EP13
Ethics, Privacy, Security and Confidentiality EP13
- Provide one example, with supporting evidence, of nurses applying available resources to address ethical issues related to clinical practice.
Clinical Nurses Address Ethical Issue on the Intermediate Care Unit
Greenwich Hospital (GH) nurses may face ethical issues in their professional practice. Resources available for nurses to use in addressing ethical issues include the Palliative Care team, Spiritual Care, the Ethics Committee and strong interprofessional and leadership support. The interdisciplinary Ethics Committee comprises GH hospital and medical staff members and a community member. It serves to provide education on ethics and to address ethical concerns raised by members of the GH community. Ethics Committee consultations may be requested by a patient, family member or any member of the healthcare team. (Evidence EP13-1, Ethics Policy)
GH’s 20-bed Intermediate Care Unit cares for patients requiring higher levels of care. Patients are admitted with cardiac, pulmonary and post-surgical issues due to co-morbidities such as management of heart failure, COPD, dysrhythmias and acute cerebrovascular accidents. Many patients require high flow oxygen or BIPAP. All are monitored by cardiac monitor techs, critical care interns and residents. The nurse-to-patient ratio is 3 to 1, and the unit houses 10 video-monitored rooms.
In fall 2016, Gina Trovato, MSN, RN, CHPN, Clinical Resource Nurse/Clinical Nurse, and Deanna Rivera, BSN, RN, Clinical Nurse on the Intermediate Care Unit, cared for a patient with a cardiac diagnosis who had been admitted by Rivera with Trovato's assistance. The patient’s past medical history included multiple co-morbidities. On arrival, the patient was alert and oriented. The patient retrieved his advance directive and handed it directly to Trovato. Trovato reviewed it, made a copy for his chart and returned the original to the patient. Trovato shared the directive with Rivera and communicated the patient’s wishes to her, which Rivera acknowledged, and Trovato documented their receipt in the patient’s electronic medical record (EMR) in Epic.
The advance directive indicated that the patient did not want mechanical ventilation or an artificial tube for feeding. It also indicated that the healthcare proxy would be a family member, who had signed and dated the document. The advance directive indicated that the patient wished to be a Do Not Resuscitate/Do Not Intubate (DNR/DNI) on admission.
Ethical Issue
Several days after admission, the patient had an unresponsive episode; post-event, he was alert but nonverbal, showing his teeth on command and tracking his eyes. A nasogastric tube (Cortrak) was placed for medication administration following discussion with the patient’s healthcare proxy. Trovato assumed the care of the patient, who raised the concern with medical residents about the presence of the nasogastric tube in the context of the patient’s wishes. Trovato presented the advance directive to the medical residents on call who were caring for the patient to discuss the concern regarding the presence of the nasogastric tube, notwithstanding its intent (Evidence EP13-2, Advance Directive in Chart, Discussion with Kathrada, MD) Trovato, with validation from Nasreen Kathrada, MD, believed it warranted a discussion with a third party.
Nurse Uses Ethical Resources
Trovato placed an Inpatient Consult to the Ethics Committee to discuss whether the presence of the nasogastric tube for medications versus a tube feeding was consistent with the patient’s wishes. (Evidence EP13-3, Inpatient Ethics Consult) Per the Ethics policy, Trovato placed a call to Donna Coletti, MD, MS, FACOG, Director Palliative Care and member of the Ethics Committee, and left a voicemail message describing her ethical dilemma in caring for the patient, questioning the appropriateness of the Cortrak nasogastric feeding tube.
Addressing Ethical Concerns
That same day, Jessica Montoya, MD, an intern caring for the patient, placed a Palliative Care Services Inpatient Consult given the patient’s overall poor prognosis. (Evidence EP13-4, Inpatient Consult to Palliative Care) Coletti, in her role as the Director of Palliative Care Services and member of the Ethics Committee, received both the Ethics Consult and the Palliative Care Consult and visited the patient to address both needs. At this time the patient was alert, non-verbal but was inconsistent when asked to follow commands such as raising a hand. With the patient present, Colletti engaged the patient’s brother in discussion regarding the patient’s wishes for care. The brother expressed his desire to follow his brother’s wishes while still ensuring a level of care that would address comfort. They agreed to the use of the nasogastric tube for feedings and medications moving forward, with a reassessment for appropriateness. Colletti documented in the patient’s medical record her follow-up to the Ethics Consult requested by Trovato and to the Palliative Care Consult to ensure the entire care team was informed. (Evidence EP13-5, Coletti Note NG Tube) The patient died peacefully shortly thereafter.
A collaborative team approach provided closure for clinical nurses and abided by the patient’s wishes. In March 2018, Trovato was given the opportunity to participate as a panel member at the Yale New Haven Health System (YNHHS) Janet Parkosewich nursing research conference, Nursing Visiting Professor Rounds. The topic of the discussion was moral distress, and Trovato shared her perspective and its impact on her as a nurse.