Nurses are constantly in direct contact with the patient, actually is the healthcare provider that spent more time with the patient than any other provider. During the nurse-patient interaction the nurse must display an appropriate ethical behavior to obtain the best patient care outcome. For the nurse to act ethically correct, the nurse must have ethical principles and model’s knowledge, and skills specially when an ethical dilemma or discrepancy interfere with the care of a patient and the expected outcome. When ethical dilemmas are present the ethical decision-making process must be applied to address the situation. The ethical decision-making process is a structured model that guides nurses to make difficult ethical decisions. The process is structured in five steps: articulation of the problem; data gathering; identification of possible strategies; implementation of strategies; and evaluation of the action’s outcomes (Parker, 2017). The ethical decision-making model will be applied to a case study presented (see Appendix A).
The problem in this situation is that there is no informed consent to administer a blood transfusion to the baby. An informed consent for blood transfusion is a document that provides written information about reasons and description, benefits and risk of the treatment, and primary components of blood or alternatives of transfusion of blood (Champion, & Saidenberg, 2017). At the same time, the desired state is to keep the baby alive and to do not create a family disruption.
During this section it is important to understand the role, moral principles, beliefs, values and concerns of those involved in the situation. First, there is the baby’s mother who according to the law has the right to accept or deny a treatment for the baby (Parsapoor, Renzaei, & Asghari, 2014). Sometimes the parental autonomy interferes with the medically reasonable alternatives available. In this situation the baby’s mother does not authorize the blood transfusion because of her religious beliefs, Jehovah’s Witness. Most of the Jehovah’s Witnesses abstain from blood as a sign of obedience and respect for Jehovah, this belief is based on the interpretation of the Old and New Testament, Genesis 9: 4; Leviticus 17: 10; Deuteronomy 12: 23; Acts 15: 28, 29. Jehovah’s Witnesses must express their religious loyalty as far as to death (Ringnes, & Hegstad, 2016). At the same time, the mother, who is expressing anxiety about the life of her baby, is under the obedience demands of her religious practice. In addition, she and her baby will be disowned by her father if she signs the blood consent. Under this religion the consequences for accepting a blood transfusion are condemnation, disfellowship, public shame, and social death because of their limited social interaction out of the religious circle, (Hoffman, 2016). Alongside the mother ability to make decisions for the baby’s, there is the father figure which is absent currently. Again, another issue will arise if the father does not agree with the mother’ s decision and will like to consent for the blood transfusion.
Generally, under standards circumstances either parent may consent for the transfusion. Based on the case scenario and the lack of information this situation can change depending on the father’s custody status in relation with the baby. The baby’s father can have legal custody, physical custody only, or no custody at all (Gomez et al. , 2016). The nurse, which is also part of the scenario, is the middle of a moral dilemma still needs to keep the ethical principles to provide care in the baby’s best interest. Nurses under any circumstances must follow the professional code of ethics, the purpose of the nursing profession, and the standards of practice. At the same time, the nurse must consider the patient, and patient’s family culture, beliefs and values. Nurses are considered as patient’s advocate and need to adhere to the principle of beneficence which requires to prevent any harm to the patient or maximize the outcomes and benefits for the patient. In this situation, the nurse must also respect the parental autonomy decision of the mother to do not authorize the blood transfusion. Also, the ethical principle of nonmaleficence should be applied to become with strategies that will help to reach the desire outcome without inflicting harm or the least possible harm (American Nurse Association, 2015). Regardless, the nurse must take all reasonable means to protect the life of the baby. Obviously, the blood refusal set the foundation for a conflict between the nurse ethical duties to preserve the life of the baby and the parental autonomy decision to refuse the treatment.
Alternatives strategies should be identify based on the desired outcome to save the life of the baby and keep the family together by respecting their cultural and religious belief. Legal, social and psychological consequences should be considered when identifying possible strategies.
Strategy 1. The first strategy to consider could be to offer, and to explain alternative blood products or volume expanders based on the availability and emergency of the situation. Beside refusing blood transfusion almost all Jehovah’s Witnesses also refuse blood components like red cells, white cells, platelets, or plasma. Therefore, another alternative could be blood derivatives like clotting factor concentrates like fibrinogen concentrate, albumin solutions, cryoprecipitate and immunoglobulins which some of Jehovah’s Witnesses may accept but is more a matter of conscience according to the religion. Regularly intravenous iron and travexamic acid are accepted, or recombinant products such as erythropoiesis stimulating agents, granulocyte colony stimulating factors, and recombinant factor VIIa (Sagy, Jotkowitz, & Barski, 2017) which will be the most considerable option under the case circumstances to keep the baby alive and to respect the religious belief. For Jehovah’s Witnesses patient with low levels of hemoglobin alternative methods are used to increase erythropoiesis and restore hemoglobin levels.
According to medical documentation subcutaneous erythropoietin and intravenous iron were successfully given to preterm Jehovah’s Witnesses twin when their parents refused blood transfusion (Poorisrisak et al. , 2014). In cases of severe anemia hemoglobin-based oxygen carriers (HBOCs) administration is another alternative. However, HBOCs are currently not approved by the Food and Drug Administration (FDA) although they may be obtained and administered if patient agreed, and under an institutional and FDA review board approval (McConachie et al. , 2018). The pharmacological treatment methods explained above are clinical cases that support the strategy.
Strategy 2. The Jehovah’s Witness religions have qualified observers to lead the congregation. They are spiritually mature men that guide and maintain the congregation together and support their members. A consultation with the body of elders who supervise the congregation could be considered to offer guidance, comfort and approval if necessary for a medical treatment in behalf of the baby.
Strategy 3. When disagreement is present between the mother of the baby and doctor regarding what could be the best for the baby’s wellbeing then the legal path should be taken through the court. Before turning to the court, it is important that the healthcare provider has consulted another colleague, that every method have been used to persuade the family and that the treatment is the best possible option under the circumstances. If the baby’s condition is critical and considered an emergency this process can be done immediately. If serious harm or death are imminent consequences then court guidance should be approached immediately (McDougall, & Notini, 2014).
The ability to make a decision requires a basic cognitive level and sense of control. Therefore, orienting and educating the baby’s mother will empower her to be able to decide what to do based on her personal values and beliefs. At the same time, the nurse role is to provide support to the baby’s family to enhance their ability to make a decision and provide the necessary resources. In general, the current situation should be evaluated to apply logical and thinking skills instead of acting automatically. The nurse should create a trustful relation with the patient, and patient’s family by being honest. Sharing knowledge and information about the alternative products, advantages and disadvantages, previous implementation in another situations where Jehovah’s Witnesses were involved, and outcomes are essential in this step. Conscious listening to feelings and concerns, empathy towards the family, flexibility, and respect to diversity should be also present.
Considering the mother opted for the pharmacological alternative treatment she may recognize that she made the best decision based on her expectations, values and religious belief. Under the right circumstances her decision will keep the baby alive and the family will stay together. In relation with the baby’s father and according to the situation he might experience feelings of satisfaction because the baby is alive. Regarding the nurse feelings of achievement, professional gratification may be experienced because a dilemma is solved by satisfying all the involved parties. The nurse understood the complexity of the situation and was able to develop a successful strategy as patient advocate where principles of autonomy, beneficence to do good, and nonmaleficence to cause no impairment or damage were applied. The application of the ethical decision-making model is a systematic process that must be applied by nurses when ethical dilemmas are present. It is expected that the nurse should have ethical principles, professional standards and social regulations knowledge to be able to apply the process. If the model is applied correctly “the moral justification for an ethical decision can be as powerful as a scientific explanation for a medical decision” (Burkhardt, &Nathaniel, 2014, p. 159).
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