Thursday, November 20, 2014

Just following orders? Is it okay to say no?

Recently the American Nurses Association (ANA) has publicly supported a Navy nurse that has refused to force-feed Guantanamo Bay detainees that have refused to eat and are on self-imposed hunger strikes.   Each case is reviewed by a senior medical officer and determined if force-feeding is necessary. If ordered, the detainee is strapped in a 5-point restraint system in a chair and the nurse then proceeds to place a nasogastric feeding tube and administers tube feed consisting of Ensure (according to the cited article: Top nursing group backs Navy nurse who wouldn’t force-feed at Guantánamo) The controversy in this case is whether the nurse was wrongly removed from duty for refusing to carry out the force-feedings. The ANA is supporting the nurse and believes that a nurse should not carry out an out that he or she feels is unethical. 

Reading this story I began thinking of patients in the hospital setting. How often do these type of situations occur? How often are nurses faced with situations that are dancing on the edge of being ethical? Whether it is placing a patient in restraints or feeding a patient that has already refused via an advanced directive or giving a medication for an unapproved use or performing CPR on a DNR patient; how many circumstances come close to being questionable? Maybe the actions are not as violent as restraining a patient to slip a tube through their nose into their gut so that liquid food may be given to them like a drug; however placing wrist or hand restraints on a frightened elderly woman with advanced dementia who keeps shaking the side rails of her bed could be similar.

The point is there are times when nurses can say "No, I cannot do this or that" for ethical reasons. Maybe the more appropriate question is how many times do nurses speak up or question the order? Is this grounds for dismissal or is there any recourse? 

I think that a fundamental question needs to be asked...will these actions either way harm the patient? If withholding care will result in injury or death the nurse has a duty and obligation to ensure the patient is safe and receives the care they need. However if the nurse is being asked to do something that could result in harm that would need to be reported that the order is not being carried out and why to the supervisor. Remember nursing practice should be guided by the ethical principles of nonmaleficence and beneficence - to "do no harm" and to be compassionate and "desire to do good." 

The story of the nurse and detainee is troubling because it makes me wonder the principle of autonomy is in this situation. Has that right been forfeited because he is a prisoner so the other principles are also null and void as well? As a nurse this is confusing and somewhat undermines are core values that guide are practice. I will continue to follow this story as the outcome is important to nurses as clinicians and decision-makers everywhere.

ANA Short Definitions of Ethical Principles and Theories 

Read more here:

Saturday, November 8, 2014

Can't we all get along? Making true collaboration work

I recently read a Blog posted on the Society of Hospital Medicine regarding relationships between physicians and non-physician providers, namely nurse practitioners. It was interesting as I could not agree more with the points in the blog as barriers to successful hospitalist or other collaborative care models. The author summarized well what I believe are key issues that can create toxic environments for nurse practitioners and physician assistants and ultimately affect patient care. I truly believe that there is a place for all providers and that are many successful   practices both in and out of the hospital setting in which physicians and nurse practitioners work along side of each other to delivery high-quality and cost-effective care.

The big winner in this is the patient. But so are all the providers if we can all get over ourselves and truly work as colleagues, together!