Grupos Guerrilleros

Fidelity

Fidelity is the individual’s obligation to be faithful to commitments made to self and others. In health care, fidelity includes the professional’s faithfulness or loyalty to agreements and responsibilities accepted as part of the practice of the profes-sion. Fidelity is the main support for the concept of accountability, although con-flicts in fidelity might arise because of obligations owed to different individuals or groups. For example, a nurse who is just finishing a very busy and tiring 12-hour shift may experince a conflict of fidelity when asked by a supervisor to work an

Justice

Mr. Brett Hunter, an 80-year-old welfare patient, developed respiratory distress and high fever and has compromised arterial blood gases. Respirations are 32 and labored. He has consolidation of right lower lobe (pneumonia) and is deteriorat-ing quickly. Dr. Maken feels he would benefit from bedeteriorat-ing in the intensive care unit (ICU) but knows that the two beds will be needed for two new post-operative patients tomorrow. He asks your opinion as the charge nurse.

Gather information on the following:

1. Would ICU admission prolong suffering?

2. Is Mr. Hunter being treated differently because of age or ability to pay?

3. Is it unfair to deny an ICU bed to Mr. Hunter today just because beds will be needed the next day?

4. How many ICU beds are available?

5. Has Mr. Hunter signed a DNR?

6. How long will he be in ICU?

7. Does he have a living will?

8. Is his condition life threatening?

9. Is his condition acute?

10. Is there an option to transfer Mr. Hunter to another facility?

11. What are the potential legal implications of denying an ICU admission to a patient who can benefit from it on the basis that the bed will be needed the following day?

Evaluate your options without regard to the consequences:

1. Admit to ICU tonight and re-evaluate the situation in the morning.

2. Admit for aggressive pulmonary treatment tonight and transfer Mr. Hunter tomorrow.

3. Cancel one of the other patients’ surgeries.

4. Use additional staffing to provide one-on-one care.

5. Transfer to another facility with ICU beds.

What would you do?

? What Would You Do?

additional shift because of “call-ins.” The nurse has to weigh fidelity to the employing institution against fidelity to the profession and patients to do the best job possible, particularly if the nurse feels that fatigue would interfere with the performance of those obligations.

Beneficence

Beneficence is a very old requirement for health care providers who view the primary goal of health care as doing good for patients under their care. In general, the term good includes more than just technically competent care for patients. Good care requires that the health care provider approach the patient in a holistic manner, including the patient’s beliefs, feelings, and wishes, as well as those of the patient’s family and significant others. However, the difficulty that sometimes arises in imple-menting the principle of beneficence lies in determining what exactly is good for another and who can best make that decision.

Nonmaleficence

Nonmaleficence is the requirement that health care providers do no harm to their patients, either intentionally or unintentionally. In a sense, it is the opposite side of the coin of beneficence, and in fact, it is difficult to speak of one term without mention-ing the other. In current health care practice, the principle of nonmaleficence is often violated in the short run to produce a greater good in the long-term treatment of the patient. For example, a patient may undergo a very painful and debilitating surgery to remove a cancerous growth to prolong his life in the future.

By extension, the principle of nonmaleficence also requires that health care providers protect from harm those who cannot protect themselves. This protection from harm is particularly evident in such groups as children, the mentally incom-petent, the unconscious, and those who are too weak or debilitated to protect themselves. For example, very strict regulations have developed around situations involving child abuse and the health care provider’s obligation to report suspected child abuse.

Veracity

Veracity, or truthfulness, requires that the health care provider tell the truth and not intentionally deceive or mislead patients. As with other rights and obligations, there are limitations to this principle, for example, in situations where telling patients the truth would seriously harm (principle of nonmaleficence) their ability to recover or would produce greater illness. Many times health care providers feel uncomfortable giving patients the “bad news” and have a tendency to avoid answering questions truthfully. Feeling uncomfortable is not a good enough reason to avoid telling patients

the truth about their diagnosis, treatment, or prognosis. The patient has a right to know this information.

Paternalism

Paternalism refers to practices that limit the liberty of individuals without their consent. A paternalistic attitude does not prioritize individuals’ choices or wishes.

Those acting in a paternalistic way assume that they know better what is good for the patient.

Autonomy Versus Beneficence

Mr. Lamy, 90 years old, has been hospitalized due to dehydration, nausea, vomit-ing, and a urinary tract infection. He also has Alzheimer’s, is a high risk for falls, has a history of falls with two broken hips, and has a tendency to wander. He was found in the parking lot on three separate occasions.

Mr. Lamy has an intravenous (IV) line. Concerned that he may fall, dislodge his IV, or wander off somewhere, the staff believes it is best to restrain him. Mr. Lamy is adamant that he does not want to be restrained.

Apply the ethical decision-making process:

1. Clarify the ethical dilemma. The scenario presents a common ethical dilemma.

As the nurse responsible for Mr. Lamy, you need to decide whether to act on the basis of beneficence (specifically, nonmaleficence—avoiding the possibility of a fall and injury to the patient) or on the basis of autonomy (supporting the patient’s decision or request not to be restrained).

2. Gather additional data. Your course of action depends on the additional infor-mation you gather. Is Mr. Lamy able to understand that he could harm himself getting out of bed without assistance? How does the family feel about restraints? What facility policies relate to this situation? What is the position of the treating physician?

3. Identify options. Have all other attempts to help Mr. Lamy maintain his inde-pendence failed? For example, has the staff tried keeping the bed’s four side rails up and the call bell within reach? Are they making frequent checks and reminding him to call for assistance? Is there staff available to perform checks every half hour? Can a sitter be provided? Are there available family or friends who might be able to stay with Mr. Lamy? How long will the IV be necessary?

4. Make a decision. The family says they can stay with Mr. Lamy as long as he needs the IV. When the IV is no longer necessary, it is hoped that Mr. Lamy can be discharged to more familiar surroundings.

5. Act. In this situation, it is essential for the staff physician and the family members to work together to provide patient safety. If the family members are available to stay with Mr. Lamy around the clock, create a schedule and notify all staff.

? What Would You Do?

Rationalism

Reason is the basis for how things or conditions appear for decision making.

Rationalism focuses on logical sequencing.

Pragmatism

Pragmatism is the process of clarifying ideas objectively through problem solving.