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Running head: NURSING ETHICS AND PROTOCOLS FOR A PATIENT 1

Nursing Ethics and Protocols for a Patient with a Head Injury who Refuses Treatment

Maninder Mour

Athabasca University
NURSING ETHICS AND PROTOCOLS FOR A PATIENT 2

Summary of the Case

In the case study presented by Pauls (2003), an emergency room (ER) physician is

confronted with an intoxicated patient who has suffered a concussion but who has refused care.

The patient has a laceration on his forehead, secondary to a fall down a large number of

concrete stairs, after which he lost and then regained consciousness (Pauls, 2003, p. 1). The

patient claims he does not remember events prior to the fall and states that he had consumed

between 10 and 12 beers earlier in the night (Pauls, 2003, p. 1). Tired of waiting in the ER, the

patient decides he wants to go home. The physician is concerned that the patient has sustained a

serious head injury and that he does not fully comprehend the medical consequences of refusing

treatment. After the physician explains the risks, the patient states that he understands the

physicians concerns and the potential medical consequences of not being treated for his injuries,

however, he nonetheless refuses treatment (Pauls, 2003). The physician decides to let the patient

leave without being treated.

Application of Ethical Algorithm

While the case study in question focuses on the ethical dilemma the ER physician faces,

the ethical and legal consequences of making the wrong decision can be applied to nurses who

are exposed to similar situations (Grace & Hardt, 2008).

Table 1.0

Application of Blaise and Hayess ethical algorithm to this case study in a table format.

Step Explanation Application


Identify the The nurse must be able to recognize that an In this case, the nurse is confronted with either treating a
potential ethical ethical dilemma exists. Ethical dilemmas potentially life-threatening head injury or respecting the
dilemma. and quandaries typically exist when the patients wishes and letting him leave without being treated.
outcome of a particular action is unknown, There is a conflict between two standard ethical guidelines:
uncertain, or conflicting with the values respect for patient autonomy and beneficence. Which value
outlined in standard ethical guidelines. overrides the other in this case, as ultimately only one can
be chosen?
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Collect, analyze, The nurse must analyze data relevant to the In this case, the patient is intoxicated and has a head
and interpret data patient in question; consider her training, as laceration. The data here leads to an analysis of two
well his/her legal and ethical obligations. assessment questions: (1) can the patient make competent
decisions for himself given his intoxicated state? (2) Can the
patient make competent decisions for himself given the fact
that he has sustained a potentially mind-altering and/or life-
threatening head injury? In further collecting data, the nurse
should consider practical diagnostic imaging and mental
status evaluation in order to help answer these questions.
State the dilemma. The nurse must be able to articulate the In this case, who the nurse speaks to regarding this patient
dilemma, especially if it must be discussed will depend on hospital policy and the nurses rank. If the
with other members of the healthcare team. nurse can make treatment decisions, she may not need to
This is particularly important in this case speak to an attending physician prior to taking action.
study, as the nurse would be working Articulating the dilemma will aid in coming to a pragmatic
together with the emergency room decision.
physician to come to the proper decision.
Can the dilemma be It must be determined whether or not the In this case, it is likely that the nurse cannot order diagnostic
solved by the nurse is able to resolve the dilemma as part tests even if the patient was shown to have impaired
nurse? Yes or no? of his or her professional scope: if so, the capacity as a result of his intoxication and/or injury. At this
proper course of action should be taken, juncture, the nurse would likely only be able to act within
however, if not, then no action can be the limits of her professional scope, and this may depend on
taken. institutional policy or on the individual nurses rank.
Dilemma can be If a solution to the problem falls within the In this case, if the nurse can order diagnostic tests or
solved by nurse. nurses professional scope, she should perform a mental exam on the patient; this should be one of
consider the hospital policies, legal and the first actions taken in order to assess two things: (1) the
ethical obligations in the next step. severity of the patients head injury and (2) the patients
capacity to make decisions. Further evaluations, if the nurse
is able to make them, should also include an assessment of
the patients capacity to refuse treatment in an intoxicated
state. If a toxicology screening or blood alcohol level can be
performed, it should be performed at this time as well.
Assess acceptable The nurse must come up with solutions to In this case, the nurses decision would mimic those of the
and unacceptable the problem if she is able to work on such physicians. Depending on hospital policy and the nurses
outcomes of actions solutions within her professional scope. Of rank, the nurse may either be able to treat the patient despite
taken. these, some solutions will be acceptable and his objections and threat of litigation on the grounds of
some will be unacceptable. Those solutions treating a potentially life-threatening head injury, or she may
which are deemed unacceptable should not be led to respect the patients autonomy if the injury is
be acted upon, while those that are deemed not life-threatening and/or the patient is deemed
acceptable may lead to the correct ethical competent enough to reject treatment despite intoxication.
decision and resolution of the dilemma.

Ethical Issues from a Nursing Perspective


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The legal responsibility of nurses who are confronted with patients who refuse care will

likely mirror those of physicians. The focus for both is clear communication with the patient:

does the patient fully understand the medical implications of refusing treatment? As per the code

of ethics outlined by the Canadian Nurses Association ([CNA]; 2008), nurses must promote and

respect informed decision-making, and ultimately, adhere to the patients wishes out of respect

for their autonomy. In the present case study, however, the nurse must consider if the patients

intoxication diminishes his capacity to make a truly informed decision about his own health. The

ultimate answer is, yes, alcohol can affect decision-making capacity, however, it does not

eliminate it outright (Pauls, 2003). Thus, even though the patient is under the influence of

alcohol, his decision to refuse treatment must still be respected. Another complication is the fact

that the laceration on the patients head is the result of that resulted in the patient losing

consciousness (Pauls, 2003, p. 1). The subsequent lucid interval is suggestive of an epidural

hematoma, which can be potentially life-threatening; however, any traumatic brain injury

warrants further diagnostic investigation (Kushner, 2001). Brain injuries, if severe enough, can

also diminish capacity (Rabinowitz & Levin, 2014). Given the severity of the patients injury and

its potential to impact decision-making, should the nurse or physician insist on treatment? Pauls

(2003) believes yes, however, this is case-specific and or a higher standard of determining a

patients capacity to make an informed decision must be implemented as reflective of this

patients particular situation.

Nursing Actions and Interventions

Medical treatment in this case would require further evaluation of the extent of the

patients head injury and the patients capacity to refuse treatment. With regards to the, head

injury, it would be prudent to order a magnetic resonance image (MRI) to determine if further
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treatment is necessary (Kushner, 2001). A Glasgow Coma Scale would aid in determining the

extent of the patients injuries if they were exhibiting abnormal motor or verbal function (Drake

et al., 2006). A mental status examination would also aid in determining the severity of the

patients head injury as it affects lucidity and cognition, and may warrant further intervention if

the patients capacity to consent to treatment appears compromised (Rabinowitz & Levin, 2014).

With regards to intoxication, urine and blood toxicology results may determine that alcohol was

not the only substance the patient ingested. It may also indicate that the patient does not have the

proper capacity to refuse treatment at this time (Hubler, Sullivan, & Erickson, 1998). In the latter

case, he would need to stay in the ER until he reaches a more appropriate blood alcohol level and

regains capacity to either consent to, or refuse treatment (Hubler, Sullivan, & Erickson, 1998). In

this case, autonomy ultimately overrode the decision to treat the patient, indicating that the need

for further diagnostic assessment was unwarranted because the patient was not intoxicated past

the point of capacity (Pauls, 2003). Given the ethical guidelines provided by the CNA, a nurse

evaluating this patient would be well within her legal and ethical obligations to allow them to

leave the ER without treatment.

Conclusion

Nurses must be well-versed in the ethical, as well as legal, implications of dealing with

patients who refuse treatment. One of the relevant ethical values that underlie many decision-

making algorithms for both nurses and physicians, is the value of patient autonomy (CNA,

2008). Driving the need to balance the outcomes of ethical decisions is adherence to guidelines

such as those outlined by the CNA, however, many ethical dilemmas force the healthcare

professional to prefer one value over another. A general algorithm such as one outlined by Blais

and Hayes can guide the nurse practitioner in the event that a patient refuses a medical treatmen.
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Clear communication and informed consent also aid the nurse practitioner in determining the

best outcomes for patients who ultimately refuse treatment.


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