Bioethics/ Health-care Dilemmas

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Zylah
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Bioethics/ Health-care Dilemmas

Postby Zylah » 06 Aug 2010, 05:52

I realize this is a workplace-specific section of the board, and this could be considered a topic that belongs only to health care professions, but I really hope to have various diverse opinions given, by anyone who has the stamina to actually read the whole thing! :oops:

Before beginning clinicals later this month, I have been required to take a course involving current health-care professional issues, with a major emphasis on Nursing Ethics. Nursing Ethics is a subdivision of Bioethics, which is a relatively new field of philosophy, having evolved primarily in the last 40 years or so, according to my textbook. This would make sense, since that has been the time during which the most recent set of major advances in medical technology have created complex new moral and ethical dilemmas.

I realize this has happened previously during human history; it seems to me that it happens in spurts, with advances in our ability to provide health care.

So in addition to the scientific and technological questions of 'How-To' that we have to ask and answer in each situation with each patient, we are also required to ask and answer moral and ethical questions of 'How-Should'. Using Kohlberg's model of biopsychosocial development, nurses are required to be morally mature individuals (for some reason that makes me laugh every time I read it) who have reached the postconventional stage of development.

With all this in view, the instructor and the textbook urge each student very strongly to develop a definite set of ethics, since we will be making all our 'How-Should' decisions from the vantage point of our own worldview. We do have the guidelines set forth by nursing organizations, such as the ANA and the international equivalent whose exact name I can't recall at this moment, but it is recognized that we as individuals need a strong platform of our own to stand on when we face each decision, particularly during rotations in places such as the Emergency Department.

There are nursing forums and so forth which I take advantage of, as well as being a part of the student nurse community on campus. However, I would also like the perspective of fellow-Druids in developing my own approach to nursing, which is what this post is trying to be about.

Naturally a personal code of ethics is created on an individual basis; however, as I see it one of the purposes of a community such as this is to create an atmosphere for open discussion and thoughtful consideration of these things together. I have a personal moral code, but I humbly recognize its probable imperfections and inconsistencies. I would like to resolve some of these if possible before being faced with it in the heat of the moment, as it were, and for a discussion of issues such as this I would like the input of other Druids.

If that makes sense (and I really hope it does), perhaps some of you would be willing to offer input regarding various hypothetical dilemmas. Naturally anything I post here will be ambiguous and general, given the fact that one vital attribute of a nurse is discretion and confidentiality.

Health care as a profession/vocation is a difficult road, fraught with emotional burdens as well as intellectual and physical challenges. I would deeply value any help you can all offer with the theoretical part of figuring things out; I value the input of others because I realize the necessarily limited perspective I bring to any situation, potential or actual.

When I pose a question here on this board, I'm asking as a Druid first. I would ask as a Nurse first on a nursing discussion board, or in a study group or with my clinical group.

All that being said, here is the first dilemma, which is disappointingly much more to do with bureaucracy than with any exciting bioethical hot-buttons like stem cell research or euthanasia (those are coming, however!): there is a serious nursing shortage; this results in severe understaffing situations. [BTW, legally, student nurses are equally culpable with licensed nurses for anything that goes wrong; we have liability insurance same as they do, and so forth. I'm not complaining, I think that's fair - I wouldn't want any less for my own loved ones when they are given nursing care.]

However: if one day I show up for work at a hospital, and accept an assignment, I am culpable for anything that may happen regardless of how overworked I am. The situation is complex, but the question is, if I know when I show up that there are too few nurses, do I do as much good as possible despite the inevitable shortcomings, or do I refuse to accept the assignment on the principle that the hospital should accept the responsibility of properly providing for patient care? To accept it and be overworked can lead to exhaustion, burnout, and dangerously increased incidence of mistakes; if nothing goes wrong, despite the understaffing, bureaucracy tends to think there's no need for spending more money on adequate staffing. So long-term, it seems right to refuse such an assignment.

Short-term, however, and knowing myself as I do, I seriously doubt I could show up to work and refuse an assignment; because I could not walk away from patients knowing I could help them, and because the guilt would probably crush me. I have always been on some level terrified of authority, and the moment someone looks at me sternly I would probably scurry away with my stethoscope and hope I didn't make mistakes.

As a druid, with the worldview that all life is sacred and deserving of the utmost respect I can give it, yet with the simultaneous belief that death is not the disastrous end-all that many other worldviews paint it to be, I feel that a good argument might be made for either decision. Hence the dilemma.

Sorry for rambling on so long; thank you to anyone who reads this, whether or not you respond. I hope some of you can and will discuss these things with me, so as to give me a clearer lens through which to perceive decisions that must be made instantaneously, but have the impact of issues that deserve long, careful deliberation.
Where the forest murmurs there is music: ancient, everlasting.
- Fiona MacLeod

"I cannot speak well enough to be unintelligible." -- Jane Austen, Northanger Abbey

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Re: Bioethics/ Health-care Dilemmas

Postby mwyalchen » 06 Aug 2010, 08:23

There is a third option: write or email a note to your senior administrator (and keep a copy) to point out that your work station is understaffed; and then go on to do your best anyway.

I'm not necessarily recommending this above the options you've set out; it won't make you popular with your admin if they keep getting these notes! But it does make it clear to them what the situation is. It might also help cover you if anything did go wrong.

Plus there's always the possibility that your notes might jog admin into doing something about it - whether out of honest concern, or from the fear that once they've been told, their own legal liability increases!

But there's one other responsiblity here that you haven't mentioned.

You've mentioned your liability to your patient if you become exhausted or burnt out. What about your responsibility to yourself. This is also important; and any viable system of healing must surely make the wellbeing of the healer a priority?

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Zylah
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Re: Bioethics/ Health-care Dilemmas

Postby Zylah » 10 Aug 2010, 16:38

Thank you for your thoughtful reply, mwyalchen :)

There are some nursing unions that do what you suggested; they have a standing letter to the HR departments of their health-care institutions and when understaffed, no nurses go on duty until the letter has been signed in acknowledgement of the poor working conditions. This does help in some cases of negligence or malpractice (unintentional torts). This may well be the best option, and as you said, if there isn't a union in place to do it for me, I can still implement it myself.

And you are quite right again, I do always need to care for myself, or I will have nothing to give anyone else. Thank you. :shake:
Where the forest murmurs there is music: ancient, everlasting.
- Fiona MacLeod

"I cannot speak well enough to be unintelligible." -- Jane Austen, Northanger Abbey

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Re: Bioethics/ Health-care Dilemmas

Postby Nightfalls » 11 Aug 2010, 04:49

If i was a health-care professional, I would take the assignment and run myself ragged to help the patients. The same i do with my jets everyday really. I take my assignment and work as hard as possible to finish them in a timely manner before my shift ends. The catch is you have to do it SAFELY. Operational Risk Management is something that is stressed every day in my workplace. Do you job, but do it safely. If you have to second guess yourself, check a reference, repair manual, publication, anything. Do not rush so quickly that you could make a fatal error that could end a life. If you can not finish your jobs, you can express concerns like under-staffing to your supervisor.
Out of the night that covers me, Black as the pit from pole to pole
I thank whatever gods may be For my unconquerable soul.

In the fell clutch of circumstance, I have not winced nor cried aloud.
Under the bludgeonings of chance My head is bloody, but unbowed.

Beyond this place of wrath and tears, Looms but the Horror of the shade
And yet the menace of the years Finds and shall find me unafraid.

It matters not how strait the gate, How charged with punishments the scroll
I am the master of my fate: I am the captain of my soul.

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Re: Bioethics/ Health-care Dilemmas

Postby Suzanne Tumnus » 23 Aug 2010, 11:28

Risk assessment!!! check the situation, asses the risk, accept accordingly, and keep sending those letters!!

Nurses are the comforters, the first healing contact, the Doctors come and look for a few moments in after care, in my experience as a patient, you trust a few nurses, because of how they respond to situations. those who look flustered and are too busy to pay proper attention need to go and have a break and relax a while to refocus on their healing work.
I understand that many hospitals are understaffed, Nurses are underpaid and overworked. It should be a calling, a desire to help the sick, not a job, but that calling is exploited in many cases, and the nurses are taken for granted and punished when things get out of their "control" or level of expertise.

I could never be a Nurse, I tried to at one point, but didnt have the necessary school leaving exams, took the old "mensa" test exam thing, and got offered a place, but I wanted to move away from where I lived at the time, my life would have been so different if I had accepted the training placement. I couldnt do it now. so good luck to you. This probably doesnt have even a reference to what you asked for, but all I can say is "follow your heart"

Nurses are valuable and I respect any who try to help others.

Suzanne
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Re: Bioethics/ Health-care Dilemmas

Postby kashi_light » 28 Aug 2010, 09:27

Zylah, I want to thank you for being such a caring nurse. I honor you for that very much. I have seen some pretty terrible things happen in the medical profession, and because of this I ask you to do whatever you can to help reform the practices in regards to ethics. It is soooo important that those involved who care speak out because otherwise nothing will change. Here is a story that is a perfect example of how under-staffing and nurses who dont care can cause a problem. My mother went into surgery for the removal of one of her parathyroids and a tumor on her thyroid. To begin with, her doctor never showed up to the surgery and the surgeon removed the parathyroid but decided the thyroid was fine even though he was given explicit direction to remove the tumor (she still has hyperthyroid disease and now the doctors are telling her to go back to her surgery but she will not do it because of the following experience with the nurses). After surgery the nurses forgot to give her any pain killers, including all of her regular medicine which she takes for several injuries and fibromyalsia. So on top of having no pain killers after major surgery, she was withdrawing from her regular meds too. However, she could not speak since she just had throat surgery. She managed to find a napkin and pen and write down "kill me" on it because she could not handle the pain any longer. The nurse in charge of her ignored the note and did not come back for the rest of the 8 hour shift. When the new shift of nurses come in only one nurse had realized what had happened and rushed to get her medicine. He also yelled at several other nurses though Im sure none of them were fired because there is a shortage of them anyhow. Im telling this story both to show my appreciation for nurses like you who DO care, and to urge you to stand up and tell whoever is in charge what is going on even if it may not be great for you image, because it is necessary for someone to speak up, anyone. And just to suggest to help with overworking in the meantime, have you tried taking supplements like spirulina and chlorella for energy? They really work great, as well as high quality whole food vitamins. Also, something else I learned from playing guitar, that it is important that you regularly relax your muscles all the way, even if for one second, to both make your energy last longer and to prevent injury from muscle strain build up. As mwyalchen said, the health of the health care practitioner is important. This is an emotional subject for me so sorry if it was said harshly at all, and thanks again so much for having such a loving and caring heart. I am considering going into the medical field as a massage therapist, as I feel strongly about caring for others too. With much love, and wishing you a well of light and blessings to share! ~kashi

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Zylah
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Re: Bioethics/ Health-care Dilemmas

Postby Zylah » 28 Aug 2010, 14:15

Nightfalls and Suzanne - thank you for taking the time to respond, and being thoughtful about it. It is much appreciated :hug: :hug: and your points are well taken.

Kashi - I am so sorry your mother (and you) had to endure such a terrible thing. There are so many things wrong with the scenario you described, the potential for malpractice lawsuit is ENORMOUS. Just sayin'....y'know, in case you might want to think about things like Criminal Negligence, failure to show compassion, etc.

I wholeheartedly agree, nursing should be a calling and not merely a job, as Suzanne stated; patients can certainly tell the difference, and so can good physicians or other members of the health care team. On the other hand, we're so understaffed and overworked that it's difficult to see what we could do differently. Those of us who do care can sometimes end up making awful mistakes because one person only has so much capacity to remember and prioritize in stressful situations. For a good nurse, a mistake that causes suffering is horrendously withering because of the intense guilt. *sigh*

I'm glad your mom had at least one nurse who did care, but I'm appalled that there was only one. I can sympathize with her refusal to go back for more surgery after such a horrific experience; that emotional damage doubles the culpability of those practitioners.

Honestly there are many times when I look around and wonder why on earth the professors allowed this one or that one to pass Anatomy & Physiology, never mind their more specific nursing courses.

Thank you for sharing your personal experience, Kashi; I know it must have been difficult. Please don't apologize for sharing honestly; I for one much prefer that to charming falsehoods and blinds. You were not harsh in the least; your tone sounded much more sad than angry - but either or both those feelings are perfectly legitimate in the circumstances.

I'm now succumbing to sleep, as I'm still recovering from surgery myself. Will send your mom healing energy and good thoughts. Be well. :hug:
Where the forest murmurs there is music: ancient, everlasting.
- Fiona MacLeod

"I cannot speak well enough to be unintelligible." -- Jane Austen, Northanger Abbey

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Re: Bioethics/ Health-care Dilemmas

Postby emmao1111 » 28 Aug 2010, 16:26

Hi Zylah - As a druid and as a human being I would not be able to walk away from any creature be it human or otherwise if they needed help. I do think though, that as well as having a responsibility to individuals (and yourself) in that moment, we also have a repsonsibility to the bigger picture, and if understaffing to an unsafe level is common practice I would be doing everything I could to a) cover my butt by sending the e-mail / letter as suggested by others and b) do everything I could to raise the profile of the situation.

I don't know how healthcare works from a financial perspective where you are. Here we have the National Health Service. As it is free we sometimes tolerate understaffing and even poor standards etc as the service is stretched to beyond capacity from a financial point of view. I have been in situations that I would never have accepted were I paying private insurance for example? Is it financial necessity or hospital policy that is posing the problem with staffing? Is it something else? What can be done to help resolve the issues?

I don't expect an answer - just food for thought for you :thinking:

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Re: Bioethics/ Health-care Dilemmas

Postby Fianait » 07 Apr 2011, 20:37

Hi Zylah,
Just found this thread the other day and just finished reading through it. I think it was very wise of you to post your thoughts and search for discussion on the subject; I hope you've found at least some of what you're looking for. I wish you all the best in your training and in your nursing work! :hug: I do echo the suggestion others have made to take care of yourself so you don't burn out. And yes, we do need more nurses who care. :D

Peace,
Fianait
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Re: Bioethics/ Health-care Dilemmas

Postby Zylah » 07 Apr 2011, 21:28

Fianait and Emma, thanks for your replies! :) So much has changed, it seems like a long time ago this was posted, though it really wasn't.

I found the clinical experiences incredibly valuable in that I did see the subject under discussion being confronted in a hospital situation in a good way, and in a nursing home in not such a good way. I also found them incredibly valuable in guiding me further along my path: mainstream medicine is so much at odds with my philosophy that I eventually decided to switch my focus to studying naturopathic medicine. I'm actually torn between clinical work and research, but I have plenty of time to decide - YEARS of study ahead for an ND degree!

Where the forest murmurs there is music: ancient, everlasting.
- Fiona MacLeod

"I cannot speak well enough to be unintelligible." -- Jane Austen, Northanger Abbey

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Re: Bioethics/ Health-care Dilemmas

Postby Fianait » 07 Apr 2011, 21:35

Hi Zylah,
I understand mainstream medicine being at odds with your philosophy; it's the same reason I couldn't work in mainstream medicine. I'm glad you found a focus more in line with your philosophy. I read your "Endings and Beginnings" in the Bards forum after I read this and realized how much must have changed for you since you'd written this thread. I wish you all the best in your new life. :hug:
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Re: Bioethics/ Health-care Dilemmas

Postby Susanne » 09 Apr 2011, 17:14

Hi Zylah
This is a great subject for discussion. In my career as a nurse I have worked on med/surg, critical care & now work in the operating room. In each of theses specialties I have seen first hand the issue of the nursing shortage & how burnout takes it's toll on the staff. As one of the officers of the nurses union where I work I can speak a bit to the specific issue of unsafe staffing.
There have been times when a fellow nurse has refused an assignment due to unsafe staffing, whether it is a factor of numbers, acuity or experience such as being given a patient that you don't have the competencies for (like pediatrics). In each case administration has found other alternatives but generally the nurse then has to deal with the fallout afterward. As a union we represent nurses disciplined by filing a grievance and following it through to what I am happy to say in all of the instances I've seen, a good resolution. This brings me to my point of DOCUMENT, DOCUMENT, DOCUMENT!
We have an actual unsafe staffing form that the nurse fills out & gives to the supervisor for that shift. This is done whether you take the assignment or refuse it but it is essential to have this in place. In a nonunion setting there are other ways to document it such as letters or emails (make a hard copy of it) to the unit manager or shift supervisor.
I am very thankful that we have a union at our hospital that allows us to act as equals with management when dealing with situations such as unsafe staffing. As nurses we have a responsibility to the people that we care for who are in a very vulnerable position and in some situations can't speak for themselves. It is essential to hold everyone accountable for safe patient care. That's my 2 cents on that one. :wink:

As far as how I bring Druidry into my work that would involve a lot of time & typing to discuss! :D I guess I just try to care for people as I would like myself or my loved ones to be cared for. Not to judge or be critical but understanding of where people are coming from and what they need. When I first meet my patients they are going into surgery which can be very scary. Being friendly but professional, honest and clear in my explanations goes a long way towards allaying fears. I After all, knowledge is power & when people are in the hospital they can often times feel just that...powerless. I let them know that I will be right there with them the whole time and will be their advocate & voice for them when they are under anesthesia in everything from ensuring that they are in a safe and comfortable position to ensuring that sterility is maintained throughout their surgery. A good attitude on my part carries over to them and their families as well.
I hope this helps and I look forward to more discussions!
Sue

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Zylah
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Re: Bioethics/ Health-care Dilemmas

Postby Zylah » 19 Apr 2011, 01:13

Thank you, Fianait! :hug:

Susanne - there is a lot of wisdom in all that you shared; thank you! Based on the admittedly limited clinical experience I have, I agree with you about documentation. It's vital to have good documentation for accountability purposes as well as for the sake of giving accurate, appropriate treatment to each patient. But it does seem to me that people such as yourself, who have a strong ethical sense of duty in this area and have developed a high level of competency, are the ones who will actually maintain documentation. Those who are less experienced and/or less conscientious really need to be providing detailed accounts *and* paying attention to those provided by their colleagues, yet they are the least likely to do so.

For instance, my last patient in a nursing home suffered dementia and was therefore unable to provide coherent accounts of anything that happened to her. When reporting off at the end of my shift, I mentioned in passing that I had checked a dressing on the patient's leg and found it clean and intact, but it would need to be changed. This was the regular day nurse, who treated this patient every day; she was appalled at this aspect of my report because she knew of no such dressing. We went together to look at it, and she became more upset because there was a total lack of any documentation regarding either the dressing or the wound it was applied to. No one knew anything about it, except that it had been present for at least a day and a half. :wow:

In the proper course of events, an incident report would have been filed, to include the cause of the wound, the method used to treat it, the time it occurred and the time the first dressing was applied and by whom, and so on. None of this happened, and the whole thing instead was a mystery. In the institutional setting, for obvious reasons, this is really dangerous.

But when you have the problem of overworked understaffed institutions, documentation is often not high on the priority list. I can understand this, although from an objective viewpoint I can also disagree with it in principle. There were days on the orthopedic floor at the hospital, for instance, when we were all running around frantically, trying to be certain we got everything done on time while also staying on top of urgent situations that came up, going in and out of isolation rooms, etc. Frankly, if I did not stop after every single thing, I was in danger of forgetting the exact details (such as temp at 1100 as compared with temp at 0800, or how many ccs of fluid to put down for 'intake' on a chart, etc.) - and there were times I could not stop to write anything down, because people were calling me to help them with this or that urgent situation.

It's a difficult situation all around, I think. :shrug:

I look forward to more discussions as well! :shake:
Where the forest murmurs there is music: ancient, everlasting.
- Fiona MacLeod

"I cannot speak well enough to be unintelligible." -- Jane Austen, Northanger Abbey


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