This section requires you to justify the use or non-use of the DNR document. It's tricky. Let's solve the puzzle by dissecting every piece from it. First, it's a legal matter. A Google search will return thousands of cases that revolve around the use/misuse of DNR. So, Mr. Miles wished to but couldn't sign the DNR directive.
Second, renal failure has not put his life and functionality to a halt though, yes, it may not be the same. The dilemma we face here (the doctor, the nurse, and the family), thus, is that dialysis is a practicable option that can save Mr. Miles' life, but he wished to use the DNR directive.
To solve the puzzle, review of literature informs us that Mr. Miles' case is that of partial DNR consent: i.e., he wished to opt for it but couldn't sign it. Let me remind you that we're only concerned here with your role, that of the nurse as a patient advocate, and we're aware that it's the nurse's professional responsibility to respect and follow his/her patient's wish.
But the dilemma does not leave us. It's still complicated. What if the family wants to save his life, and I think it's pretty logical for them to do so. Note the point here that we need to discuss the legal framework about the authority a family member has in giving his/her consent in such a scenario. The hierarchy has the spouse on top, then the children, and then anyone else (surrogate).
So, because it's complicated, I cannot say what to do. However, I have dissected all the pieces of the puzzle for you to decide whether you'll follow Mr. Miles' last wish for the DNR or the family's directive (if different).
Whichever you choose, remember, you must discuss the significance of discussing the situation at length with relevant stakeholders and witnesses. Here, we have the family, probably the doctor, and you as the witnesses. Make your decision, and this section is complete.
Remember to cite references for these points.
B1. Moral Responsibility
You need to discuss the nurse's moral responsibility in relation to the patient, the nurse (your legal role), the family, and the hospital. So, we must justify these in the light of available legal framework.
First, the patient. Morally, ethically, and per Ethics Code, I think you understand what your moral responsibility is. Since it is an open-ended area, you should decide what you are to the patient (Mr. Miles) in this situation. You have full legal right to advocate for your patient.
Now, the nurse. You must justify your role, responsibility in this scenario. As a nurse, what does the law of your state say about partial DNR? Google it. Consider the principle of patient autonomy. You should also find out your hospital's policy for partial DNR. Nurse Practice Act is equally applicable here.
So, whatever your decision is, whether to let Mr. Miles respectfully pass....or to follow the family and/or the hospital's policy, your role MUST be justified. This is the prime principle of nursing Ethics Code and the law. Justify your decision, and if you undergo a moral dilemma, be open, involve your team, discuss it thoroughly, etc. Your decision must be accountable. So, I think you can decide what to you.
Hint: You'd first look into the hospital's policy, Mr. Miles' wish, your role as an advocate, and discuss the possible decision with relevant people in the management, and take a position.
The family. There are no easy answers in real-life scenarios that match that of Mr. Miles. Say the same thing here. Highly the role of open and transparent communication with the family, and...REMEMBER...emphasize that you as a nurse must insist on documenting a decision whatever it be (recall the accountability principle).
Agency here clearly implies the scope of the nurse's individual action. But, it should be remember that while you want to highlight the individuality of the nurse (yourself), you should link your role to other processes that mediate this agency. You can't take a decision without considering the state law, the NPA, etc. So, agency is to be exercised within the available scope (say the same).
B2. Stakeholder Impact
Patient: So, up to this point, I think it's pretty clear that we're heading toward a big decision, and Mr. Miles as probably the most important stakeholder will be the center that decision. Hospice can be highlighted as a rational route to the decision if you want to go in that direction.
Family: Whatever the final decision is, family is an equally important stakeholder facing the trauma probably of the worst kind. So, here we want to highlight the role of education to the family about the process of the decision (any), and the steps of care planned for Mr. Miles.
C. Discussion of Code of Ethics
Which Provision from the Ethics Code is applicable here? Probably, more than one, but you just want to focus on the most relevant: Provision 2. Quote it with full reference.
Now your analysis of the provision should point to the direction of your primary responsibility as an advocate of your patient, and under this provision, what role you're going to play. Hint: No matter the intensity of the conflict, your job is to advocate for the patient's wish.
C2. Importance of Patient Autonomy
I think this pointer should become self-explanatory to you now. It requires a little expansion. So, with the help of literature highlight what autonomy means for a patient, and as a nurse what your obligation is to this principle. Also, write a few sentences for patient's independence and its relevance to this scenario.
D1. Legal Conflicts
Legal conflict is expected. Here, we need to highlight the principle of patient autonomy, his right to self-determination, and the nurse's professional obligation to stand for her patients. So, she must guard his interest, AND any decision MUST be documented properly through every step. This is the only way to avoid ramifications in the wake of the decision. Certainly, the family is the surrogate, so probably, once they are convinced of the viability of the decision, the spouse or children will sign it.
Family must be taken into full confidence about the patient's wish, possible options, (e.g. CPR), and expectations from the family. This is a mandatory exercise in any situation. After that, whatever decision you choose, legal conflict can be avoided by transparently recording it.
As a nurse your role and obligation must be communicated to every stakeholder out there while the organization's policies and position in such cases must be integrated by consultation with the management.
D2. Legal Implications on Nursing Role
The implications may be serious. Thus, here you have to discuss your obligation to advocate for the patient's rights within the available legal framework (NPA, state, and hospital laws/policies). You action must be justified by these frameworks, and this is the only way for the nurse to avoid legal ramifications.
Potential disciplinary action against a nurse may be relevant to one or more of these areas: negligence, consent, accountability,
confidentiality, and advocacy. As far as your course of action is justified, your position is safe.
Potential Litigation is highlighted in two cases in literature: (1) when there is a DNR directive, but CPR is
initiated; (2) when there is no DNR directive, but caregivers don’t use the CPR
approach. Thus, a clear route to either decision is needed to avoid litigation.
D3. Actions to Prevent Conflicts
Same as above: clear legal understanding, clarity of each stakeholder's role/responsibilities, and transparent consultation while keeping in view relevant legal framework at all the levels of the hierarchy are needed to prevent conflicts. Some detail from above can be represented here to make the case more solid.
That's it. We're done. Keep in mind that each section requires just a few sentences (4-5 maybe). It is this succinct approach that will still lead to a large overall piece.
I'd be happy to have your feedback.
Should you need any further assistance, please do not hesitate to reach me at: /meokhan2/at/gmail/./com. Thanks.
