Ethical Case Study

Pick one of the case studies that follow and read the story and then answer the questions that are listed below the story. Case #1: Mr. B.: Family Conflicts Mr. B. is a 21-year-old African-American male who has been treated over the last year at your hospital for widely metastatic Burkitt’s lymphoma. Mr. B. had lived at home with his mother, but a few months ago against his mother’s wishes, he married his long time 17-year-old girlfriend who is the mother of his 2-year-old son. His mother does not get along with the patient’s wife. The couple have a small apartment and his wife has been trying to keep working nights as a nurses’ aide to support them. He’s applied for disability, but they currently have no consistent source of financial support except her part-time job. Unfortunately, after his first course of chemotherapy, he became septic and nearly died in the ICU. His disease has continued to progress through second and third line treatment, and he has been hospitalized almost continuously for the last two months for dehydration and fevers, among other problems. He has been evaluated for bone marrow transplant, but has steadfastly refused it because “I don’t want my family to lose everything because it’s probably not going to work at this point.” He has told you that he was pressured by his mother to have the evaluation: “It’s really hard to say ‘No’ to her. Mom told me she’d take the hospital to court, if they don’t do a full court press. She’s already contacted a lawyer. My wife can’t stand up to her, so I guess I’ll end up doing it even though I don’t want to.” Questions: What ethical principle(s) is/are at issue in this case? Does this situation warrant an ethics consult from the hospital ethics committee? If so, who should initiate it? What, if any, legal issues should be examined? What patient/family issues should be addressed? What advocacy role do you have as the oncology nurse taking care of this patient? Case #2: Ms. D.: Patient & Interdisciplinary Team Disagree on Treatment As a nurse working in an inner city medical center hospital, you take care of many underserved patients. On rounds with the gynecology oncology team, you meet Ms. D., a 33-year-old white unmarried woman with Stage IIIC ovarian cancer. Ms. D. has refused all offers of chemotherapy treatment for ovarian cancer that has now spread throughout her abdomen and inguinal nodes. She has malignant ascites and a bowel obstruction. Her condition has worsened to the point that she has to have daily paracenteses and the team has told her that they may have to operate to partially alleviate the obstruction. She tells you she has schizophrenia and she hasn’t taken her psychotropic medications in a while because “they’re poison.” She tells you, “I may be crazy, but I’m not stupid. That treatment is going to kill me. I don’t want it.” The treatment team tells her that treatment is her only chance of curing her cancer, and they will contact her family against her wishes to make sure she gets appropriate treatment. Assignment Questions: What ethical principle(s) is/are at issue in this case? Should an ethics consultation be requested? What advocacy roles do you have as the oncology nurse taking care of this patient? Do you think Ms. D. is capable of being her own decision-maker? If not, what resources does your hospital have to assist in appointing a DPOA (Durable Power of Attorney) or guardian (social services, patient advocates, relationship with state Ombudsman)?

Case #1: Mr. B.

Ethical Principle(s) at Issue:

Autonomy: Mr. B. has the right to make his own decisions about his care, even if those decisions go against the wishes of his family and the recommendations of his healthcare team.
Beneficence: The healthcare team has a duty to act in Mr. B.'s best interests, which they believe includes receiving bone marrow transplantation.
Nonmaleficence: The healthcare team also has a duty to avoid harming Mr. B., either physically or emotionally.

Does This Situation Warrant an Ethics Consult from the Hospital Ethics Committee?

Yes, this situation warrants an ethics consult. The ethics committee can help to mediate the conflict between Mr. B. and his family, and to ensure that Mr. B.'s autonomy is respected.

Who Should Initiate It?

The ethics consult can be initiated by any member of the healthcare team, including the oncology nurse, the physician, or the social worker.

Legal Issues

There are a few legal issues that should be considered in this case. First, Mr. B. has the right to refuse treatment, even if that treatment is in his best interests. Second, his family does not have the right to overrule his decision. Third, the healthcare team must respect Mr. B.'s autonomy, even if they disagree with his decision.

Patient/Family Issues

The following patient/family issues should be addressed:

Mr. B.'s fear of bone marrow transplantation and his concern about the financial burden it would place on his family.
Mr. B.'s mother's desire for him to receive all possible treatment.
The strain that this conflict is placing on Mr. B.'s relationship with his family.

Advocacy Role of the Oncology Nurse

The oncology nurse can play an important advocacy role in this case by:

Educating Mr. B. about the risks and benefits of bone marrow transplantation.
Helping Mr. B. to communicate his wishes to his family and the healthcare team.
Supporting Mr. B.'s right to make his own decisions about his care.

Case #2: Ms. D.

Ethical Principle(s) at Issue:

Autonomy: Ms. D. has the right to make her own decisions about her care, even if those decisions go against the recommendations of her healthcare team.
Beneficence: The healthcare team has a duty to act in Ms. D.'s best interests, which they believe includes receiving chemotherapy treatment.
Nonmaleficence: The healthcare team also has a duty to avoid harming Ms. D., either physically or emotionally.

Should an Ethics Consultation Be Requested?

Yes, an ethics consultation should be requested in this case. The ethics committee can help to mediate the conflict between Ms. D. and her healthcare team, and to ensure that Ms. D.'s autonomy is respected.

Advocacy Roles of the Oncology Nurse

The oncology nurse can play an important advocacy role in this case by:

Educating Ms. D. about the risks and benefits of chemotherapy treatment.
Helping Ms. D. to communicate her wishes to her healthcare team.
Supporting Ms. D.'s right to make her own decisions about her care.

Is Ms. D. Capable of Being Her Own Decision-Maker?

Whether or not Ms. D. is capable of being her own decision-maker is a complex question. On the one hand, she has schizophrenia and is not taking her psychotropic medications. On the other hand, she has expressed a clear understanding of the risks and benefits of chemotherapy treatment, and she has stated that she does not want the treatment.

The ethics committee can help to assess Ms. D.'s decision-making capacity. If she is found to be incompetent, the ethics committee can recommend that a guardian be appointed to make decisions on her behalf.

Resources for Appointing a Durable Power of Attorney (DPOA) or Guardian

Social services: Social workers can help patients to appoint a DPOA or guardian.
Patient advocates: Patient advocates can help patients to understand their rights and options, and to assert their autonomy.
State ombudsman: The state ombudsman is an independent office that investigates complaints about healthcare facilities and services. The ombudsman can also provide information and assistance to patients and their families.

I hope this information is helpful.

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