Mrs. Hursey is an alert 90-year-old woman visiting her cardiologist for a routine appointment. She is accompanied by her daughter. An exam reveals Mrs. Hursey is in complete heart block. Carol, the nurse assisting the cardiologist is surprised to hear him try to get Mrs. Hursey to sign a consent for a permanent pacemaker. Although Mrs. Hurseys heartbeat is only 36 bpm, she is asymptomatic unless active, and her daughter reports she is rarely active. Carol is concerned neither Mrs. Hursey nor her daughter fully understands the anticipated risks and benefits of the pacemaker as well as the option of nonpacemaker treatment since the cardiologists disclosure has been inadequate. She wonders how best to respond when the cardiologist gets exasperated by Mrs. Hurseys slowness to respond and begins persuading the daughter to sign the consent.
Provision 3 of the ANA Code of Ethics for Nurses states, The nurse promotes, advocates for and strives to protect the health, safety and rights of the patient. In this instance it is quite clear Mrs. Hurseys autonomy rights are being violated. Without understanding the anticipated benefits, risks and burdens associated with both pacemaker and nonpacemaker treatment, it will be impossible for Mrs. Hursey to make a valid decision, consent or refusal. Similarly, if Mrs. Hursey has the capacity to make her own treatment decisions, albeit with support, the jump to secure the daughters consent is premature. Complicating this scenario is the fact the nurse, Carol, is new to this office practice. She left hospital nursing 10 years ago to care for her own aging mother. After taking a refresher course, she accepted a nursing position with this cardiology practice and has only been working here for three months. She is concerned about repercussions if she challenges the cardiologist. Remembering the class on the code of ethics in her refresher course, Carol knows Provision 2 of the ANA Code of Ethics states, The nurses primary commitment is to the patient, whether an individual, family, group, or community. Carol feels conflicted about her responsibilities in this situation.
While Carol is uncomfortable with the cardiologists pressure to obtain consent for the pacemaker, she suspects at worst he is guilty of focusing narrowly on a pathology that is potentially treatable. Respecting his senior status as head of the practice Carol is willing to accept his tendency toward paternalistic practice, making decisions he believes advance the interests of patients deemed incapable of making these decisions for themselves. Rather than rock the boat and possibly incur repercussions, she decides to remain silent, and evaluate the outcomes. While this response is understandable, it is very clear that Carol has placed her own interests above that of the patient and has failed her responsibility to promote, advocate for, and strive to protect the health, safety and rights of Mrs. Hursey.
Carol is outraged with the cardiologists condescension to Mrs. Hursey, suspects his motivation is financial and challenges him on the spot. Wait a minute. Mrs. Hursey, do you really want a pacemaker? Do you understand what’s involved with getting a pacemaker? Have you considered other options? While Carol may be advocating for her patient, she has jumped to conclusions about the cardiologist and his motivations, and her rash behavior may end up hurting everyone. Mrs. Hursey and her daughter may lose trust in the medical profession and Carol may find herself without a job and the ability to help the very patients she wants to serve.
Carol tries to slow the decision making, hoping to learn more about Mrs. Hurseys values and goals at this point in her life and to learn more about the cardiologists motivation and intentions. Before either Mrs. Hursey or her daughter consent to the placement of a pacemaker, shouldnt we talk a little more about what they can expect both with and without placement of the pacemaker? At this point we know very little about Mrs. Hurseys values and what is important to her at this point in her life. Perhaps we can explore this? In this response Carol demonstrates respect for all participants in the decision, her commitment to patient engagement/partnerships and to collaborative practice and to her Code of Ethics responsibilities. If necessary Carol is committed to ensuring Mrs. Hurseys decision-making capacity is assessed and documented and ideally Carol assists her with advance care planning.