Nursing Case Study - A Clinical Reflection

This nursing case study discusses the ethical dilemma faced by a nurse while caring for a terminal patient. The scenario describes the conflicting moral principles of beneficence, non-malfeasance, fidelity, autonomy, justice and integrity. The action plan followed by the nurse is also discussed.

Running head: Nursing Case Study
Nursing Case Study
-A Clinical Reflection
Name of the Student
Name of the University
Author Note

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Introduction:
The nursing profession entails caring for individuals, their family and even
communities in order to achieve, maintain or recover mental and physical well being and
quality of life. It also includes promoting well being, preventing illness, and caring for the ill,
disabled or dying individuals (who.int, 2018). Nursing philosophy therefore is based on
several ethical axioms that ensure respect to human rights (icn.ch, 2018). The ethical codes
include: beneficence, non-malfeasance, fidelity, autonomy, justice and integrity (Shahriari,
Bahrami, Abbaszadeh & Bahrami, 2018). Several dilemmas are caused while trying to
maintain the ethical code of conduct in nursing, and can include issues related to informed
consent, disclosure of medical conditions and incompetence among peers (Cherry & Jacob,
2016; Zahedi et al., 2013). Jie (2015) pointed out that nowadays, nurses face an increased
number of situations of moral dilemma, and this is especially while caring for terminal
patients.
Gibbs Model:
Description of scenario:
The patient Mr X (name withheld to protect patient’s privacy) is a 60 year old
gentleman suffering from aggressive prostate cancer, and was being treated in the oncology
department of a general hospital in Malaysia. The diagnosis was done 5 years ago, however
the patient chose to opt for alternative treatment, and refused medical or surgical intervention.
The patient also did not follow up with any urologist over the last five years and currently the
patient has been diagnosed of anaemia and hypoproteinemia. Subsequent diagnostics showed
the local spread of the cancer to the lymph nodes and metastasis to the bones, while the
primary tumour invaded the bladder, partially blocking the left kidney. Over the last 3
months, Mr X was admitted repeatedly to the hospital, that last admission was after a

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cystectomy that showed more extensive growth of the tumour, after which further surgical
and medical treatment was deemed inappropriate, and the patient was recommended
palliative care. After this, the patient resigned to the fact that he was about to die, and
confided in me about his wish to kill himself, and stop his suffering, and requested me not to
divulge this to anyone else. However, upon serious consideration of the request, and its
consequences, I had to report this incident to my supervisors, after which intervention was
planned for the patient, to help him overcome his emotional trauma. He was provided
palliative care, and stopped showing any signs of suicide attempt. He passed away peacefully
after 2 days of being discharged, in the midst of his family and friends.
Feelings in the scenario:
This was a difficult situation for me, since fulfilling the patient’s wish and being silent
of his plan to end his own life had a serious ethical conundrum. As per Beauchamp & Walters
(1982), ethical dilemma is a situation where an individual has to choose between mutually
exclusive alternatives, while Chally & Loriz (1998) suggested that ethical dilemmas occurs
while choosing between two or more, morally correct but mutually exclusive issues.
In the scenario described above, my moral dilemma was due to conflicting moral
principles. One that dictates respect for beneficence and autonomy of patient’s decisions, and
other that emphasizes on non beneficence, fidelity and integrity. Respecting the wish of the
patient not to divulge his plan of suicide would be in agreement to the principles of autonomy
(respecting patient’s wishes) and beneficence (as the patient feels his suffering can be
stopped only with his death). However, doing so will also jeopardize the principles of Non-
Malfeasance (ensuring no ham is done to the patient, either intentionally or unintentionally),
fidelity (maintaining the virtue of caring) and integrity (ensuring ethical practice is
maintained in nursing care). Also, divulging the wish of the patient can have judiciary

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implications, as it can lead to discrimination of the patient, and breach his trust and
confidentiality (Kelley et al., 2015; Saunders, 2017).
Evaluation of the experience:
Ethical dilemmas can be caused due to logical incompatibility between two opposing
principles, especially in moral situations, where two different principles are applicable, but
following one principle can cause violation of the other. Effectively, regardless of the choice,
one moral principle will be violated (Ganz, Wagner & Toren, 2015; Christensen et al., 2014).
This justified the evaluation and prioritization of the conflicting principles, trying to
understand which principle should take precedence over other, and following that. The
preference will be given as per action that can have most benefit and least harm for the
patient. Since obeying the patient’s wishes would have resulted in the patient attempting
suicide, and thus risking his life, while not doing so would mean breach of trust,
confidentiality as well as show disrespect to patient autonomy, but would not cause loss of
life, I decided to respect the principle of non malefiscence. Furthermore, it also was in
accordance with my principles of integrity of ensuring care being provided to the patient, and
reports any situation that can lead to the harm of the patient.
Analysis of the situation:
A good action is one that can minimise suffering and maximise well being. This
axiom is a part of the utilitarian principle, and is fundamental to ethics, and dictates that
morally correct action should have the best outcome for the most number of people (de
Lazari-Rad & Singer, 2017; Felzmann, 2017). In my scenario, choosing to report the incident
to the authorities would not only prevent the patient from harming himself, but also protect
the concerns of the patient’s family and also prevent jeopardy to the healthcare staff (in the
event of patient committing suicide in the hospital premise). This can be justified by the

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consideration on how suicide can have negative impact on family and healthcare staff, and
can cause a sense of guilt, shame or upset (Peters et al., 2016; Pitman et al., 2014). Therefore
my analysis considered it morally wrong to keep the patient’s intent a secret.
Conclusion:
Incidents of patients attempting to harm themselves or end their lives are becoming
increasingly common in nursing practice (Jie, 2015). This necessitates critical analysis of the
ethical dilemmas posed by such situations. Since nurses have an ethical and moral
responsibility of providing care for the sick, disabled and elderly, any moral and ethical
challenges to the providence of proper care should be studied.
Action Plan:
The action plan that I followed in this scenario was to repost the incident to my
supervisors, which allowed the prompt implementation of an intervention to help the patient.
The effectiveness of the intervention was exhibited by the patient finally deciding not to
attempt suicide, and was subsequently discharged.

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References:
Beauchamp, T. L., & Walters, L. (1982). Contemporary issues in bioethics.
Chally, P. S., & Loriz, L. (1998). Ethics in the trenches: Decision making in practice. AJN
The American Journal of Nursing, 98(6), 17-20.
Cherry, B., & Jacob, S. R. (2016). Contemporary nursing: Issues, trends, & management.
Elsevier Health Sciences.
Christensen, J. F., Flexas, A., Calabrese, M., Gut, N. K., & Gomila, A. (2014). Moral
judgment reloaded: a moral dilemma validation study. Frontiers in psychology, 5,
607.
de Lazari-Radek, K., & Singer, P. (2017). Utilitarianism: A Very Short Introduction. Oxford
University Press.
Felzmann, H. (2017). Utilitarianism as an Approach to Ethical Decision Making in Health
Care. In Key Concepts and Issues in Nursing Ethics (pp. 29-41). Springer, Cham.
Ganz, F. D., Wagner, N., & Toren, O. (2015). Nurse middle manager ethical dilemmas and
moral distress. Nursing ethics, 22(1), 43-51.
icn.ch. (2018). Code of Ethics for Nurses. Icn.ch. Retrieved 6 February 2018, from
http://www.icn.ch/who-we-are/code-of-ethics-for-nurses/
Jie, L. (2015). The patient suicide attempt – An ethical dilemma case study. International
Journal Of Nursing Sciences, 2(4), 408-413.
http://dx.doi.org/10.1016/j.ijnss.2015.01.013

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Kelley, M., James, C., Alessi Kraft, S., Korngiebel, D., Wijangco, I., Rosenthal, E., ... & Lee,
S. S. J. (2015). Patient perspectives on the learning health system: The importance of
trust and shared decision making. The American Journal of Bioethics, 15(9), 4-17.
Peters, K., Cunningham, C., Murphy, G., & Jackson, D. (2016). Helpful and unhelpful
responses after suicide: Experiences of bereaved family members. International
journal of mental health nursing, 25(5), 418-425.
Pitman, A., Osborn, D., King, M., & Erlangsen, A. (2014). Effects of suicide bereavement on
mental health and suicide risk. The Lancet Psychiatry, 1(1), 86-94.
Saunders, B. (2017). First, do no harm: Generalized procreative non‐
maleficence. Bioethics, 31(7), 552-558.
Shahriari, M., Bahrami, E., Abbaszadeh, A., & Bahrami, M. (2018). Nursing ethical values
and definitions: A literature review. PubMed Central (PMC). Retrieved 6 February
2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3748548/
who.int. (2018). Nursing. World Health Organization. Retrieved 6 February 2018, from
http://www.who.int/topics/nursing/en/
Zahedi, F., Sanjari, M., Aala, M., Peymani, M., Aramesh, K., & Parsapour, A. et al.
(2013). The Code of Ethics for Nurses. PubMed Central (PMC). Retrieved 6 February
2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3712593/