Authors

  1. Olsen, Douglas P. PhD, RN

Abstract

The background ethical dimension of care is often overlooked but always present.

 

Article Content

Ethical consideration in health care is often thought to be the application of specialized knowledge in exceptional situations, generally when some aspect of care has gone wrong and often involving discord among clinicians, patients, or families. Yet even ordinary episodes of care present the need for ethical consideration. This article presents a routine case in which, despite no contentiousness or disagreement, ethical considerations emerged at almost every juncture.

 

Clinical ethics is traditionally taught by examining dilemma cases and identifying and assessing mutually exclusive actions, each of which has a valid ethical justification. The literature often examines dramatic situations, such as whether assisted suicide is justified by the principle of respect for patient autonomy or forbidden by the principle of do no harm. This perspective of ethics as a tool for resolving fraught, exceptional dilemmas with little relevance to the course of most patient care is incomplete. Although ethical analysis is a crucial guide in dilemma situations, its primary function is to guide all, even routine, care. Caregiving is the ability to assess and apply professional values grounded in ethics. The American Nurses Association (ANA) Code of Ethics for Nurses with Interpretive Statements expresses the values agreed on and promulgated through the professional process to which nurses are held accountable.1

 

The events of this case took place over three days of care in a Magnet hospital during the summer of 2020, with a follow-up visit 10 days later. The case presents the recollections of the patient and his wife, supplemented with unedited excerpts from the medical record the patient was able to access through the institution's online patient portal. This is a real case; the names of the patient and clinicians have been changed.

 

Despite the unremarkable character of the patient's care, the stay involved multiple instances of actions with ethical consequences, each revealing the relational nature of health care ethics and the value of relational skill. In this case, relational ethics refers to occasions when a determinative factor in the morality of an action is the nature and quality of the relationship between the clinician and the patient; relational skill is used here to mean the ability to convey information accurately, empathetically, and therapeutically through verbal and nonverbal interaction.2 This case demonstrates how deeply moral significance is embedded in care-so deeply that the background ethical dimension of care is often overlooked.

 

THE CASE

Jake Stewart is a 64-year-old man who presents to the ED at 10 AM on a Tuesday with abdominal pain. The pain has increased over the past three days, to such an extent that it prevented him from sleeping the previous night. Mr. Stewart reports having had a low-grade fever overnight and mild anorexia, but no nausea or vomiting. He describes the pain as beginning diffusely, becoming more localized in the right lower quadrant. In the ED, he is afebrile, and reports the pain as improved, a 6 to 7 on a scale of 0 to 10. His lower abdomen is tender to palpation. He has a history of type 2 diabetes controlled with diet and of hyperlipidemia resolved with dietary changes. He takes no medications and has had no major surgeries. He quit smoking at age 25 and has no more than two alcoholic drinks per week. He exercises and is otherwise in good health.

 

Because of the ongoing COVID-19 pandemic, Mr. Stewart's wife cannot accompany her husband to the ED. She waits in the parking garage, exchanging texts with him.

 

At 1 PM, after the ED physician's examination, Mr. Stewart is given a hospital gown, an IV line is started, and he is placed in a waiting room for admitted patients referred to as "pending results." From there, he is sent for an abdominal computed tomography (CT) scan and then returned to the waiting area. He describes the space as exceedingly cold. Staff provide a warmed blanket, which cools quickly.

 

At 2 PM, the CT scan confirms the physician's diagnosis of appendicitis (see Computed Tomography Results). Staff take Mr. Stewart to a private area and inform him he requires surgery and then return him to the same waiting area.

 

At 3 PM, the ED physician speaks with Mr. Stewart privately, advising him that the CT scan showed "spots" on his liver, kidney, and lung requiring follow-up with his primary care provider. She assures him several times that these are probably "of no concern."

  
Box 1 - Click to enlarge in new windowBox 1. Computed Tomography Results

At 4 PM, a surgical NP and then the surgeon have brief conversations with Mr. Stewart about informed consent for laparoscopic and possible open appendectomy. They offer an opportunity for questions. He can think of none and signs the consent form but does not retain a copy. He later remembers being uncomfortably cold and in pain. Despite having above average health literacy, the process moves too quickly for him to process details or consult with his wife. Shortly afterward, he is taken to the operating room.

 

Staff direct his wife to the surgical waiting area. After a few hours, she realizes the surgery has taken much longer than it would for a simple appendectomy. At 8 PM, the surgeon speaks with her. He reports removing part of Mr. Stewart's colon owing to the presence of a mass, in addition to the appendix. He offers the rationale that removing the tissue immediately, to be sent for a biopsy, would prevent the need for a repeat procedure, adding, "I would not have done your husband any favors by waiting."

 

She asks if the surgeon suspects cancer. He responds that he is "95% confident" the mass is cancerous, adding that he cannot say how extensively the cancer has spread until the pathology report comes back. He also suggests that the mass has been in place for about two years.

 

According to Mr. Stewart's wife's report, the surgeon relayed his findings in a professional and empathetic manner; if he had asked for permission to proceed during the surgery, she would have agreed.

 

The discharge summary explains: "He was taken for an emergent surgical intervention with Dr. Sharp for an appendectomy that converted to exploratory laparotomy when there was a cecal mass found intraoperatively and resulted with a right hemicolectomy."

 

The surgery lasted almost four hours from induction of anesthesia to recovery of consciousness. Mr. Stewart awakes before 9 PM. He is aware he had open, not laparoscopic, surgery. Upon learning the time, he has suspicions regarding the extent of the pathology.

 

Despite restricted visiting due to the pandemic, the nurse allows Mr. Stewart's wife to visit briefly since Mr. Stewart is the last patient in recovery. With limited time and concerned about her husband losing sleep, she opts not to discuss the surgeon's assessment of probable cancer. She also asks staff to wait until morning to mention it to him. Arriving on the unit, Mr. Stewart asks the nurse about the extent of the surgery; she tells him to wait for the surgeon.

 

Mr. Stewart sleeps only in brief intervals. The IV line placed preoperatively in his left antecubital space stops flowing whenever he bends his elbow, setting off an alarm-a frequent occurrence during the night, requiring resets by staff. Around 3 AM, a nurse shows him how to reset the alarm.

 

Early the next morning, a resident arrives to conduct rounds with medical students and informs Mr. Stewart of the right hemicolectomy but not the assessment of probable cancer. Mr. Stewart find himself disturbed by her disrespectful treatment of the medical students, which he describes as "flippant."

 

Mr. Stewart's wife arrives at 9 AM and the two share what they have learned. Later that morning, the surgeon stops by to review the surgery and his impressions. The couple accepts that Mr. Stewart probably has cancer and expects the pathology report to reveal its extent and hence the prognosis.

 

The next day, a surgical NP arrives to assess Mr. Stewart for possible discharge and tells him he may go home later that day. Mr. Stewart asks about his pathology report. Consulting the in-room computer, she states that the mass was benign. When his wife arrives a few minutes later, Mr. Stewart tearfully tells her the result of the biopsy, and they call their son to share the good news. However, about an hour later the NP returns and tells the couple she had mistakenly read a pathology report from his colonoscopy seven years prior, one that coincidentally occurred on the same month and day as his appendectomy. Expressing embarrassment, she apologizes and explains that the current pathology report is pending.

 

The hospital discharges Mr. Stewart later that day and an appointment is set up in two weeks with an NP in the surgeon's office, by which time the pathology report should be ready. His discharge diagnoses were "acute appendicitis, mass of cecum."

 

Mr. Stewart returns home. With good family support, he has an uncomplicated recovery. He repeatedly tells his family to hope for the best yet prepare for the worst. The family's online research reveals that, based on what they've been told so far, their best hope seems to be stage I cancer with a 90% five-year survival rate, and the worst seems to be stage IV with a 14% five-year survival rate. Either way, Mr. Stewart anticipates considerably more contact with the health care system, and the couple begins planning for an uncertain future.

 

On a Sunday evening 10 days after surgery, the night before his follow-up surgical appointment, Mr. Stewart receives an e-mail about a new report in his online patient portal (see Excerpts from the Pathology Report).

 

At Mr. Stewart's appointment the next day, the surgical NP confirms no cancer was found.

  
Box 2 - Click to enlarge in new windowBox 2. Excerpts from the Pathology Report

ETHICAL ISSUES RAISED BY THIS CASE

Each event in Mr. Stewart's care required clinical knowledge to apply professional values.

 

Informed consent: more than just a document. Mr. Stewart's procedure turned out to be more extensive than he expected from the informed consent discussion. In addition, Mr. Stewart's written documentation about the consent process is not available-either he was not given a copy or the copy he was given was lost. He knew his appendix would be removed, either by laparoscopic or open surgery, but he was given little indication during the informed consent discussion that additional tissue might be removed. Because of his health literacy level, Mr. Stewart had considered the possibility that his pathology might be more extensive than uncomplicated appendicitis. Acute appendicitis, most common in people ages 15 to 40, is often associated with colon cancer in older patients.3 However, Mr. Stewart did not ask the clinicians about this during the discussion and the clinicians did not raise the possibility.

 

Informed consent is not simply a document signed by the patient, but rather the entirety of the process itself-including disclosure of relevant information and attention to ensuring the patient's understanding and appreciation of the information. Only in that state of understanding can the patient consent, uncoerced, to the treatment.4

 

If, during a procedure, a surgeon finds a condition amenable to an immediate surgical intervention that was not anticipated during the informed consent, the surgeon has two choices: prioritize what is best for the patient and proceed with surgery without consent, or give priority to self-determination and refrain from the extended intervention until the patient or surrogate consents. The latter course of action may in some cases sacrifice the patient's presumed best interests. In this case, the surgeon decided that waiting would likely mean a second major surgery and time lost addressing a progressive pathology.

 

Roads not taken. There are options available to clinicians faced with such a situation. One is to seek surrogate consent during the surgery. Mr. Stewart's spouse was available, but his chart did not list her as a documented health care proxy. Another is to anticipate contingencies such as this one during the informed consent discussion. This means deciding which contingencies merit inclusion in the informed consent process and which are so rare that inclusion would make the process unwieldy and confusing to the patient. This situation is analogous to whether it's helpful to discuss every potential adverse effect in medication teaching.

 

In this case, the surgeon did not seek a surrogate decision maker and proceeded with removal of the cecum, the ileocecal valve, and about eight inches of the ascending colon. The contingency of open laparotomy was discussed during the informed consent process, but Mr. Stewart recalled no other contingencies mentioned.

 

Ethical evaluation of an informed consent process relies on a review of its major elements4:

 

* Disclosure: Did the patient receive essential information?

 

* Capacity: Did he have decisional capacity?

 

* Consent: Did he give uncoerced authorization?

 

 

To discuss Mr. Stewart's case solely in terms of these elements, however, would be to ignore ways in which obtaining informed consent is insufficient to constitute ethical care. Informed consent can be thought of as a technique to implement the value of self-determination by ensuring that patients make autonomous decisions. Mr. Stewart-weary from lack of sleep, pain, and cold-was not in a state of mind conducive to thoughtful consideration of a major decision. He reports that after prolonged waiting he had difficulty processing what was being said to him while simultaneously perceiving an urgency to respond quickly. Despite this state, it's likely that formal testing at that time would have found Mr. Stewart to have decision-making capacity. It's notable that he didn't consult his spouse in this instance, although he typically did when they had to make major decisions. He probably would have been allowed to call her had he asked, but this wasn't offered. Proactively presenting him with the possibility of making such a call would have been a more effective implementation of the ethical principle of respect for autonomy.

 

The impediments to ideal informed consent in this case were not unusual and not due to lapses or substantive deviations from the standard of care. Rather, this case illustrates that ethical care is dependent on relationships in addition to the application of objective principles. Mr. Stewart, lacking both personal knowledge of the surgeon's character and knowledge of the clinical issues, had to trust the surgeon's clinical competence in determining the most effective treatment as well as the system that employed and supported the surgeon. A more ethical treatment of Mr. Stewart might have entailed blending the principles embodied in informed consent with the relational skills needed to communicate with the patient and family. Although he had decision-making capacity and a high level of health literacy, Mr. Stewart depended on his providers' professional ability to navigate any potential ethical issues posed by his care and reliably implement professional values.

 

Conveying negative news. The need for clinicians to discuss bad news with patients and their families requires that they remain empathetic while resisting the temptation to avoid giving the bad news or to react defensively if confronted.

 

There were several instances where providers relayed bad news to Mr. Stewart or his wife. Immediately following surgery, the surgeon advised Mr. Stewart's wife to expect a cancer diagnosis. Speaking to a patient's loved one in such a situation involves balancing the gravity of a presumed prognosis with accurately conveying the uncertainties that remain until the pathology report is complete. Self-reflection is essential for ethical communication of bad news, as is relational sensitivity. In some cases, there is a tendency to avoid telling people bad news. In others, there is a tendency to justify one's actions, perhaps by emphasizing certain aspects of the situation, such as the gravity of the prognosis. In the surgeon's case, such a prognosis might have justified his choice to undertake more extensive surgery than had been anticipated. Every situation has its own pressures and complexities, but clinicians should be understood as accountable for clearly justifying their actions to patients and family members while at the same time refraining from defensiveness that might skew the information and risk damaging the patient relationship.

 

Another aspect of conveying bad news is knowing when to convey it; sometimes this may mean withholding information temporarily. After her discussion with the surgeon, Mr. Stewart's wife asked that her husband not be told right away about the presumed cancer diagnosis so he could sleep and confront the issues the following morning with his family. She requested that providers go along with this decision, which they did. Mr. Stewart's spouse, sensitive to her husband's needs, had no intention of permanently withholding this knowledge from him, instead framing the request to his caregivers as being in Mr. Stewart's best interest.

 

Addressing mistakes. Handling mistakes forthrightly and transparently is supported in the ANA Code of Ethics by provision 1.2, requiring the establishment of a trust relationship, and provision 4, requiring that nurses take responsibility and be accountable for their actions.1 The NP's response to realizing she'd mistakenly given Mr. Stewart a benign pathology report from a much earlier procedure illustrates how to ethically handle mistakes.5 She returned quickly and explained what had happened, conveyed the correct information, and apologized. Self-reflection and relational skill are essential when errors are made because of the temptation to avoid, deny, justify, shift blame, and engage in cover-up.

 

Another issue that comes up regarding how clinicians respond to their mistakes concerns charting. In some cases, there may be a temptation to rectify the mistake but not record it, a move that may be justified by the rationale that the mistake had no direct effect on treatment. But not charting the incident is a deception of omission. Should the error come to light, it may be perceived more negatively because the incident wasn't charted. In this case, Mr. Stewart doesn't know if the incident in which he was initially given the incorrect diagnosis was ever charted.

 

Conveying information. Based on the surgeon's verbal assessment to Mr. Stewart's spouse of a 95% chance of cancer, Mr. Stewart assumed the pathology report would reveal a commensurate level of severity and prognosis. The report he received 11 days later on a Sunday evening through a patient portal notification was an unfiltered pathology report written in technical language. With help from online searches, Mr. Stewart was able to comprehend the report's main point that there was no cancer. However, because of his expectation of a negative report given the surgeon's original grave prognosis, it took several readings and consultation with family to fully grasp the actual report's positive details and implications.

 

Transparency is an important value in conveying information to patients. At the same time, professional values that may conflict with total transparency in this case include not harming patients without strong evidence of worthwhile benefit (nonmaleficence) and supporting patients at difficult times. While Mr. Stewart appreciated receiving the information as soon as it became available, clinicians must consider the effects of such an online report on patients with lower health literacy. In this case, the news, once Mr. Stewart and his family interpreted it, turned out to be positive, but if a pathology report contains bad news, the damage of releasing it to a patient in this unmediated (and highly technical) way could be substantial.

 

Timing and context for conveying information must be considered. The ED physician advised Mr. Stewart, as he prepared for surgery, that his scan also detected multiple anomalies requiring follow-up.

 

Professionalism and civility. Mr. Stewart perceived the resident's treatment of medical students at his bedside on the morning following surgery as a breach of professional values. He reports that although he did not view the resident's treatment as overtly abusive, he felt uncomfortable witnessing the flippant manner in which she asked the students questions and their embarrassment when they were unable to answer. Mr. Stewart was in a vulnerable position-sleep deprived, in pain, physically compromised, wearing a loose hospital gown with a catheter in place-and, as such, may have been particularly sensitive to the professional atmosphere. Clinicians should be aware that staff disagreements or incivility in front of patients can increase patients' concerns about the overall quality of care.

 

Alarm fatigue. Another ethical dilemma that could give rise to discussion is whether staff should have given Mr. Stewart responsibility for controlling the alarm on the IV pump. The frequent alarms during the night were annoying for Mr. Stewart, his roommate, and the staff. Showing him how to silence the alarm did considerable good, granting Mr. Stewart and his roommate better sleep while saving the nurses time. However, the purpose of alarms is to alert nurses to problems requiring professional evaluation; therefore, it may not be appropriate to ask patients to make that evaluation. The extensive literature on the topic reveals concerns about the increasing numbers of devices with alarms that go off frequently, often for trivial reasons. Such alarms may cause more harm than good by costing patients rest and diverting staff attention. But nurses must consider multiple factors before giving a patient responsibility over an alarm, including the patient's cognitive ability, the degree of potential harm should the device be mishandled, and the potential for a slower response to a critical issue. This is another matter where self-reflection is required, as the nurse must carefully control for the desire to end this annoyance and ensure that all factors have been considered.

 

CONCLUSION

Mr. Stewart's case demonstrates the ubiquity of ethical issues in patient care-even when this care is relatively routine and without controversy. Mr. Stewart was in the hospital for three days, including the time in the ED, and ethical considerations related to his care awaited clinicians at every turn. Nothing in Mr. Stewart's care required an ethics consult or prompted Mr. Stewart or his wife to make a formal complaint. The clinicians involved handled most of the issues raised here in a professional manner.

 

How one addresses concerns such as presenting bad news, establishing trust for consent to treatment, and revealing mistakes depends on relational skills and ethical considerations, as does whether one treats colleagues with appropriate respect.

 

This case had two substantial advantages in preventing a contentious outcome between patient and institution. The first is that Mr. Stewart recovered from surgery without complication and found that loss of his appendix and ascending colon had little effect on lifestyle or health. If the extended surgery had had a more lasting effect, such as a colostomy, his perspective on the surgeon's choice to proceed with the surgery without further consent, as well as on other factors, might have been less positive. Second, the clinicians with whom Mr. Stewart had the most contact-the surgeon, nurses, and surgical NP-treated him and his wife with empathy and respect. In areas with potential problems, whether relaying bad news or revealing a mistake, the clinicians acted prudently, forestalling the potential for contentiousness.

 

Ethical consideration pervades all aspects of care. Anticipation and contemplation of the values the nurse wishes to implement are essential even for the most routine care. Ethical consideration and care are one and the same. Clinicians require the sensitivity to identify the moral dimension of care and the skills to analyze the ethical considerations necessary to plan and implement effective care.

 

REFERENCES

 

1. American Nurses Association. Code of ethics for nurses with interpretive statements. 2nd ed. Silver Spring, MD; 2015. [Context Link]

 

2. Bergum V. Relational ethics in nursing. In: Storch JL, et al., editors. Toward a moral horizon: nursing ethics in leadership and practice. Toronto, ONT, Canada: Pearson Prentice Hall; 2004. p. 485-503. [Context Link]

 

3. Hajibandeh S, et al The incidence of right-sided colon cancer in patients aged over 40 years with acute appendicitis: a systematic review and meta-analysis. Int J Surg 2020;79:1-5. [Context Link]

 

4. Beauchamp TL, Childress JF. Principles of biomedical ethics. 8th ed. New York, NY: Oxford University Press; 2019. [Context Link]

 

5. Westrich SJ, Jacob N. Disclosure of errors and apology: law and ethics. J Nurse Pract 2016;12(2):120-6. [Context Link]