Patient’s rights are the most important when in context with healthcare. Patient has the right to decide related to treatments and interventions. As a nurse, we were taught what are the best treatment options for a disease, or the interventions needed to regain full recovery. Ethical decision making occurs when patients are not educated on what is the best intervention for them, or when they are too focused on the suffering they are going through and refuses treatment that benefits them. We as nurses always battle this ethical decision makings as we know we must respect patient’s rights but also must ensure interventions are given so they will recover. There are solutions available for nurses for such cases where nurses must go against patient’s rights to ensure patient recover from illness.
In this scenario, Mr Tan is mentally sound and can make decisions. He refused to insert the Ryle tube, due to the pain and suffering he has to go through. He will be severe lack of nutrients if the tube is not inserted but harm will be done if we do. Should we follow doctor’s order or respect patient’s decision? The use of hand mitten is to prevent him from pulling the Ryle tube out. Hand mittens are a type of restrain and should only be used as a last resort. Are hand mittens necessary or using other methods, such as persuasion, better?
Ryle tube, also known as nasogastric tube, is used for therapeutic and diagnostic purposes like evaluating upper intestinal bleeding, aspiration of gastric content, feeding, bowel irrigation, etcetera. (Shlamovitz, G. Z., 2017) Hand mittens are a type of restrain that prevents the wearer from scratching their skin, from pulling out tubes or harming others. Restrains should not cause harm to the wearer and should only be used as a last resort. (Jennifer, K.M., 2017)
The principle of autonomy and respect. Autonomy refers to providing information and respecting one’s rights to self-determine whether to proceed with an action or to reject the action. Respect refers to respecting one’s decision, rights and the individual himself. In this scenario, Mr Tan does not want to insert the Ryle tube as there is a lot of discomforts. If we follow his rights, Mr Tan will not receive enough nutrients as he is not eating well. But if we don’t, we are breaching his rights to receive treatment or not. The principles contradict paternalism where healthcare professionals make the decision for the patient. Respecting patients or making a decision based on their best interest, which principle should be applied in this case?
The principle of fidelity. Fidelity is having loyalty, fairness, truthfulness, advocacy, dedication and keeping promises based on the virtue of caring, to our patients. Based on the virtue of caring, we nurse pledged to care for our patient and promises to nurse our patient back to full health. To do so, interventions must be done, but patients might refuse to prevent us from keeping our promises. In this case, we inserted the Ryle tube to ensure Mr Tan have enough nutrients, but by doing so, we are going against his decision of refusing the insertion. There is the dilemma where nursing Mr Tan back to health, keeping our promises contradicts respecting his decisions, having loyalty.
The principle of beneficence. Beneficence refers to having the desire to do good for your patients. It is to do treatments or interventions that will benefit the patient, improving their condition. In this case, we have inserted the Ryle tube so that nutrients can be administered to Mr Tan, improving his nutritional status. But by doing so, we contradict the principle of nonmaleficence. Nonmaleficence is doing good that causes unintentional harm to the patient. Using beneficence, Mr Tan should not be suffering or in pain, but nonmaleficence overrides that as we are causing harm to him to do good for him.
The principle of nonmaleficence. Nonmaleficence refers to causing unintentional harm to the patient that has a good cause. Many medical interventions cause unintentional harm to the patient, in order for the patient to recover. In this case, we are causing harm to Mr Tan, but we are doing so that he could recover. But the dilemma is that we are inflicting more harm on the patient that is already suffering so much. Although the result is something positive, the harm done is still there.
The first solution is using verbal communication, to persuade Mr Tan to agree to this procedure. This includes explaining the purpose of this procedure and what are the complication if his condition is not treated promptly. I must encourage Mr Tan to endure the discomfort and convince him to not pull out the tube. If I am not successful, I can contact his next of kin, to persuade him while visiting him. The chances are higher as patients often listen to their family members more compared to strangers.
The second solution is using an intravenous route to provide nutrients to him. A solution containing carbohydrates, fats, protein, electrolytes, vitamins and minerals is customised for him to replenish the nutrients needed for body function (2017). The solution is administered through a vein into the bloodstream. This method is an alternative to Ryle tube, but this can lead to complications like extravasation and phlebitis due to prolonged use of the same intravenous line (Lisa, B. 2015).
I will choose the second solution which is using the intravenous route to administer nutrients. An intravenous plug is usually inserted at the emergency department to administer fluids to him. Since there is already a plug inserted, nutrients and normal saline can be administered through the plug into the bloodstream. This can prevent Mr Tan from undergoing the suffering of inserting a Ryle tube and feeling uncomfortable afterwards. This can also prevent the trauma of the unpleasant experience. However, continuous monitoring should be carried out to observe for signs of complication. The therapy should be stopped immediately should there be signs of complication to prevent worsening of the condition.
Using the code of ethics and professional conduct by Singapore Nursing Board(SNB), we have breached value statement 2, respect and promote client’s autonomy, and value statement 4, respect and preserve client’s privacy and dignity. But we have applied value statement 6, maintain competency in the care of clients (Singapore Nursing board, 2018).
In value statement 2, nurses should respect the client’s rights to making a decision concerning their own care. By inserting the Ryle tube while Mr Tan is refusing profusely, we did not respect his rights to make the decision on whether to insert the Ryle tube. Value statement 4 requires nurses to protect the privacy and dignity of their clients, ensuring that client’s self-respect and self-esteem do not suffer. Mr Tan’s eyes were in tears when we left him. His self-esteem was greatly damaged as we forcefully inserted the Ryle tube into his body. We did not consider his feelings of being forced to participate in something that he does not like, being tortured by nurses who did not consider his suffering. This will also lead to lower self-respect. When nurses do something to him that goes against his decisions, he will feel that he is not respected and that there is no one respecting him, thus thinking that there is no point in respecting himself. Value statement 6 expects nurses to always be competent in knowledge and skills, as well as being effective in caring for their clients. Even though inserting the Ryle tube is uncomfortable, we know that inserting the Ryle tube is the better option for Mr Tan to acquire all the nutrients and water he lacks due to dehydration and loss of appetite. (Singapore Nursing board, 2018)
I learnt that there will always be an ethical dilemma when caring for my patients. There are no right or wrong choices, but I must be able to justify my actions. Ethical principles are in place to guide us nurses into providing the best care available while ensuring patients are not harmed in the process. It is important to make sure that knowledge and skills are proficient and always gather data, so I know what can be done under certain circumstances. For example, I must know all the different types of solutions available so that the best choice can be given to my patient. I learnt how to manage ethical dilemmas and how to better nurse a patient.