Materials

The ten example patient cases will be examined with the students over four weeks in the order below. In addition, during the four weeks the students can create their own cases. These ten example patient cases work as basic examples in the background while the students practice their own ethical sensitivity and ethical thinking in the clinical practice area.

CASES

Week #1

Information about the patient’s significant others

A dementia patient, who has not given any information about her significant others, is coming to your ward. The patient is not familiar to you. She has no one who has taken care of her financial affairs and neither has she any children. A couple of days later the patient’s friend arrives at the ward and says that she has taken care of the patient’s financial affairs and has made the care decisions.

  • How you would act in this situation?

Operating theatre

A female patient is lying on the operating table in the operating theatre during the operation and the staff are speaking about her badly. The senior nurse responsible for the instruments and the assisting nurse are commenting on the patient’s hair style or body and having a good laugh. The junior nurse who is acting in the team as the anesthesia nurse is feeling very uncomfortable. She has learned that “Even though the patient is sedated, the patient can remember the discussions in the operating room”. The junior nurse did not dare say anything.

  • Why does the junior nurse find it difficult to say anything?
  • How would you act in this situation?
  • What ethical principles and codes can be applied in this case?

Week #2

Phone call

Your patient’s sister, living in another country, telephones you during your evening shift to inquire about the diagnosis and prognosis of your patient. She tells you that she is very worried about her sister and cannot understand from her what her diagnosis is really is about and what is the further treatment planned.

  • How would you act in this situation?
  • Which ethical principles and codes can be applied in this case?
  • What information you can tell your patient’s sister?

Measles

Two nurses and an assistant nurse are working night shift on a ward at the department for infectious diseases. A nurse from the emergency department calls and says that a patient will be admitted to the ward. The patient is a woman, 40 years old and the reason for admission is suspected measles. The suspicion is caused by her symptoms and the fact that she visited an area in Italy one week ago where a measles outbreak recently occurred. The patient has not been vaccinated. Two of the night staff have not been vaccinated and the third one is unsure whether she has been vaccinated or not. They declare that none of them will go into patients’ room since they do not want to expose themselves. They communicate with the patient by standing outside the room and talking through a door with a glass window. The only person who enters the patient’s room during the night is the doctor who examines the patient and leaves the ward afterwards.

Discuss the case and identify the ethical issues

  • Which ethical principles and concepts could be applied in this case?
  • How would you have acted?

Professional behaviour, collegiality

Week #3

Research study

A male patient, 39 years old, is admitted to an infectious diseases ward from the emergency department with severe pneumonia and septicemia. In the morning when the nurse prepares to take blood samples she notices that the patient has been included in a medical research study at the emergency department and there are multiple blood samples to be taken that are just for the research study. The patient is autistic and cannot communicate verbally meaning that the nurse is unable to explain the procedure. It is not easy to take any blood samples since the patient is dehydrated and is moving around in the bed all the time. The nurse finds out that permission to take part in the study was given by a patient’s family member who also takes care of the patient’s financial affairs.

Discuss the case and identify the ethical issues.

  • Which ethical principles and concepts could be applied in this case?
  • Do you think it was correct to ask and include the patient in the study, give reasons for your answer.
  • How would you have acted regarding the blood samples?

HIV/AIDS

Robert is dying and staff are aware that he has HIV/AIDS. Robert is in a coma and, prior to lapsing into the coma, Robert specifically asked that the fact that he has AIDs not be shared with anyone until after his death. Robert’s partner Linda and his sister have been regular visitors to the ICU unit where Robert is being cared for. They are not aware of Robert’s condition. One morning, Linda asks the nurse who seems to be Robert’s main carer to tell her more about Robert’s condition.

  • How would you act in this situation?
  • Which ethical principles and concepts could be applied in this case?

A mean senior nurse

One nurse has been working a long time on the ward and she thinks that she is a better and more competent nurse than any other nurses on the ward. She intervenes all the time in the care of other nurses’ patients. In addition, this nurse tells the head nurse about issues which, according to her opinion, are handled incorrectly. Because of this she does not get along with any of the staff of the ward. You come to the ward as a new nurse and you notice that this nurse is cannulating a patient incorrectly and this is a risk to patient safety. You say that to the nurse in the nurse station when there are just the two of you there. This aggravates her and she says that you will be thorn in her flesh. She tells tales against you even about things that you have not done. She shows a lack of collegiality towards you in every way.

  • How should the superior/head nurse act in this situation
  • How would you act if you were involved in this kind of workplace harassment?

Week #4

Suicide

The patient Mr. Brown is a 54 year old gentleman with aggressive prostate cancer who is taken care of by the nursing team in the oncology department. Mr. Brown was diagnosed with prostate cancer seven years ago but refused medical and surgical treatment at the time. He chose to seek alternative treatment and did not follow up with the urologist over that seven year period. Mr. Brown now has anemia and hypoproteinemia and it was discovered that the cancer had metastasized. Mr. Brown was admitted several times over a two month period for various reasons. On the last admission Mr. Brown was told that he may only have 4-6 weeks (previously it was 6-12 months) to live, it was determined that any further surgical/medical intervention would not be appropriate in this case and that a palliative care regime was the next step. At this point the patient reported to the health care team that he had resigned himself to the fact that he was going to die. Mr. Brown took one of the author’s colleagues aside and confided to the nurse that he planned to kill himself and that is was a secret that the nurse was not to tell anyone.

  • How would you act in this situation?
  • Which ethical principles and concepts could be applied in the case?

Outpatient women’s clinic

You work as a nurse-midwife at an outpatient women’s clinic and regularly perform pap smears as part of cervical cancer screenings. Your patient is a 24 year old woman who is living with HIV. Her infection is well-controlled. The patient informs you of her infection and that she has been on treatment for many years. You are not familiar with the routines at your clinic for patients who have blood transmitted infections and approach an older colleague for guidance. Your colleague tells you that you must use two pairs of gloves to take the required tests from this patient and that you should disinfect the entire room afterwards. When you return the patient notices that you seem nervous and asks you if this is the first time you have met a patient living with HIV.

  • Which ethical principles and concepts could be applied to the above scenario?
  • Which would be the best way to find out about best practices related to certain infectious diseases?
  • Could the nurse have done anything differently? Give reasons for your answer.

Terminal Care

A patient who has pulmonal cancer at very advanced level will come to the ward for terminal care. He also has mental health problems, which can be seen as misrepresenting of the facts about his care to relatives and the patient continuously changes his mind about care decisions.

The care is further complicated by the fact that the patient has a fluctuating relationship with his daughters, who also disagree with the patient’s care plan. The situation has been demanding and challenging for a long time now and it has now come to a head because of the patient’s misrepresentations. Finally, the patient’s condition deteriorates and the patient is no longer capable of making any decisions related to his care. The daughters get so angry with the situation that they blame the doctor and nurses and in the end they verbally attack the doctor who has donee his best for the patient. You are present at the time when this happens.

  • How would you act in this situation?
  • How would you act during the care of this patient as a nurse?
  • Why is the recording of patient care extremely important?

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