Crucial element to maintaining confidentiality

Ethical-Legal Dillema in Advanced Nursing Practice

Ethical-Legal Dilemma involving a Patient in Emergency Department (ED)

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The case study discussed in this paper presents ethical-legal principles in nursing which protects patient’s privacy, confidentiality and security. Nurses have a professional obligation to protect the privacy of patients. Nursing Law and confidentiality define privacy as the right of patients to have their personal, identifiable medical information kept discrete and only accessible to the physician of record and other health care and insurance staffs as necessary. The governments have laws that maintain the confidentiality and privacy of patient’s medical data, particularly to information about transmittable diseases and mental health issues. According to Mullinex & Bucholtz (2009), nursing information is transforming the nursing field rapidly and the major issues causing the changes are the nursing ethics relating to patients privacy. According to Pearson (2009), there are penalties, both civil and criminal crimes that are enforceable if there is any breach of health information. Application of these penalties provides motivation for conformity among nurses with the confidentiality principle observed.

When nursing standards, rules and policies are set and intended in maintaining the privacy of patient’s information prevents any deliberate and unpremeditated breach in patient’s confidentiality. The crucial element to maintaining confidentiality is to ascertain that only competent personnel have access to patient’s information that is relevant to them. Nursing informatics has policies that preserve secret codes in order to prevent illegal viewing of patient data. According to Ritter & Hansen-Turton (2008) legal reasoning constructs entails comprehensive understanding of the legal statutes pertaining to particular medical conditions of patients and application of deductive and inductive logic skills in dealing with the situation. Sarhan (2009) define ethical reasoning constructs as the application of suitable role of ethical reasoning to promote the welfare of the patients.

Advanced Practice Ethical-Legal Dilemma

In this paper, Hispanic male, 30 years old in the emergency department after sustaining serious injuries following a car accident. After the diagnoses, the patient showed signs and symptoms of internal bleeding and nurses advised the patient the significance of accepting blood transfusion and immediate surgery to identify the injured parts, but the patient refused on the ground of his religious beliefs. The ethical-legal dilemma in this case is whether to respect the patient’s decision and ignore standards of care or disrespect the patient’s independence in an effort to save his life. This paper presents a clinical case study, identifies the ethical-legal dilemma, and discusses the ethical and legal principle that applies in this case.

Violation of Ethical Principles and Law

Ethical reasoning

An ethical dilemma emerges when the patients and nurses disagree in their understanding of the right and wrong decisions in caring and treating patients. Nurses deal with ethical dilemmas in their everyday nursing practice; and they have the obligation of analyzing and examining any ethical problem that may emerge. Any decision made by nurses should come from on ethical-legal standards that protect the rights and privileges of both the patient and the nurse. There are numerous ethical principles that provide guidance to the caring and treatment of patients. They comprise, respect for patients, beneficence, justice and autonomy. This case addresses patient’s autonomy in medical diagnoses. First, it is essential for nurses to evaluate patients’ knowledge of their risk of health, and reasons for recommending particular diagnoses, and possible results so that they can make knowledgeable medical-based decisions.

Informed decision ascertains the right of patients to make independent decisions based on their personal values and beliefs, whether cultural or religious. The informed decision depends on the ability of the patient s to make autonomous decisions about their healthcare information following sufficient examination of the patients’ medical conditions and recommendable diagnoses. Prior to diagnosing the patient, nurses should disclose to the patient about their health status, the risks involved and the diagnoses suggested to save his/her life. Such disclosures should comprise an explanation of the nature and rationale of the diagnoses, the health risks and benefits, the principle of confidentiality, the right of refusal without legal attachments and other options.

The ethical standard of autonomy coerces nurses to avoid any harm towards their patients, capitalize on the likely benefits, and reduce the likely harms of the diagnoses recommended. However, misunderstanding may cause psychological anguish to the patient. For instance, in the case study, misunderstanding arises based on the patient’s religious beliefs and mistrust of medical procedures, especially, when the recommended diagnoses lacks treatment options. Some patients feel pressure from their families and concerns about the effect on their future life or discovery of other health issues during the diagnoses.

In examining a nursing ethical dilemma, the first procedure is analyzing the medical condition and diagnoses based on the underlying ethical-legal standards that are applicable and the likely related ethical theories involved. In understanding the decision-making procedures, the healthcare providers apply the ethical standards of autonomy, beneficence, nor-maleficence, and justice. These are some of the nursing healthcare standards applied by healthcare providers in the case of a patient presented in the emergency department. The recommendations proposed by the nurse regarding the patient’s status ascertained that the patient was in a critical condition that required immediate attention. Even if there were other treatment options to treat the patient, surgery was the only appropriate diagnosis to establish a meaningful tension of preserving life. However, the patient disagreed with the suggestion, and such a disagreement with the proposed plan of care compromises the moral responsibility of adhering to the patient’s decision and his preferred mode of treatment. When the condition of the patient worsens, there is a need to resolve the conflicts of reciprocal autonomy.

Patient’s Autonomy empowers patients to make their own decisions without interventions from the nurses or other people. The ethical dilemma presented in the case study is whether to adhere to the patient’s autonomy or ignore his wishes by performing the surgery in order to save life. In such a scenario, the healthcare provider either presents an alternative medical treatment that may favor the patient’s wishes. However, based on the patient’s condition, nurses recommend immediate surgery. Even though respecting the patients autonomy yields contentment for the individual, while intervening with the decision may impose pain and suffering, nursing ethics preserves the patient s’ autonomous. Pearson (2009) states that adhering to the patient’s autonomy takes priority over beneficence, as the care of the patient is the proposed care. Thus, nurses evaluate treatment options that keep the patient alive before discharging him/her.

In essence, disrespecting the patient’s autonomy means defying the patient’s medical preference and this may result to severe legal penalty. Autonomous directs the nurses to follow the patient’s medical preference. This principle emphasizes on making the patient comfortable and free of pain in the process of treatment. In some instances, nurse face dilemmas when there is communication breakdown between nurse-patient, and therefore, the stress of illness and dying creates tension even if nurses recommend a diagnosis without the patient’s interference. In some situations, family members can cause the dilemma, whereby, the decision of the patient differs with the decision of the family members. In solving such conflicts, nurses provide counseling to the patient and the family members pertaining to the health status of the patient and the recommended diagnosis. Nurses emphasize on the value of immediate care required to the patient based on his/her status and the efficiency of the suggested diagnosis as opposed to their own decisions.

Nurses face difficulties expressing emotional statements about the dying patients, but, they must provide facts about the health status of the patient in order to assist create harmony around the immediate medical decisions and course of action. In this case, the health providers feed the patient with facts concerning his health status and the effect on his quality of life. However, what are the obligations of nurses, when either the patient or the family members disagree about the suggested treatment options? The dilemma that nurses face while attending to a dying patient is whether to respect the wishes of the patient or perform their own obligations. The decision of maintaining patient’s autonomy may have devastating effects and poor medical care at the final stage of the illness. According to a recent research by Sandman & Munthe (2009) on ethical issues in nursing practice, extending the living-dying process with wrong measures is one of intense and disturbing experiences that nurses face and witness. Even though saving life is the obligation of the nurses, providing medical treatment against the wishes of the patient is a violation of the nursing ethics — Autonomy.

Legal reasoning

Failure to adhere to nursing standards constitutes either a civil or a criminal violation. Ethical standards work hand in hand with legal principles. This implies that patients are entitled to fair treatment using available resources to save life. Therefore, in this scenario, it is justifiable for the patient to enjoy the comfort care he requires based on his religious belief. However, the involved nurse’s attempts to interfere with the patients decision which results into a conflict. When a patient is in the emergency department, sometimes use of the advanced technologies may bring unrealistic expectations or even cause death. Therefore, accepting the suggestions provided by the nurse does not assure life, but an immediate response to a life-threatening condition based on the nursing practices. For this reason, the right to autonomy empowers the patient to accept the preferred mode of diagnosis. However, the healthcare provider has the right to respect that autonomy to exercise ethical belief.

However, there are various aspects of euthanasia practice are overlooked if nurses adhere to patient’s autonomy as the major moral element. In the first place, a critical issue in the debate resulting in the legal acceptance of euthanasia is the exceptional character of termination of life by the nurse. Even though autonomy is a common value in medical practice, practicing euthanasia entails several impacts on life. Comfort care requires a conflict of responsibilities on the side of the nurse. The principle approach, which focuses on matching autonomy with other values, is impractical to the cases of euthanasia. This is because; the only alternative to end the suffering is terminating the patient’s life.

It is, however, uncertain whether the decision of terminating life comes with the physician or with the patient based on the condition of the patient. This is because the patient disagrees with the nurse’s recommendation of performing immediate surgery and requests for an alternative based on his religious belief. The only alternative is euthanasia. While the principle of autonomy erroneously regards the patient as the final decision-maker, the principle of beneficence considers the nurse as the crucial contributor because he/she performs the diagnosis. The role of the patient is accepting with the decisions made by the nurse and suffering the consequences. The patient takes part in the process of slowly reaching the decision that euthanasia is the only alternative available (Ekman, et al., 2007). Physicians should not agree to requests from their patients to engage in unethical or illegal conduct, as consent by their patients will be no defense against disciplinary or criminal charges. In this case study, the physician’s consent to patients autonomy amounts to criminal charges. The law requires nurses to refuse requests from patients that thwart good medical practice, and to seek other autonomy even if it means limiting patient autonomy and losing their patients.

The Case of Karen Ann Quinlan

On April 15, 1975, Karen Ann Quinlan, for unknown reasons stopped breathing for two fifteen-minute periods. The insufficient of oxygen (anoxia) caused significant brain damage, leaving the twenty-one-year-old first in a coma and then in an unrelenting vegetative state, reliant upon a respirator to breathe. The Quinlan family first requested the treating neurologist, Dr. Morse, to do everything possible to keep Karen Alive. After a couple of three months without any medical improvements in her neurological status and without any hope that she would ever recover any level of cognitive function, however, Karen’s parents conferred with their local parish priest, who advised them that the Roman Catholic Church’s teachings allow withdrawal of extraordinary medical treatment under such circumstances.

Mr. And Mrs. Quinlan then approached Dr. Morse and demanded the withdrawal of the respirator, being certain that, their daughter would die. In making their decision, they signed a statement that allowed the physician to withdraw the respiratory without any liabilities. However, even with the signed statement, Doctor Morse refused by claiming that doing so is against the moral ethics of saving life. In response to Dr. Morse’s decision, Mr. Quinlan sought judicial intervention. He petitioned the chancery court to assign him legal guardian of Karen’s person and property because of her incompetency, and asked that the court grant “the express power of authorizing the discontinuance of all extraordinary means of sustaining the vital processes of his daughter.” The court ruled on the ground of equity by invoking the parent’s patriae power of the court to help and defend the incompetent Karen Ann Quinlan, and favor her interests. According to Judge Muir, he ruled in favor of Dr. Morse by asserting that the healthcare provider is the guardian of morality in life-and-death decision-making, charged by society to “do all within [its] human power to favor life against death.”

Prevention of violation of Ethical Principles and Law

Respect for a patient’s autonomy and human rights require the consent from both the nurse and the patient before carrying out any medical diagnosis. This is essential to quality medical Practice. The total refusal of blood transfusion by a Jehovah’s Witness may differ with advanced nursing practices, personal values and an urge to save life. Legally, it is apparent that a health practitioner must respect the patient’s autonomy. An individual with the right frame of mind has absolute right to refuse any medical treatment recommended to him/her even if it may cause death. The basic legal and ethical responsibilities of a physician towards the patient are fixed and to carry on with the transfusion of blood to a patient who has persistently refused to accept it is a serious personal violation. Such actions are illegal.


Clinical circumstances that raise ethical questions are a challenge to explore. Often, there are numerous clinical facts to consider. In addition, the nurse must take into account the patient preferences and the concerns and values of family. Nurses often deal with ethical and legal dilemmas in the clinical field. The case study discussed in this paper illustrates an ethical-legal dilemma nurses encounter when caring and treating patients in Emergency department because of severe medical situation. A 30-year-old Hispanic male placed in the emergency department in serious condition after sustaining serious injuries following a car accident. The patient showed signs and symptoms of internal bleeding and nurses recommended immediate surgery in an effort to save his life. The patient declined surgery performed on him based on his religious belief. The ethical-legal dilemma in this case is whether to respect the patient’s decision and ignore standards of care or disrespect the patient’s independence in an effort to save his life.

In the study by Needleman & Minnick (2009) pertaining to nurses’ dilemmas in patient’s care, most of the situations are linked with moral distress, extending life and performing pointless tests and treatment on fatally ill patients. The emotional feeling of dissatisfaction and distressed in providing end- of- life care comprises the overuse of life-supporting technologies, a deep sense of responsibility for patient’s well-being, and a need to alleviate suffering (Pearson, 2009). The kind of care requested by the client relates to his religious belief. In the case study, the patient wants to experience comfort care until he dies. However, the nurse believes that there is quality and suitable care if the patient accepts immediate surgery. This would give clear diagnoses of the parts affected and quick response to medical care. However, the principle of patient’s autonomy empowers to decide the mode of treatment.


1. Nurses should build support networks by identifying persons that support their nursing practices or those that Act or address the moral distress.

2. Nurses should focus on changes in the nursing field. Focusing on the nursing environment is more productive that relying on an individual patient

3. Nurses should take part in moral distress education.


Ekman, B.B, Granger & I. (2007). Standard medication information is not enough: poor 40 concordances of patient and nurse perceptions’, Journal of Advanced Nursing 60 (2), 181-186

Mullinex, C., & Bucholtz, D. (2009). Role and quality of nurse practitioner practice: A policy issue. Nursing Outlook, 57

Needleman, J., & Minnick, A.F. (2009). Anesthesia provider model, hospital resources, and maternal outcomes.

Pearson, L. (2009). The Pearson report. American Journal for Nurse Practitioners, 13 (2), 8 — 82.

Ritter, A., & Hansen-Turton, T. (2008). Primary care paradigm shift: An overview of the state-level legal framework governing nurse practitioner practice. Health Lawyer, 20(4), 21 — 28.

Sandman, L & Munthe, C (2009). Shared Decision Making and Patient Autonomy. Theoretical Medicine and Bioethics, 30 (4): 289-310.

Sandman, L & Munthe, C. (2010). Shared decision-making, Paternalism and Patient Choice

Sarhan, F. (2009). Telemedicine in healthcare: exploring its uses, benefits and disadvantages. Nursing Times; 105: 42, 10-13.

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