Cancer: Making Framework, Case Study Example

Ethical dilemmas are inevitable in the healthcare setting. Health professionals are faced with ethical dilemmas when it comes to attending to their clients. The dilemmas become challenging when patients involved are suffering from chronic illnesses, such as cancer, as there are limited options for providers while the client’s needs demand autonomy. This decision-making framework explores the case of Juliet; a 48-year old Biochemistry Lecturer diagnosed with colon cancer. Working in an Intensive Care Unit (ICU), attending to cancer patients is challenging, particularly to student-nurses. However, following the decision-making framework based on McDonald and Then (2019), this report will offer the appropriate guidelines for the right options to consider in Juliet’s case. To come up with a comprehensive and effective decision for Juliet in this case, it explores the ethical and legal principles that are appropriate for the nursing profession in handling patients upon facing dilemmas. Therefore, this work deploys the first three steps of the decision-making framework of McDonald and Then (2019), which are the identification of issues, assessment of the identified issues, and making decisions on the final action that needs to be of the best interest of the patient in context. The work intends that by using the first three steps of the proposed framework as the foundation for planning and execution of the expected action plans, it will result in a constructive resolution for Juliet.

Step 1: Identify Issues and Collect Information

In the case study in question, Juliet is a 48-year old diagnosed with colon cancer. Based on the situation, the client is in intense pain and is not willing to cooperate further with health professionals as far as subsequent medications are concerned. Although initially, Juliet had conformed to the requirements of the treatment by accepting surgery alongside all the needed activities to see her condition improving, she seems to have changed her mind when the aftermath of the surgery led to multiple complications.

One of the critical issues facing the case in question is the ethical dilemma. In the contemporary state, Juliet does not want to comply in signing the consent form for the review of her colostomy and subsequent removal of the tissue scar. To the medical staff, Juliet presents a quagmire instance in the sense that providers are in a state of confusion of whether to conform to Juliet’s decision or pursue the right thing of having the colostomy reviewed. According to the nursing principles and ethics, there is a need to respect the decisions of the patient, which promotes autonomy (McDonald & Then, 2019).  At the same time, nurses or medical staff are entitled to enhance non-maleficence and beneficence, which is to not-do harm and promote good, respectively (Valery et al., 2020). The instance where the nursing principles contradict the rights of patients brings about the state of an ethical dilemma.

The legal implication associated with the situation is ethical distress. The existence of an ethical dilemma presents moral distress in the sense that nurses or health providers are in an emotional state where what they feel is ethically correct contradicts what they are being told to do (Dunn et al., 2017). The Australian Law supports the patient’s autonomy and the health providers, and I are bound to adhere to the implications associated with the right of the patient. In this case, nurses and I included, feel that it is morally right for Juliet to have her colostomy re-examined for further effective treatment. However, the failure of Juliet to conform to signing the informed consent, which is her right- according to the Australian Law, is hindering health providers from adequately serving her, thus instilling a sense of ethical distress.

The individuals involved in the case in question include the patient, Juliet, the registered nurse, the doctor, and I, the nursing student, on clinical placement. Juliet is the central focus of the case as she is the patient who needs to make decisions that ascertain her recovery. The registered nurse and I are entitled to take care of Juliet and see to it that she makes the best decision concerning her treatment course (Hulbert-Williams, Hulbert-Williams, Whelen, & Mulcare, 2019). The doctor is also involved as he/she will have to consider the needs and rights of patients before executing any further medical interventions on Juliet. At the end of the day, health providers are in a state of ethical dilemma and moral distress (Grant, Hunter, Bensoussan, & Delaney, 2018); that is when Juliet’s demands do not conform to their intended way of treatment. At the same time, Juliet is at risk of ultimate death when appropriate actions are not considered timely. Therefore, her life is at risk if care providers leave her alone, and that also puts them at risk of breaching the ethical principles of non-maleficence and beneficence. Further information could be looking into the type of support or family Julie has, to talk about the situation. Determining Juliet’s previous experiences that could be influencing her decision is also critical.

Step Two: Evaluate the Issues

To effectively explore and assess the issues identified in the case study in context, this section will focus on the ethical dilemma observed in Juliet’s case. In the line of duty in nursing, there is a need to uphold the nursing principles and ethics, which include respect to the patient’s autonomy, non-maleficence, beneficence, justice, and accountability, among others (Fisher, 2017).  By focusing on the case in question, the state of ethical dilemma presented by Juliet to the medical staff reveals challenges in upholding nurses’ principles and respecting the patient’s autonomy.

The relevant legal, ethical, and professional guidelines in line with Juliet’s case include the need to uphold the patient’s right, which is the right to autonomy. Autonomy refers to respecting the right that a patient has the ability and freedom to make independent decisions about his/her medical care/treatment, devoid of the influence of medical practitioners (Theobald et al., 2020). In this case, the idea of signing the informed consent by Juliet for a subsequent surgery of the colostomy is depended on her personal decision. Since she is not willing to sign the informed consent, health providers are not entitled to coerce her into acceptance as that is against the ethics of nursing (Rainer, Schneider, & Lorenz, 2018).  According to the code of conducts for nurses in Australia, the health provider is entitled to give a client adequate time to ask questions, make decisions, decline care, interventions, or treatment, and proceed according to his/her decision while upholding local policy (Code of Conducts for Nurses, 2018). Therefore, based on the legal guidelines of upholding the patient’s right to autonomy, nurses and care providers are restricted to do as per the wish of the patient even when they are emotionally distressed. Since the patient seems to be in the right form of mind, it is difficult for nurses to advocate on her behalf as it will contradict her interest. Therefore, implementing the needs of the client based on her decisions is what must be advocated.

The doctor in question fails to deem the patient’s needs. Sedating the client to attain consent is unethical and illegal by Law. Doctors have a moral obligation to promote ethical principles as they are entrusted by society. Thus, the situation with which the doctor is putting me into instils a sense of ethical distress as he is my superior. While the doctor might want to promote beneficence, he is also bound by the right to promote the patient’s autonomy. While I have educational knowledge to determine the doctor’s action as unethical, based on the Australian code and standards of practice, being on placement within the facility requires guidance from my clinical facilitator.

From the perspective of non-maleficence and beneficence, nurses are entitled to promote good and avoid engaging in activities that lead to harm to clients (Crawford-Williams et al., 2018). The fact that the patient restrains care providers from conducting further surgery, the remaining options are narrow. Nurses might offer palliative services to Juliet to help alleviate the pain associated with cancer until her death since that decision is poised to uphold the patient’s right to autonomy while avoiding harm, non-maleficence (Muntlin Athlin, Brovall, Wengström, Conroy, & Kitson, 2018). Consequently, it is not wise for health providers to offer palliative services to the patient while knowing that there is another alternative to the situation that may turn out to be effective. However, a question may arise as to whether conforming to the client’s demand for being left alone will be not doing harm and promoting good. The reality of the matter is that leaving Juliet unattended in terms of addressing the scar tissue is promoting harm and not doing good to the patient.

Beneficence entails doing the right thing for the patient (Smith et al., 2018). In the case of Juliet, the right thing is to go ahead with the surgery to remove the scar tissue. Currently, Juliet has not reached the final stages of cancer, and not all the options available have failed to be effective. There is still hope for the client as long as she is willing to undertake the surgery. As such, the appropriate approach to implement is to give Juliet time to think over the suggestion, and hopefully, she will change her mind.  However, care providers need to be careful not to influence the client in making any decision as that will breach the right to autonomy.

Essentially, medical staff has limited options to address Juliet’s case, and the only available ones are to wait for her to change her mind or proceed with offering palliative care to alleviate the pain associated with the disease. In either case, as long as the patient is in the right sense of mind, then medical providers are limited in offering the required medication as patients have the right to reject a particular treatment or medical procedure.

Step Three: Action

Response Plan

While patients have the right to decline a particular medical intervention, there are ways that health officials can deem to ensure that they have tried to understand the basis of such a decision and offer the best medical services possible (Registered Nurse Standards For Practice, 2016). In the context of Juliet, it is important to ensure that she is on the same page as the medical staff to adequately attend to her needs (Lyford et al., 2018). Being a biochemistry lecturer implies that Juliet has a vast knowledge of the implications of cancer when left untreated. Therefore, as a nursing student, there is a need to determine the basis with which Juliet opted for no further surgical interventions and ascertain that she is aware of the consequences associated with no further operations (Williams, Hauck, & Bosco, 2017). The following are the major steps or plans to execute in Juliet’s case;

Ascertain Clarity of the Situation to the Client

This point involves ascertaining whether a client understands the repercussions of the projected outcome failure to proceed with the medication.  This stage entails distinguishing if the client understands his/her medical situation or not (Coyne & Dieperink, 2017). Juliet, although being a biochemistry lecturer, might be having a blurred idea of the situation she is in, which hinders her decision making. Extreme pain can invoke anger or a sense of confusion, making a victim claim ideas that he/she would not have intended while in the right sense of mind (Murray et al., 2017). The clarity, in this case, can be ascertained by giving Juliet time to think about the issue and relax, then ask whether she understands the condition that she is in.

Inform the Client of the Possible Effects of Her Decision

The subsequent step upon ascertaining whether the client understands her condition is to clarify the consequences of her decisions (Lin, Cohen, Livingston, & Botti, 2019). In this case, I will inform Juliet about the effects of leaving her condition unattended. Upon ensuring the client is aware of the effects of her decision, and she is still determined not to undertake the surgery, then I will know she is determined and ready to face the consequences; hence, little can be done to change her mind.

Understand Their Story

Step three is to try and understand the background of the patient/family story to demystify any attitude towards her decision and fairly understand the reasons for her decisions (Ostaszkiewicz, Thompson, & Watt, 2019). This is the time where I will ask the client to tell me more about her decisions and what prompted her conclusion. I will then try and share with my University Clinical Placement supervisor to understand diverse perceptions concerning the case and gain more insights into what are the valid options that will ensure the client is safe, irrespective of her condition.  Consequently, I will engage the registered nurse to help in understanding further ideas on how to deal with such an issue.

Ask the Patient to Talk With the Doctor in Charge

Monterosso et al. (2016) advocate for validating patients’ concern to ascertain their viewpoint. Upon validating the client’s concerns, it is important to ask if he/she is willing to talk with the doctor concerning the decision and if the treatments might help. Based on the discussion, the client may still maintain her initial option of not accepting further treatments (Cormie et al., 2018). If Juliet, in this case, finally accepts to have the treatment, then the response plan is complete. However, in case she is reluctant and upholds her initial decision, then I can encourage her to seek a second option.

Support the Right to Seek another Opinion

The Code of Conducts for Nurses in Australia supports the idea of encouraging patients to seek a second opinion concerning their health complications (Nursing and Midwifery Board of Australia (NMBA), 2018). In case the client expresses the wish of seeking another opinion in line with her situation, then it is important to encourage her.

Supportive Care

In the event none of the above interventions come into fruition, then nurses are obliged to offer supportive care, which cancer patients need even if they do not want treatment. Palliative care helps cancer patients to navigate through extreme pain and associated symptoms (Ossenberg, Mitchell, & Henderson, 2020). Subjecting the patient to hospice care is the last resort for Juliet in the event she adamantly rejects the treatment. However, it should be noted that Juliet can as well reject the hospice care as long as she is in the right sense of mind to make independent decisions, according to Dieperink, Coyne, Creedy, and Østergaard (2018). Since euthanasia is not an option in this case under the Australian Law, Juliet needs supportive care from her loved ones or the healthcare facility as cancer takes its course, as established by Atkins, De Lacey, Ripperger, and Ripperger (2020).

It should be noted that the above action plans are not within my scope as a student on clinical placement. However, they are the rational steps a health provider would consider to implement for the sake of helping the client.

Other actions would be

Engage Juliet’s family or close friends for further discussion of her outcomes and moral support. The options of counselling can also help in case the patient has had a bad experience with cancer cases. At the same time, the nursing unit manager should be informed of the doctor’s intention and intervene. Since I am a student nurse and I need to adhere to the code of conduct, observing an unethical activity necessitates immediate report to the unit manager.

Conclusion

Ethical dilemmas are commonly observed in healthcare facilities. The right to uphold the patient’s autonomy alongside the ethical principles of non-maleficence and beneficence instils moral distress and dilemma among medical providers. As long as a patient is in the right sense of mind, his/her decisions need to be considered. In the case in question about Juliet, she is in her right sense of mind and understands the complications associated with not receiving the appropriate medication. With background knowledge in biochemistry, Juliet is aware of the challenges she is yet to encounter as cancer ravages her body, devoid of the needed medication.  However, as a nursing student, I am entitled to ensure that Juliet understands the challenges she is yet to face in case she fails to undertake the needed surgery. At the same time, there is a need to widen options for the client to have an alternative prognosis of her conditions just in case she is willing to have her case re-examined by other specialists. With the ethical and legal guidelines for nurses, I am not entitled to convince the client to change her mind. Rather, I am mandated to ensure she understands the implications of her actions and offers relevant help to the best of my abilities. Nevertheless, upholding nursing ethical principles, devoid of breaching the patient’s right, is critical for the success of the nursing career.

References

Atkins, K., De Lacey, S., Ripperger, B., & Ripperger, R. (2020). Ethics and Law for Australian nurses. Cambridge University Press.

Code of Conduct for Nurses. (2018). Nursing and Midwifery Board of Australia.

Cormie, P., Atkinson, M., Bucci, L., Cust, A., Eakin, E., Hayes, S., … & Adams, D. (2018). Clinical Oncology Society of Australia position statement on exercise in cancer care. Medical Journal of Australia, 209(4), 184-187.

Coyne, E., & Dieperink, K. B. (2017). A qualitative exploration of oncology nurses’ family assessment practices in Denmark and Australia. Supportive Care in Cancer, 25(2), 559-566.

Crawford-Williams, F., Goodwin, B., March, S., Ireland, M. J., Hyde, M. K., Chambers, S. K., … & Dunn, J. (2018). Cancer care in regional Australia from the health professional’s perspective. Supportive Care in Cancer, 26(10), 3507-3515.

Dieperink, K. B., Coyne, E., Creedy, D. K., & Østergaard, B. (2018). Family functioning and perceived support from nurses during cancer treatment among Danish and Australian patients and their families. Journal of Clinical Nursing, 27(1-2), e154-e161.

Dunn, J., Garvey, G., Valery, P. C., Ball, D., Fong, K. M., Vinod, S., … & Chambers, S. K. (2017). Barriers to lung cancer care: health professionals’ perspectives. Supportive Care in Cancer, 25(2), 497-504.

Fisher, M. (2017). Professional standards for nursing practice: How do they shape contemporary rehabilitation nursing practice?. Journal of the Australasian Rehabilitation Nurses Association, 20(1), 4.

Grant, S. J., Hunter, J., Bensoussan, A., & Delaney, G. P. (2018). Guidance for establishing an integrative oncology service in the Australian healthcare setting—a discussion paper. Supportive Care in Cancer, 26(2), 471-481.

Hulbert-Williams, N. J., Hulbert-Williams, L., Whelen, L., & Mulcare, H. (2019). The Psychological Impact of Cancer (PIC) Scale: development and comparative psychometric testing against the Mini-MAC Scale in the UK and Australian cancer survivors. Journal of Psychosocial Oncology Research and Practice, 1(2), e8.

Lin, C., Cohen, E., Livingston, P. M., & Botti, M. (2019). Perceptions of patient participation in symptom management: A qualitative study with cancer patients, doctors, and nurses. Journal of advanced nursing, 75(2), 412-422.

Lyford, M., Haigh, M. M., Baxi, S., Cheetham, S., Shahid, S., & Thompson, S. C. (2018). An exploration of underrepresentation of Aboriginal cancer patients attending a regional radiotherapy service in Western Australia. International journal of environmental research and public health, 15(2), 337.

McDonald, F., & Then, Shih-Ning. (2019). Ethics, Law and health care: A guide for nurses and midwives (2nd Edition) London, UK: Red Globe Press

Monterosso, L., Platt, V., Krishnasamy, M., Yates, P., & Bulsara, C. (2016). The cancer nurse coordinator service in Western Australia: Perspectives of specialist cancer nurse coordinators. Australian Journal of Advanced Nursing, The, 34(2), 16.

Muntlin Athlin, Å., Brovall, M., Wengström, Y., Conroy, T., & Kitson, A. L. (2018). Descriptions of fundamental care needs in cancer care—An exploratory study. Journal of Clinical Nursing, 27(11-12), 2322-2332.

Murray, M. J., DeBlock, H. F., Erstad, B. L., Gray Jr, A. W., Jacobi, J., Jordan, C. J., … & Patterson, A. J. (2017). Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient: 2016 update—executive summary. American Journal of Health-System Pharmacy, 74(2), 76-78.

Nursing and Midwifery Board of Australia (NMBA) (2018). Code of Conduct for Nurses. Retrieved from: https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx

Ossenberg, C., Mitchell, M., & Henderson, A. (2020). Adoption of new practice standards in nursing: revalidation of a tool to measure performance using the Australian registered nurse standards for practice. Collegian, 27(4), 352-360.

Ostaszkiewicz, J., Thompson, J., & Watt, E. (2019). A national project to develop and validate practice standards for Australian nurse continence specialists. Australian and New Zealand Continence Journal, The, 25(1), 16.

Rainer, J., Schneider, J. K., & Lorenz, R. A. (2018). Ethical dilemmas in nursing: An integrative review. Journal of clinical nursing, 27(19-20), 3446-3461.

Registered Nurse Standards For Practice. (2016). Fact Sheet. Nursing and Midwifery Board of Australia.

Smith, C. A., Hunter, J., Delaney, G. P., Ussher, J. M., Templeman, K., Grant, S., & Oyston, E. (2018). Integrative oncology and complementary medicine cancer services in Australia: findings from a national cross-sectional survey. BMC complementary and alternative medicine, 18(1), 289.

Theobald, K. A., Coyer, F., Henderson, A., Fox, R., Thomson, B., & McCarthy, A. (2020). Co-designing an industry-academic postgraduate professional education framework for emergency nursing.

Valery, P. C., Bernardes, C. M., De Witt, A., Martin, J., Walpole, E., Garvey, G., … & Bailie, R. (2020). Patterns of primary health care service use of Indigenous Australians diagnosed with cancer. Supportive Care in Cancer, 28(1), 317-327.

Williams, N. F., Hauck, Y. L., & Bosco, A. M. (2017). Nurses’ perceptions of providing psychosexual care for women experiencing gynaecological cancer. European Journal of Oncology Nursing, 30, 35-42.