
A number of nurses, physicians, and other hospital workers are clustered around an infant patient who is having his respirator tubes withdrawn in preparation for being moved out of the ICU. Frances comments that nurses must speak up when there are disagreements among the staff about which patients are ready to be moved, even though “nurses don’t have the final decision in that.”
Finally another nurse, Jane, observes that the increasing scarcity of funding and other resources is causing us to ask more frequently the serious ethical questions about allocation of resources and the appropriate use of medical technology: “Should we?… and which patient should we?… is the question that’s going to come up.”
Questions for Discussion:
Do you think the situation seen in this ICU is realistic? Do such problems arise in other, non-ICU settings such as general wards, nursing homes, clinics, emergency rooms, mental health facilities, public health agencies, etc.?
To what extent do you think nurses are really involved in making such decisions where you work? To what extent should they be? Who else should be involved: families? physicians? administrators?
When you have had to deal with such situations, what factors affected your decisions?
Do you think issues of ability to pay affect these decisions at the unit level? What about in determining which patients will be admitted to the hospital in the first place? What do you think about this?
Have you ever experienced a situation where a famous or “important” person was a patient in your institution? Do you think that they received the same care as any other patient? If not, how was this justified or explained? How do you feel about this?
Suppose you were confronted with the following group of patients awaiting admission to your ICU, which has a limited number of beds. Their medical conditions are similar. List the order in which you would assign them to the available beds: (You can give the same priority number to more than one patient.)
___ a 38-year-old police officer,
___ a severely retarded 5-year-old,
___ an indigent chronic alcoholic,
___ an accused rapist,
___ Your state Senator,
___ the husband of a nurse on another unit,
___ an attempted suicide,
___ an 85-year-old woman with other severe health problems,
___ an infant ward of the state,
___ a beautiful and famous actress.
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