Reference no: EM133848209

The Nurse Who Thought the ANA Code of Ethics for Nurses Was Wrong

Martha Levy, staff nurse in a small nursing home in a Midwestern community, has just reviewed the physician's orders for Mr. Carson, an 84-year-old man who is being readmitted to the nursing home after a 2-week stay at the county medical center. Suffering from diabetes, chronic brain syndrome, frequent urinary tract infections, and heart disease, Mr. Carson had been admitted to the medical center for treatment of his gangrenous left foot. An amputation had been recommended to prevent additional deterioration of his condition and possible death, but the operation had been refused by Mr. Carson's niece, his only surviving relative and legal guardian. The niece, Mrs. Myers, refused to consent to the surgery on the basis that Mr. Carson would not have consented to the procedure if he were competent and able to state his wishes. The surgery was not performed and over a period of several days, Mr. Carson's condition improved to the point where he could be discharged to the nursing home, his residence for the past 6 years. While Mr. Carson was in the medical center, a gastrostomy tube had been inserted to facilitate his feeding and nutritional intake. The physician's orders stated that he was to be fed a high-protein, low-sodium, tube feeding preparation. This order would not pose any problem in the nursing home, as several of the home's residents were on tube feedings via gastrostomy or jejunostomy tubes. Mr. Carson was largely unaware of his surroundings, but he did move his extremities and moaned loudly when the nursing staff tried to move him or give him small sips of liquids. There was no expectation that his condition would significantly improve. During the first 24 hours after his return, the nursing staff noted that Mr. Carson apparently experienced some discomfort from the g-tube feedings. He frequently moaned and placed his hands over his abdomen. The nurses were not concerned by these behaviors because it was not unusual for patients to occasionally experience discomfort when receiving feedings via a g-tube. The following day, Mrs. Myers visited her uncle and was visibly upset by his general condition, the presence of the g-tube, the feedings, and what she perceived as his discomfort during the procedure. She told the nurse that although she thought the g-tube might have been necessary in the hospital, she had presumed that it would be removed before Mr. Carson returned to the nursing home. She had not been aware that it was still in place. Mrs. Myers called her uncle's physician from the nursing home and asked that the feeding tube be removed. Even though it was doubtful that Mr. Carson would be able to take sufficient nutrition by mouth, the physician agreed to the removal of the g-tube. He then asked that she stop the feedings. He said he would come by the nursing home in the evening and remove the tube. Mrs. Levy objected to the decision to stop Mr. Carson's feedings and remove the g-tube. She did not feel that Mr. Carson would be able to receive adequate nutrition without the tube and that removing the tube would contribute to a deterioration of his condition. Despite Mr. Carson's discomfort with the tube feedings and his niece's wishes to have the tube removed, Mrs. Levy did not want to participate in a procedure that, in her opinion, might contribute to his death. Her reasons, in part, stemmed from the fact that she was a strictly observant Orthodox Jew. She had learned that the Talmudic tradition places the highest emphasis on the duty to do what was necessary to preserve an identifiable, individual human life. She had, in discussions with her rabbi, debated on several occasions the ethics of maintaining terminally ill patients, especially those who were near death. She had gradually become convinced of the wisdom of her religious tradition, which had consistently taught that even moments of life should be preserved. Her religious commitment required her to do what she could to ensure that risk of death be avoided or at least minimized. Other nursing staff members and Mr. Carson's physician sharply disagreed with Mrs. Levy, however. They cited the right of the patient to refuse treatment, as exercised by his legal guardian, and the obligation of the nurse not to prolong the dying process. When she consulted the ANA Code of Ethics for Nurses for direction, she discovered that the obligation of the nurse to practice "with compassion and respect for the inherent dignity, worth, and uniqueness of every individual . . ." had recently been interpreted by the profession in the following manner: "Nurses actively participate in assessing and assuring the responsible and appropriate use of interventions in order to minimize unwarranted or unwanted treatment and patient suffering . . . . The nurse should provide interventions to relieve pain and other symptoms in the dying patient even when those interventions entail risks of hastening death." She took this statement to mean that nurses may withhold feedings from individuals even though this action would reduce adequate nutrition and hydration in the patient and might hasten death. This professional ethic apparently would agree with the niece's and the physician's decisions to stop the tube feedings.

Discuss Mrs. Levy difficult moral dilemma: The ethics of her nurses' association pulls her in one direction, whereas her religious heritage pulls her in another. Determine which, if either, should take precedence.