Assignment:

Mrs. R., an 87-year-old patient, has a past history that includes coronary artery disease, a previous stroke,  and advanced Alzheimer's disease. Ten days ago, Mrs. R. was hospitalized for aspiration pneumonia and has been ventilator-dependent since being admitted to the intensive care unit in a small rural hospital. Family members visit daily and have repeatedly voiced their concern to the nursing staff about the continued ventilator support that Mrs. R. is receiving, most notably the fact that Mrs. R. would never have wanted such care. They also note that Mrs. R. has not recognized them in past months and that they plan to visit less in future days, but can be contacted should any change in Mrs. R.'s condition occur. Her primary physician has practiced in this community for multiple years; he is well known for his reluctance to discontinue any type of life support for any patient. When questioned, Dr. G.'s consistent response is, if this were his frail 92-year-old mother, he would prescribe the very same treatment for her. Dr. G. has now requested that the nurses talk to the family about moving Mrs. R. to a major medical center, where she can receive more advanced care, including vigorous rehabilitation and physical therapy. so that she may eventually return to a long-term nursing care facility. How might the nurses in this scenario respond to the physician's request? How would this scenario begin to cause moral distress among the nursing staff, and what are the positive actions that the nurses might begin to take to prevent moral distress?

Read exercise 4.1 (Guido, p. 44) and apply the moral model to resolve the dilemma

Read the case study presented at the end of Chapter 3 (GUido, p.41). You are one of the staff registered nurses in a busy emergency department in a large metropolitan area. Several of the patients have existing chronic healthcare problems and frequently return to the emergency center for reevaluation and follow-up treatment. As a means of working with these patients, you and some of your co-workers

have increased the amount of time discussing discharge orders and the need for compliance with discharge orders, prescriptions, and treatment plans. This has resulted in longer "wait times" for incoming patients, and the nurse manager has dictated that nurses are to limit their discharge instructions to essential facts, informing the patients that they need to read the written materials and call their family health care providers if further problems arise.

• What compelling right does this case address?
• Whose rights should take precedence?
• Does a child (Here, a competent 14-year old) have the right to determine what will happen to him? Should he ethically have this right?
• How would you have decided the outcome if his disease state has not intervened?

Examine the above scenario from the perspective of health care policy. How would you begin to evaluate the need for the policy and the possible support or lack of support for the policy from your peers, nursing management, and others who might be affected by the policy? Do the 10 questions outlined by Malone (as listed in Guido,  P. 50) assist in this process? Draft a proposed policy to address the issue you have identified.