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... ing patients condition frequently and assessing that there was no worsening was very indicated in this case. Addressing patients needs, trying to get new orders and make the doctor to personally assess the patient was very crucial in this matter. The other important principle is nonmaleficience, it means doing no harm. I was unsuccessful to positively benefit the patient, but by all means I had no right to harm her. I realized that persistent nausea or emesis were the side effects of Morphine and high blood pressure or they could be due to paralytic illeus.
My patient had IV running so I was replacing the volume she had lost plus I had quick access to vein, in case there was a need for IV medication. I was aware that Gravol could make my patient sleepy and it could be difficult to assess her level of consciousness. I knew that my patient would benefit from a few units of regular insulin, but giving a combination of short and long acting insulin in the middle of the night or early morning was more than wrong. Giving a large dose of insulin against the doctor's order would put my patient and me in jeopardy. I had no guarantee that this patient would be eating in the morning. My goal was also to promote my patients rest. It was a fine line between my responsibility to check if patient condition is worsening and providing undisturbed rest periods. I explained to my patient why she is not receiving mentioned above medications.
The final principle in ethical theory is justice. It is described by Gual, 1990, page 26 as a person is treated justly when he or she is given what is owned or legitimately claimed. For me other name for justice is fairness, as it is stated in Code of Ethics prepared by CNA. Looking at this situation I know that I spent a lot of time with my client responding to her needs. I was consistent in trying to promote health and well-being and I used the resources which were available at this moment. The kind of care which I provide for this client was not influenced by her age or social status.
I am convinced that my action would be the same in case it could happen to other client at this time. I was glad to have a chance to talk with my PCL shortly after my shift was over. In my quiet thoughts, I was convinced that this patient would receive different care if there was an access to other doctors during a night and she could get better treatment. It is very easily to notice other people should or could, it is much more difficult to see my own mistakes or explore different options. Analyzing this scenario I am pretty sure that events on this specific shift had some contributing factors which were not under my control. Having access to one doctor is not enough in the hospital setting.
I am pretty convinced that night shift had significant influence in sequence of this scenario. The day shift will automatically give me more possibilities to explore new intervention and I would be able to contact other doctors which could allow me to initiate different actions and treatments. Thinking the whole situation over, I am positive that my ethical duties from the nurse - patient relationship would not be changed. I did tell the truth to that patient and explained my actions. By interactions with my client I could tell that she knew that the care which I delivered to her was constant. Admitting to my patient that I did not have any medication to work with, kept my patient calm but not better.
I could feel that this patient was able to understand the position in which I was, it is also called nurse in the middle syndrome. On that specific shift I thought that there was no other possibilities but if it would be truth my feeling of powerless and frustration would not be so strong. It is time to look at this ethical dilemma with a little critiscm in regards to my actions and it is time for some suggestions. I thought that I explored all the possibilities. Starting from the nurse in-charge, I shall be more assertive with her. Instead updating her with the care which this patient received I shall ask her to step in and show some leadership role. Together we shall look for other option as she was more experienced than me and was working longer for this hospital.
I shall state clearly that my patient was not getting adequate care, plus my response shall remind her that this is also her patient and we supposed to decide about our action together. Our common goal shall be to improve this patients condition and we could reach this by working together and supporting each other. Other alternative was to be persistent with doctor, act better as a patient advocate, try to tell my suggestion or ask doctor to explain his rationale for his orders. I did not call nursing manager in-charge on this specific shift. In previous practice we never had to do such a step but I had this in my mind and did not proceed with it. I was certain that by doing so I would still not get the appropriate order for my client and did not speed things up.
This was probably important decision as it would address the problem on the spot, get over with the disagreement about insulin administration with me and the nurse in-charge. Therefore I cannot comment about decision making on the Meso level as I did not explore it. My practice is not perfect and there is always room for improvement. If I would approach this situation again for sure I would be more assertive. I think it is beneficial to explore other alternatives and encourage other coworkers or professionals to discuss the possibilities of different actions plus to decide together what would benefit our patient. After all, we are the most responsible for the care which we give to our client and if there is an indication that the care is not appropriate we shall make the attempts or steps to provide better and more satisfying care. Refrences 1.
Canadian Nurses Association: Code of Ethics, August 1999. 2. Gual Al. Ethical decision making in the critical care units. Critical care Nurse 1999; 16, p. 24-26 3.
Omery A, (1989). Values, moral reasoning, and ethics. Nursing clinics of North America. 24 (2), 449-508. 4. Reich WT. Speaking of suffering: a moral account of compassion.
Soundings 1989; 72; p. 83-108 5. Rushton C.H. (1992) care giver suffering in the critical care nursing. Heart and Lung.
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