NURSES are involved with bioethical, moral and advocacy roles frequently in endoscopy labs, due to the fact that consents, patient care, and medical goals are all involved in the outcome of the procedures. Ethics cover a broad range of concepts that have an effect on many varied cultures and beliefs in our diverse communities. Trying to explain all the concepts would require volumes of books. Concepts that come to mind first for endoscopy would include autonomy in regard to consents, based on the patient’s wishes. Beneficence and non-maleficence are concepts that are related to a physician’s motivation to perform or not to perform a procedure, and veracity, which has to do with truth-telling and at least an obligation to offer the truth.
Non-maleficence and beneficence are ethical principles that serve as guides to achieve the aims of prevention and cure of disease and improve the functional abilities of patients. The questions to concern ourselves with when we are involved with practicing a medical intervention is: How can this medical intervention help this patient? The physician’s obligation under the Hippocratic Oath is to, “Help, or at least do no harm.” The motivation to perform or not to perform a procedure is the motive based on what the patient wants and what will help. How does a nurse intervene as an advocate on the patient’s behalf?
For example, there is the case involving a 60-year-old female with pneumonia, diabetes and gastrointestinal bleeding, on a ventilator with a dopamine drip for her blood pressure, who was consented by family for an “endoscopy with control of bleed.” The critical care nurse was intuitively leery of doing the procedure on a labile patient. The respiratory therapist also concurred that her condition had worsened within the last four hours, and that the bleeding was not increasing but that her vital signs were unstable.
The astute doctor acknowledged the input of the registered nurse and the respiratory therapist and made a wise choice to delay the procedure. Three days later, the patient had stabilized and a percutaneous gastrostomy tube was inserted successfully. The nurse’s encouragement to postpone the procedure helped to reinforce the doctor’s obligation of non-maleficent behavior. The busy physician can often manifest a desire to just ‘get the job done’ when it is convenient for his time. This particular doctor was able to rethink his timing after considering the facts given to him.
Another area of ethical concern is veracity, an obligation to patients ever since 1980. The idea is for physicians to deal honestly with their patients and colleagues. Veracity is based on the respect owed to others. The respect is for autonomy, and provision for justification and disclosure for consent. Veracity involves keeping promises of speaking truthfully so as not to deceive our listeners, because our relationships are based on trust with our patients.
Having said this, there are still other obligations to consider in giving healthcare, which may lead to one not fully disclosing the entire truth — to fulfill our obligation to enhance healing and waiting time for disclosure, or not, due to cultural norms. Endoscopy procedures can become ethical entanglements when the consent for procedure, medical need for the procedure, unexpected outcome or prolonging of life come into question.
The medical need for the procedure is out of the hands of the registered nurse, but the readiness and awareness of a patient, family or conservator is part of the RN’s obligation. The California Health Care Association provides a consent manual guide for reference of questions. Health directives, refusals, deaths, the clarification of who may give a consent, patient rights and much more are addressed in the manual. One of the areas in the consent is to ensure a clear understanding of possible outcomes. Physicians usually have to pad the possibility of “perforation or death” with a statistical study indicating that this is a rare instance. I am reminded of a case with a painfully brutal outcome, yet the family consented in the hope of prolonging their father’s life.
Mr. X, a 70-year-old man on a ventilator in intensive care, was bleeding profusely both orally and rectally, and his hemoglobin had dropped to 5 from 12. He had been on blood thinners and IV drips to keep his blood pressure up. The family consented to an endoscopy with control of the bleed and the patient died during the attempt to control his bleeding. Sclerotherapy or a clip procedure would have been useful had the patient been more stable. The question that comes to mind is, was the strain of placing the scope in the esophagus causing a blood clot to break loose and further exacerbate his problem? Or was the risk a worthy attempt to prevent an already fatal condition? The family appeared relieved after we shared with them that their father did not survive the attempt. They said they’d been through a lot with him and wanted every best effort to prolong his life knowing this was a possible outcome. In this case, the family clearly understood the pros and cons of what they consented to. The doctor had communicated clearly.
Another scenario indicates what can happen when the outcome is not clear. A 35- year-old male patient with end-stage cirrhosis, ascites and delirium tremors was admitted for variceal banding. Jaundice was visible and varices were a potential source of bleed. The consent for the procedure was obtained, and the patient’s family believed their son would be a liver transplant candidate and wanted any and all treatments to be done. The patient was on morphine and his respirations were slow. The procedure was tolerated with 1 mg of Versed, and the patient was returned to his room in a similar vital sign state compared to that in which we had received him. He died two hours post-procedure. The family was devastated and not completely clear on the possible outcomes of banding and end-stage liver failure. The patient was not stable and perhaps needed to suffer through his delirium tremors before the procedure was performed. This was a medical decision, but nurses still can provide input for the benefit of the patient even though the nurse’s scope of training is apart from medical assessment.
Autonomy, in regard to consent, involves choices that a surrogate decision-maker would make for a patient. The need is for the consent to be based on the patient’s wishes, and in regard to paternalistic physicians who might make decisions that they think are best for the patient. Informed consents are a part of this decision-making. In the 1970s, as a result of the Nuremberg trial and the horrifying accounts of the experimentation in the concentration camps, the patient now was determined to need a quality understanding of the researcher’s or physician’s plan of intervention. Five elements are involved in the informed consent: competence, disclosure, understanding, voluntariness and consent. The importance of this in endoscopy and especially with patients undergoing a percutaneous endoscopic gastrostomy (PEG) tube placement, is that it can prolong an incompetent patient’s life, outcome and understanding of care.
In another case, a 61-year-old man had a massive heart attack and a stroke that left him obtunded, without speech, and unable to eat, and left him bed-ridden. His wife of 25 years was hopeful that his condition would change, and continued to say for 10 months that she had cared for him and would keep the faith that he would recover. An EKG revealed some lower brain function, but higher functions revealed little hope. Inserting a PEG was performed as requested by his wife. We must ask the ethical question, What are we accomplishing? Is the expected outcome worth the effort? Do the benefits justify the risks? Sustaining life that is clearly deteriorating is not always a wrong choice as some may think. There really is no clinical definition for “terminal.” The word terminal is often loosely used to refer to any patient with a lethal disease. Under Medicare eligibility rules, reimbursement for hospice care requires a diagnosis of a terminal condition with a prognosis of six months or less to live. It really is perilous to predict how long a “terminal” patient will live, because inaccurate predictions abound. In the case of this 61-year old male, the wife was determined to do all she could to restore what was left.
There are five focal virtues important to the health professional: compassion, discernment, trustworthiness, integrity and conscientiousness. Do these words go without saying? Having a definition of these concepts enables one to be fair in distributing these attributes to all.
Compassion is defined as regard of another’s welfare with awareness and emotional response of deep sympathy, tenderness and concern over another’s misfortune. The focus is on others.
Discernment is described as sensitive insight, acute judgment, understanding and action, the decrease of influence of extraneous circumstances, fears or personal attachments. It also means knowing what ends to choose and the range of possible actions, as well as respect of autonomy and beneficence, which varies in different contexts.
Trustworthiness is relying on the moral character and competence of another person, and confidence that another will act with the right moves and appropriate moral norms.
Integrity indicates the core beliefs at the heart of our conscience. Moral integrity means soundness, reliability, wholeness and integration of moral character, being faithful to moral values. Hypocrisy, insincerity, bad faith and self-deception indicate a lack of moral integrity.
Conscientiousness is to do right because it is right. Critical reflection of oneself brings one to judge on acts, answering the question, Is this right or wrong, good or bad?
Conscientiousness means you risk the demands made by others in order to do what you know is best. All of these virtues come into play in caring for your patients and in checking them for procedures that need informed consents due to the potential risks involved.
The patient is reliant on his family or significant others to achieve a goal, so the question needs to be asked again, What are we accomplishing?
The nurse’s role in endoscopy is one of advocacy, whether it be for the rights of the incoherent patient or the patient himself who signs a consent hoping for better health, yet knowing what the limitations are of the procedure.
Marcia West, RN, is a staff nurse for the Washington Hospital Health Care Systems Endoscopy Team, located in Fremont, Calif.