Fundamentals of Nursing and Midwifery 2e

Unit II Foundations of nursing and midwifery practice

204

BOX 11-5 Resolving ethical conflict: A care study Jean Watts is a delivery room midwife in a small regional hospital that serves both private and public patients. Jean has always felt that certain members of the obstetrics–gynaecology medical staff have treated these two groups of patients differently. On this particular morning, Jean is caring for a woman who is scheduled for an elective caesarean delivery. The woman (who is a public patient) has made it very clear she wants to be awake for the delivery and has requested epidural or spinal anaesthesia. Jean is dismayed when the anaesthetist enters the delivery room because the anaesthetist’s success rate with epidural anaesthesia is poor. The anaesthetist unsuccessfully attempts to perform an epidural block. After waiting 20 minutes for results, the obstetrician is growing impatient and instructs the anaesthetist to put the patient to sleep. Jean feels the rights of this patient are being violated but is unsure of what her response should be. Step 1: Assess the situation (gather data) The woman is in stable medical condition (elective caesarean delivery, not an emergency) and has made it very clear she wishes to be awake for the delivery. She is not a privately paying patient of the obstetrician. The nurse believes her role is to promote and protect the patient’s interests; she knows of no reason in this case why the patient’s preferences should be disregarded. The anaesthetist has a poor success record with epidural anaesthesia. The obstetrician seems to want to complete delivery quickly. In the past, he has seemed to give more weight to follow- ing wishes of private patients as opposed to public patients. He is the head of the obstetrics–gynaecology department; he believes nurses and midwives should obey doctors unquestioningly. Nurses have in the past expressed dissatisfaction with the different levels of care being provided to private and public patients, but no-one to date has formally addressed the concern. Step 2: Identify the ethical problem Jean objects to the obstetrician’s intent to disregard the women’s wish to be awake for her delivery; she is aware of no good reasons justifying this course of action. Jean will be a participant in carrying out the decision. The decision for this case must be made immediately; it would be helpful to plan to avoid situations like this in the future. Step 3: Plan a. Identify options Jean can say nothing to the obstetrician and help with the delivery. If asked by the woman later why she needed to be put to sleep, Jean can: (1) tell the truth; (2) refer her to the obstetrician; (3) express sympathy that she could not be awake; or (4) say nothing. Outcome : The woman’s wishes are disregarded; delivery occurs in record time, and the obstetrician is happy; Jean fulfils Jean can remind the obstetrician that the patient was adamant about wanting to be awake and suggest that a different anaesthetist be called in. If the obstetrician agrees, the woman may get her wish and everyone is satisfied with the outcome (Jean must still decide how to prevent recurrence of this dilemma). If the obstetrician refuses and insists that the woman be put to sleep, Jean can: (1) refuse to participate (if another midwife is unavailable or unwilling to replace her, Jean has abandoned the woman and harm may ensue); or (2) participate and proceed as above or resolve to speak to the obstetrician in a ‘cool moment’ after the delivery to see how to avoid this problem in the future. If Jean does not get satisfaction with the obstetrician, then she must decide whether to move through the proper administrative channels. Depending on the institution and people involved, Jean may be affirmed or censored for this move. Long-term outcome : Future patients may be helped by the nurse following through with her concerns. Or Jean can say nothing and assist with this delivery, believing it to be the wisest course of action for the time being, but resolve to take the steps above to correct the perceived injustice. Outcome : There is no benefit for the woman but potential benefit to future. obligation to the doctor and hospital but feels she has betrayed the patient’s trust. Long-term outcome : There is a good probability the same problem will happen again. Or