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During the time of my clinical placement at the Women's and Children's Hospital in Adelaide, South Australia, I was being placed in a children's haematology/oncology ward. In the oncology ward, I was taking care of many child patients but there was a child named Abdul who was just 15-year-old. Abdul was diagnosed with a rare malignant blood condition and was known by every staff member because of the way he was, a little matured than his actual age. He liked by every staff members and even I enjoyed taking care of him. He was different than others. After his recent tests he was back in the hospital as his test result showed a re-emergence of his medical condition. Abdul attended the hospital with his parents and he was recommended a new treatment by the paediatric oncologist that has been just become available at the hospital settings. As soon as the meeting with the paediatric oncologist was done, Abdul came to me when his parents were out and we started a conversation. There told me that his parents are not letting him receiving this treatment that was recommended by the paediatric oncologist, as they are concerned with the high risks of this treatment. But, he told me that he wanted to be treated with this recommended treatment even after knowing the related risks as he feels and consider this as his best chance to get cured (McDonald & Then, 2019).
For this assessment, the case study will be explored and the relevant legal and ethical implications will be discovered and discussed. This would be done by using ethical decision making framework. There are in total five steps in ethical decision making framework. They are identification of the issue, evaluation, action, implementation of solutions, and the assessment of the outcomes (Akrami et al., 2018) out of which first, second, and third step would be used.
Identification of the issue:
The first step of ethical decision making framework is to identify the ethical issue. There are generally three types of ethical issues that have been identified in a clinical setting and they are ethical violation, ethical dilemma and ethical distress (Milliken, 2018). An ethical violation can be defined as any action that is violating the ethics and affecting the patient or anyone in the clinical setting (Jafree et al., 2015). An ethical dilemma in clinical setting is a situation where the nurse encounters two situations and has to select one between them; both of the situations can be morally correct but would be conflicting at the same time (Haddad & Geiger, 2020). While, ethical or moral distress is the stress that occurs when either the nurse’s or patient’s values are compromised (Morley, 2018).
So, as per the above justifications, there are two identified ethical issues in this case scenario and they are ethical dilemma and ethical distress. When Abdul and I had conversation and he told me that he really wants to have the treatment but his parents are refusing to do so. This is reflecting an ethical dilemma as at that point of time both of the situations are ethically correct but are conflicting at the same time. The patient himself is giving consent for his treatment but as he is of just 15 years of age he would be considered as a minor and his autonomous right could not be considered. Even, though the patient is considered to be matured than his age by all the staff members but his age cannot be ignored. So, the decision of his parents would be taken into consideration. This situation of ethical dilemma between selecting either patient’s decision or his parents would be considered as an ethical issue.
The second ethical issue identified in this case scenario is the ethical distress. In Abdul’s case he has to compromise with his decision and this compromising with what he wants for himself leads to create stress. The patient is quite mature regardless of his age and he feels that this treatment will definitely get him cure from this serious disease but just because he is minor his decision will not be granted and this thing will bring the situation of ethical distress for the patient.
Who is involved?
Step one of the ethical decision making framework also entails that who are involved in the identified ethical issues (Akrami et al., 2018). In the first identified ethical issue i.e., ethical dilemma the nurse is involved as it is an ethical dilemma for her to select one between the two decisions that are ethically correct. While, in the second ethical issue i.e., ethical distress, Abdul, the patient is involved as his decisions is being compromised.
Evaluation of the issues:
The evaluation of the issues could be done by exploring the related ethical and/or legal principles ensure the issues are correctly evaluated. There are four ethical principles i.e., autonomy, non-maleficence, beneficence and justice (Jahn, 2011). In the given case study, there are three ethical principles that are identified and they are autonomy, beneficence and non-maleficence.
Respecting the autonomy of the patient refers to acknowledging the patient’s decision regarding the care, interventions, or treatments given to him. The patient has the right to make their own decisions regarding their treatment processes, even when the decisions of the patient contradict with that of the clinicians’ recommendations (Valero, 2019). Here, in this case Autonomy is an identified ethical principle because patient’s decision of getting treated is his autonomous right. However, according to the study presented by Sedig, (2016) it has been stated that a patient’s decision must be acknowledged in order to respect his autonomy. But, patient’s decision is not being acknowledged and cannot be acknowledged because he is a minor. Even, his decision regarding his treatment and the recommendation of the paediatric oncologist both are similar and are not contradicting still his decision cannot be acknowledged. Though, it will not be considered as breaching the patient’s autonomy because according to a study presented by Vargas & Pavez, (2019) it has been stated that as per the law child is considered as minor and he has no legal ability to take decisions and in this case, the child’s parents must take the decision regarding the interventions and treatment of their child.
This principle focuses on the moral duty of the health care professional to perform the interventions and provide the care for the benefit of the patient. It works on 2 aspects i.e., providing the benefits to the patient as well as balancing between the benefits and harms. To achieve this there are certain moral rules or obligations that is implicated into practice by the nurses and is supported by beneficence principle. This includes protecting as well as defending the rights of the patient; preventing the possibly occurrence of the risks as well as harm to the patient; removing the conditions or situations that may potentially cause harm to the patient; providing help to the disabled patients; and rescuing the patients from any possibly occurring danger (Bester, 2020). In this case the re-emergence of the patient and the related health risk can be cured if he has been given the recommended treatment. Giving this treatment would be considered as beneficence.
According to Girdler et al., (2018) the core principle of nonmaleficence needs the practitioners to do no harm to their patients whom they have given assurance to help. This principle of bioethics develops an understanding among the health care provider that the benefits of all the clinical actions should always be focused to prevent the risks or any consequences that may harm the patient. The medical procedure should be like that does not inflict the patients. In this case, the patient already had rare malignant blood condition and he got a re-emergence that could be treated with the recommended treatment. However, not providing him this treatment as per the decision of patient’s parents would lead to increase the risks to the patients and can also cause harm. So, this would be considered as non-maleficence. Because, this principle also suggests that possible harms and risks should be removed.
The patient is a child and discussing about the treatment or care related things in the absence of his parents would be considered as a legal implication even if the conversation was started with by the patient itself and he has been admitted earlier. Because, in case of children, all the decisions and decision-related talks should be done in front of the child’s parents and as per them only.
Step 3 of the ethical decision making framework is the possible actions that could be taken in order to help the patient. Actions must be like that it will help in addressing the patient’s health issue without violating his parents’ decision by taking their consent.
Possible actions to be taken:
The possible actions that could be taken would be:
Patient advocacy has been considered to be as a foundational duty of the nurses, and certain characteristic features of the nurses often influences the performance of their role. Patient advocacy, can also be termed as nursing advocacy, it is a part of the ethical practice. This helps in representing the patient as well as his family’s needs and preferences in order to ensure that the medical decision making process is actually in line with the preferences of the client as well as his family (Dadzie, Aziato & Aikins, 2017). Patient advocacy is also considered as a core duty of the nurses as well as their character traits. This includes moral courage and empathy, both of them have been found to persuade the role of the nurses. Nurses are actually the first advocates of their patients. They have been seen as a link between the health care system and the patient (Davoodvand, Abbaszadeh & Ahmadi, 2016). So, being the patient’s first advocate they can advocate the patient in front of his family because technically the decision of the patient is also not wrong but, because all the powers regarding his care is in the hands of his parents there is a need to help the patient so that he will be get treated as per his preference with the consent of his parent.
Counseling of the parents
Counseling the parents in order to make them understand the need of this treatment and how important it is for their child. As parents their concern is not wrong because this treatment has been introduced new to our hospital settings so, it is obvious for them to be concerned regarding this and to deny the treatment process. However, the condition of the patient is such that this treatment is required so, counseling of the patient’s parent by letting them know about the pros of this treatment for their child’s health and assuring them with the outcomes of this treatment. Counseling them will entail few important things out of which listening will be the first and foremost priority. By listening the views of the parents and showing them concern, compassion, and empathy this could be done.
Shared decision making
After counseling the parents that they will be convinced with the treatment process because every parent wants their children to be healthy and good and effective counseling skills will just help the in making them understand the significance of this treatment. And, this will lead to the shared decision process among the clinician, patient, and parent. Shared decision-making is considered as idiosyncratic in the field of pediatrics. In this field the parents of the children play a vital role as they take part in all the decisions regarding the patient’s care and treatment. Shared decision making in the field of pediatrics could be understood as a process in which the clinicians, patient, and the parents/caregivers discuss all the treatment processes and alternatives (if present). They engage in the communication and discuss all the available evidences in favor or against the various options. They collaboratively share their values and preferences and eventually come at a decision that has been taken collaboratively with the consent of parents as well (Hubner, Feldmen & Huffman, 2018). So, in Abdul’s case the shared decision making would be achieved when all participants such as patients, his parents, and the clinicians will work in a collaborative manner and will share all the information regarding the treatment by communicating with each other and sharing their preferences.
Shared decision among all of them would lead to family-centered care along with the patient-centered care. Family-centered care could be described as a collaborative approach to health care decision-making between the family and the clinicians and plays an important role in the field of pediatrics. As the viewpoint of the family centered care, and the associated term patient-centered care are considered to be interlinked in pediatrics. It has been recognized as integral to the patient health, patient satisfaction, and the quality of care by multiple medical societies, state and federal legislative bodies, health care systems, the Institute of Medicine, as well as by the healthy people 2020. It is considered very important in the field of pediatrics between the parents of the child and the health care providing team (Hill, Knafl, & Santacroce, 2017).
This assessment has discussed about the ethical decision making framework in details. This has been done by explaining and connecting the initial three steps of the framework with the given case study. This ethical decision making framework by identifying and evaluating the issues in the case study along with the possible course of actions would be helpful in obtaining the desired results with the shared decision making among the clinician, patient, and his parents.
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