Nursing Case Study

Ethical dilemmas are often presented as case studies centered on medical decision making, such as ventilator withdrawal, tube feedings or resuscitation status.  However, nurses also encounter dilemmas in their daily practices.  Following are some brief case scenarios intended to promote discussion about nurses’ experiences.  In discussing each scenario, it is useful to name the ethical issues, identify potential actions in the situation, and discuss the principles that would guide decisions in each case.

1. Smith is a 78-year-old woman who was admitted six days ago to a medical-surgical unit with a CVA and has experienced severe neurological deficits and a MI. Her daughter, who is her Durable Power of Attorney for Health Care has provided a copy of Mrs. Smiths’s advance directive indicating that she requests DNR.  It is 9 pm and Mrs. Smith’s daughter has gone home for the evening when her son arrives from out of state.  The son approaches the nurse and says, “I don’t know what my idiot sister is thinking.  You better get my mother to the ICU and turn this mess around.  My mother has a lot of years left and by God I’m not going to stand here and let her die.”  How do you respond?
2. Brown is visiting her mother who was admitted for diagnostic tests and evaluation for a breast mass. Her mother, Mrs. Green, is 75 years old and is physically frail due to osteoarthritis but is cognitively intact.  Mrs. Brown tells you that they expect to hear today about the biopsy results and that she plans to “corner” the doctor first to get the news.  She says that if it is cancer, she want the physician to just tell her mother it is a benign mass as she doesn’t think her mother could take bad news, especially since her husband’s death six months ago.  How do you respond?
3. The night shift nurse enters the room of a patient, Mr. Long, on the oncology unit. The man is a 56-year-old in final stages of pancreatic cancer.  He has recently developed liver failure and has rapidly declined and is expected to die in the next few days.  The nurse has become very close to Mr. Long and to his wife and teenage children over the past six months as he has received chemotherapy.  Tonight, Mr. Long asks the nurse if she could help him with a small request and the nurse says, “of course” and sits at the bedside.  Long tells the nurse that he would like to see his ex-wife, a woman he divorced 20 years ago, so he arranged for the ex-wife to come visit tonight at midnight while his family is at home.  He asks the nurse to allow this exception to the usual visiting hours and can the nurse please be sure that no one mentions this visit to his family.  How should she respond?
4. A new graduate nurse, Sarah, begins work in the Emergency Room and develops a good relationship with her preceptor/mentor Joe, an ER nurse for over 20 years. One day as Sarah and Joe are leaving the hospital after a difficult shift, Sarah confides that she was relieved, as an elderly patient with cancer was admitted by ambulance today.  The patient had metastatic cancer and near death but that because he had an advance directive they did not attempt resuscitation.  Her mentor, Joe, tells her that he “doesn’t believe in that DNR crap” and that as an ER nurse he intends to make everyone a full code.  He says that if somebody else, “lets them die” later, that’s OK, but he is an ER nurse, ‘not a hospice nurse’ and will do what he’s trained to do.”  What should the nurse do?
5. Li is a 65-year-old Chinese-American man, diagnosed one year ago with lung cancer. The patient has been told he has a “lung disease.” His wife died 2 years ago.  Despite the fact that his disease is clearly advancing, the family insists that he not be told of his diagnosis or prognosis. Mr. Li is losing weight (20 lbs in the previous two months) and is having increasing back pain and difficulty swallowing. He recently became a resident in your nursing facility. His two sons are both married and live in the area. He denies any religious affiliation. The health care team is increasingly frustrated with the fact that Mr. Li is not able to fully participate in decisions about his care and is considering an ethics consultation.