Personal Opinion or Professional Advice?
Ethical obligations when a patient asks
Several years ago I filled the parish nurse position for my church. It was interesting work; I was paid to visit sick parishioners, help them make informed choices about their care, coordinate screening programs and generally dispense nursing advice. What I was not allowed to do was any direct, hands-on care because I was not operating under the direction of a medical advisor, which is out of my state’s scope of nursing practice law.
One of the cases that stuck with me, for a number of reasons, was an elderly Italian woman whom I was requested to visit. Mrs. I, as I will call her, had not left her home in the two years since her husband died and she was happy enough to direct others to do her shopping and cleaning.
In fact, she barely left the recliner that she sat in all day watching game shows at top volume. The first time I visited I saw a heavy woman, hard of hearing, whose legs were wrapped in filthy bandages.
It took several visits for me to convince her to unwrap her legs so that I could see what was underneath, and as I feared her feet were grossly swollen with large discolored lesions constantly oozing fluid.
I convinced her to have a podiatrist visit, and from that point on everything spiraled out of control in a way that I hadn’t predicted. In short order she was taken by ambulance for an MRI, admitted to a rehabilitation facility, lost her teeth and glasses, had a heart attack and died.
While initially I had feared she would become septic in her home and a volunteer would find her dead, I now felt that I had contributed to her death by convincing her that the healthcare system could help her. I grieved about my participation for months.
In a roundabout way, this forced me to look at the issue of ethics. Ethics committees are often formed to review special cases and help the hospitals to avoid lawsuits. Their goal is to allow all parties to understand the particulars, which brings me to “informed consent.”
For example, I’m often asked what I think about certain vaccines and their appropriate use. Two that come up in my clinic are Gardasil and yellow fever. My personal opinion is oftentimes not exactly in line with the information presented by the CDC’s no-nonsense VIS sheet, so I may think that a 25-year-old woman with a list of sexual partners has probably already been exposed to many strains of HPV and not necessarily a good candidate for the vaccine. I’ve also spoken with HIV-positive patients who need live yellow fever vaccine for a vacation to Africa, and although the yellow fever map may show no risk of yellow fever at coastal resorts, can I be sure that the native mosquitoes are also reading the map?
I can defer to the knowledge of my medical superior and the straightforward language of the CDC, but I’m left wondering about the concept of personal ethics and whether the patient really wants my informed opinion. I know it is my professional duty to make sure that patients understand the document they are signing, but how far do I go in ascertaining that they’ve really investigated all the ramifications of their choice?
Medical ethics may be something that we should all review occasionally. Boston College’s William F. Connell School of Nursing has a nursing ethics department with a wide variety of resources available on their website (see “Resource” below) to help you shape your personal development.
William F. Connell School of Nursing Ethics
Christine Contillo, RN, BSN, has worked as a nurse since 1979 and has written extensively for various nursing publications, as well as The New York Times.
This article is from workingnurse.com.