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Nurses face more and more ethical dilemmas during their practice nowadays, especially when they are taking care of the patient at end of life stage. The case study demonstrates an ethical dilemma when nursing staff are taking care of an end stage aggressive prostate cancer patient Mr Green who expressed the suicide thoughts to one of the nurses and ask that nurse keep secret for him in Brisbane, QLD, Australia.
The ethical dilemma is identified as “if the nursing staff should tell other health care team members about patient's suicide attempt without patient's consent”.
To better solving this case and making the best moral decision, the ethical theory, the ethical principles and the Australian nurses' code of ethics values statement, the associated literature relative with this case are analyzed before the decision making.
After consider all of the above factors, in this case, the best ethical decision for the patient is that the nurse share the information of Mr Green's suicide attempt with other health care professionals.
In Mr Green's case, the nurse chose to share the information of Mr Green's suicide attempt with other health care professionals. The nursing team followed the self-harm and suicide protocol of the hospital strictly, they maintained the effective communication with Mr Green, identified the factors which cause patient's suicide attempt, provided the appropriate nursing intervention to deal will these risk factors and collaborated with other health care professionals to prefect the further care. The patient transferred to a palliative care service with no sign of suicide attempt and other self-harm behaviors and passed away peacefully 76 days after discharged with his relatives and pastors accompany.
Nurses face more and more ethical dilemmas during their practice nowadays, especially when nurses have responsibility to take care of patients with terminal diseases such as cancer . The case study demonstrates an ethical dilemma faced by a nursing staff taking care of an end stage aggressive prostate cancer patient Mr Green who confided to the nurse his suicide attempt and ask the nurse to keep the secret for him. This essay will present the clinical case regard to Mr Green's attempt to suicide, identify the ethical dilemma arise from this clinical case, discusses ethical theory and principles apply to this case, apply the western countries' nurses' code of ethics values statement to this case, analyze the opinion in the associated literature and give some suggestions on how to solve this ethical dilemma.
The patient Mr Green is a 57 year old gentleman with aggressive prostate cancer who is took care of by the nursing team in the oncology department of a general hospital in Brisbane, QLD, Australia. Mr Green 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 Green has now presented with anemia and hypoproteinemia. After several diagnostic tests over a period it was discovered that the cancer had metastasized to his bones, it had spread locally to his lymph nodes and the primary tumor was invading the bladder and partially obstructing the left kidney. Mr Green had several admissions over a two month period for various reasons. On the last admission Mr Green was told that he may only have 4–6 weeks (previously it was 6–12 months) to live after a cystoscopy showed further extensive growth of the tumor, it was determined that any further surgical/medical intervention would not be appropriate in this case and that a palliative care regimen 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 Green pulled 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.
According to the patient's case, the patient Mr Green with end stage aggressive prostate cancer who had been confirmed that he only have 4–6 week to live expresses the suicide attempt to a nursing staff and asks nurse do not tell others. The behavior of patient put the nursing staff in a difficult situation, which can be identified as an ethical dilemma. Beauchamp and Walters  defined an ethical dilemma as a situation happens when person must make a choice among mutually exclusive alternatives. According to Chally and Loric . an ethical dilemma always occurs when “a moral problem involving two or more mutually exclusive, morally correct actions” (p. 17). In Mr Green's case, after the patient confided the suicide attempt, the nursing staff has two exclusive, morally correct choices. If the nurse chooses to keep secret as patient required, this behavior will respect patient's own decision. However, the nursing staff's decision may cause the patient actually commit suicide without any healthcare intervention. If the nursing staff chose to tell other health care team members about patient's suicide attempt, the health care team would be involved in monitoring, prevention and avoiding suicide, but the patient's autonomy, confidentiality would be violated. Therefore, the major ethical dilemma of this case can be identified as ‘if the nursing staff should tell other health care team members about patient's suicide attempt without patient's consent.’
Some research identified the relationship between the ethical dilemmas and ethical principles. According to Johnston . the logical incompatibility between two principles can cause the ethical dilemmas, especially in the moral situation that two different ethical principles can be applied, but using one principle must violate the other principle. In the Mr Green's case, the ethical principle autonomy and beneficence can be applied equally, but none of them can be chosen without violating other one. The significant logical incompatibility between autonomy and beneficence in this case is the major reason which causes the ethical dilemma about ‘if the nursing staff should tell other health care team members about patient's suicide attempt without patient's consent’. In addition, the ethical principle non-maleficence is considered in this moral situation which infringes autonomy principle but gives support to beneficence principle. Therefore, when considering Mr Green's case, three ethical principles are in conflict: respect for autonomy, non-malefience and beneficence.
Bate  defined beneficence as “the quality of doing good, taking positive steps to help others, or the notion that one ought to do or promote action that benefits others” (p. 343). It can be referred as actions which mainly focus on benefiting other people . In the health care area, one of the most important obligations of nursing staff is take the positive action to promote health and wellbeing of patients . It means that the nursing staff has to consider which actions will be better for patient. Applying beneficence to ethical dilemma in Mr Green's case, the nurse has to consider the question which choice will be better for Mr Green. Department of Ageing Disability and Home Care stated that the beneficence principle requires nursing staff do everything to promote patient's health and maintain patient's safety. It is obvious that the nursing staff tells other health care professionals about Mr Green's self-harm attempt, thus the health care intervention can be involved to prevent the actual suicide will be a better choice and will fit the beneficence principle.
Beside beneficence principle, “Non-malefiecence invokes the obligation not to harm others”. Refer non-malefiecence to health care area, it emphasized that the health care staff has to make sure their actions would not cause harm to patient . In Mr Green's case, the non-malefiecence principle requires the nurse take an action to ensure patient not to harm himself instead of ignoring patient's potential self-harm. Therefore, the action of telling others ensures no further self-harm behavior of patient corresponds with non-malefiecence consideration.
There is an issue which needs to be noticed. It is important that when applying the beneficence and non-malefiecence principles, the patients' own perspective about benefit and harm of themselves needs to be assessed . Therefore, in Mr Green's case, Mr Green's own perspective of benefit and harm need to be considered. Mr Green's concept of greatest benefit would be to be allowed to die. And nurse's behavior of keeping silent would not be considered as harmful from his perspective.
Friedman  defined Autonomy as “a form of personal liberty of action in which the individual determines his/her own course of action in accordance with a plan chosen by himself/herself” (p. 450). It means that the autonomy principle respects competent patient's right to make their own decisions. In the meantime, autonomy also required nursing staff to respect patients' confidentiality and ensure nursing staff's actions have informed consent of their patients  Applying this principle to Mr Green's case, the choice of keeping secret respects patient's right of self-determination and informed consent.
But the choice of keeping secret would ignore patient's potential suicide and would lead to patient's self-harm behavior. According to Howard, Fairclough, Daniels and Emanuel  the cancer patients would be more likely to seek assistance with dying. One type of assisted dying behavior of health care staff is “refraining from interventions to prevent or dissuade the patient from taking his or her life”. In Mr Green's case, the choice of keeping secret can be classified into assisted dying. Sneesby  pointed that “the ethical principle of autonomy is not upheld in law regarding euthanasia and assisted suicide, ‘as people do not have the right to be assisted to die at any time they choose’ ” (p. 456). Therefore, although Mr Green's autonomy should be respected, but it can not override the common law which identifies that professionals' behavior of assisted dying are prohibited restrictedly.
Some research also pointed that if patient in some special situation made the irresponsible decision which would cause severe consequences to themselves or/and others, the health care professionals should override their wishes in order to minimize and prevent these consequences . In Mr Green's case, the suicide attempt can be identified as a decision which causes the serious self-harm result. Therefore, Mr Green's autonomy can be overridden in order to avoid his suicide attempt. In addition, the assessment of Mr Green's current situation when he made the decision is needed, because some research emphasized that patient with mental disorder or unstable emotional condition can not be considered as a competent person who can make decision for themselves.