ethical of nurses

NBBS 1104 MANAGEMENT AND MEDICAL LEGAL

1.0 INTRODUCTION

At its core,nursing deals with issues and situations that have elements of ethical

or moral uncertainty. A spiraling dependence on technology and the resulting

longer lifespan and higher health care costs, coupled with increasing professional

autonomy,creates an atmosphere in which we are faced with problems of ever-

increasing complexity. We need to be able to recongnize situations with ethical

and moral implications, and make coherent and logical ethical decisions based

upon recognized ethical principles and theory.

Nurse need to be able to recognize ethical components of practice and engage in

a structured ethical decision-making process. Ethical decision making models

offer a variety of methods for coming to rational conclusions.

( Margaret & Alvita 2002 )

1.1 Definition of ethic

Ethic is concerned with motives and attitudes and the relationship of these

attitudes to the good of the individual. Ethics may be distinguished from the

low as ethics concerns the good of individual within society while low

concerns society as a whole. Low can be reinforced through courts and

satues while ethic are enforced via ethics committee and professional code.

(Raijah,Khatijah & Rohani 2010).

1.2 Definition of ethical dilemma

Ethical dilemmas can be definined as having to choose between two equally

Desirable or undersirable alternatives ( Marquis & Huston 1994). Curtin

(1982) maintain that for a problem to be an ethical dilemma, it must have

there characteristics:

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The problem cannot be solved using empirical data

The problem must be so perplexing that deciding what facts and data

need to used in making the decision difficult.

The result of the problem must affect more then the immediate

situation: there should be far-reaching effects.

By the very nature of and ethical dilemma, there is no good solution,and the

decision made often has to be defended against those who disagree with it.

The ethical decision making process provides a method for nurses to answer

key questions about ethical dilemmas and to organise their thinking in a more

logical and sequential manner.

1.3 Ethical decision making

Ethical decision making requires knowledge and attention to many factors.

Determining the existence of an ethical dilemma is the beginning step in the

process which includes defining the problem, identifying desired objectives,

listing and evaluating alternatives, choosing, the best course of action based

on one’s knowledge and the current circumstances, and evaluating the

outcomes of the action taken.



2.0 SCENARIO

Mr Y malay, 64 years old was hospitalized due the severe left diabetic foot

with gangrene,fever and decrease oral intake for one week. Patient have

hypoglycemia attack before.

Seen by doctor X suggest for left below knee amputation,but patient and

relative were refused. Explaination was given by doctor regarding side effect

of gangrene of left foot such as can be septicaemia and worse patient’s

condition.

2.1 ETHICAL ISSUE: THE RIGHT TO REFUSED TREATMENT

FOR BELOW KNEE AMPUTATION.

2.2 Definition of right to refused treatment

The right of a patient to refuse treatment after the physician has informed the

patient of the diagnosis, prognosis, available alternative interventions, risks

and benefits of those options, and risk and probable outcome of no interva-

tion.

( Mosby’s Medical Dictionary 2009)



2.3 Difinition of Below Knee Amputation

Below knee amputation is transtibial amputation in which the devision is in

The proximal third of tibial or distal or the tibial.

( Mosby’s Medical Dictionary 2009)

2.4 Implications if patient refused for below knee amputation

2.4.1 Based on hospital implications

Higher cost hospital for example cost medication,material for dressing

or equipment for treatment. Another implication increase workload for

nurses such as to do activities daily living for patient, dressing , etc.

Implication to the doctors spent more time to do same work. Lastly can

be congested in ward.

2.4.2 Based on the patient’s and family’s refused for below knee amputation

The implication to patient would be high risk for septicaemia and can

cause of death. Implication for family members such as increase

cost due to prolong hospitalization.

.



3.0 CONCIDER THE 4 STEPS

3.1 ASSESSMENT ( by using 5 steps ethical decision making process)

3.1.1 Collect , analyse, and interpret data.

Data collected shows the patient is considered severe weakness

Looking pale and bad smelling from gangrene side. Investigation

result become worse especialy haemoglobin was decreased.

Patient and family refused for below knee amputation because their

feel that wound can heel. Besides his family used more cost for

traditional treatment before.

Patient and family make hasty dicision under unstable emotion.

Patient’s family have to bear living cost when to looking for patient

in hospital or stay with patient in ward and can be stress.

3.1.2 State the dilemma

The dilemma in this case is a conflict between nurse’s decision and the

patient ’s family’s decision. The nurse’s decision is patient need do below

knee amputation due to high risk of septicaemia.

The patient’s family’s decision is refused to do below knee amputation

because their feel that wound can be heeling later.

In this case, the nurse prefer doing what is best for patient,applies the

principle of beneficence and non maleficence or do not harm, whether

Can cause pain or suffering but can bring out good for the patient.



However before do any action must be take consent from patient or patient’s

family.

3.1.3 Consider choices of action

My opinion, patient should do below knee amputation because to prevent

septicaemia and for live on.

3.1.4 Analyse the advantages and disadvantages of the course of action

Advantages if below knee amputation done.

Patient not stay in ward too long time and can be save his leg.

If amputation is not perfomed in these circumstances gangrene can be

fatal. Besides this save patient’s and family’s cost regarding hospitalized.

Another advantage patient can use prosthesis when after stump healing.

Disadvantage after below knee amputation.

However disadvantage become for temporary example pain in the

amputation stump. It’s main cause is the presence of neuromas

adhered to the local scars also swelling can cause pain and limit

movement.

The loss of foot it means that cannot walk or run as before. Losing

of a limb has also a negative psychological impact. It least amputee

feeling depressed,angry or alone



Recovery is never a fast process. Each step is difficult example

Sitting up in bed, sitting in a wheelchair and standing when using

Crutches.

Lastly patient can feel phantom limb pain. In the amputation

"phantom" limb which has been removed, such as itching, tingling,

warmth, cold, pain, cramping, constriction, movement and any other

imaginable sensation; it is experienced by almost all amputees.

The brain is “remembering” the missing part of the limb, and is still

“reporting” its feelings.

In the missing or amputated part of the limb; it varies from person to

person - a little annoying, very unpleasant, severe, or disabling; it is

different from pain in the residual limb and experienced by about 60–80

percent of amputees.

3.1.5 Make the decision

Consider with patient’s condition, making decision to do below knee amputa-

tion more advantages to patient.



3.2 PLAN OF ACTION

3.2.1 Convince patient and family regarding need for below knee amputation is a

very important to save his leg becomes worse.

In this case , amputation is performed because the arteries of the

leg has become blocked due to hardening of the arterie (atherosclerosis).

Blockages in the arteries result in insufficient blood supply to the limb.

Because diabetes can cause hardening of the arteries, about 30-40% of

amputations are performed in patients with diabetes. Patients with diabetes

can develop foot/toe ulceration and about 7% of patients will have an active

ulcer or a healed ulcer. Ulcers are recurrent in many patients and

approximately 5-15% of diabetic patients with ulcers will ultimately require an

amputation. Because hardening of the arteries occurs most commonly in

older men who smoke, the majority of amputations for vascular disease occur

in this group. Diabetes may be an important factor in nearly 40% of patients

undergoing major amputation (Moxey et al 2010).

When hardening of the arteries becomes so severe that gangrene

develops or pain becomes constant and severe, amputation may be the only

option. If amputation is not performed in these circumstances infection can

develop and threaten the life of the patient. Sometimes bypass surgery can be

performed to avoid amputation, but not all patients are suitable for bypass

surgery. Before amputation, the limb can cause serious problems with

infection and pain and may even be a threat to the life of some patients.



3.3 IMPLEMENTATION

Amputations in the case of disease are performed as a lifesaving measure.

The diseases that cause the most amputations are peripheral vascular disease

(poor circulation of the blood) and cancer.

The arteries of the legs have become narrowed, hardened and, finally blocked

due to a disease called atherosclerosis or arteriosclerosis. Blockages in the

arteries result in insufficient blood supply to the limb. In this case, diabetes can

cause vascular insufficiency, about 30-40 percent of amputations are

performed in diabetics. When narrowing or hardening of the arteries becomes

gangrene develops and amputation may be the only option. If left untreated –

depanding on the severity of someone’s condition infection can develop and

threaten the life of the patient. If amputation is not performed, in these

circumstances gangrene can be fatal.

Preparation

Before an amputation is performed, extensive testing is done to determine the

proper level of amputation. The goal of the surgeon is to find the place where

healing is most likely to be complete, while allowing the maximum amount of limb

to remain for effective rehabilitation.

The greater the blood flow through an area, the more likely healing is to occur.

These tests are designed to measure blood flow through the limb. Several or all

of them can be done to help choose the proper level of amputation.

measurement of blood pressure in different parts of the limb


http://medical-dictionary.thefreedictionary.com/Rehabilitation


xenon 133 studies, which use a radiopharmaceutical to measure blood

flow

oxygen tension measurements in which an oxygen electrode is used to

measure oxygen pressure under the skin. If the pressure is 0, the healing

will not occur. If the pressure reads higher than 40mm Hg (40 milliliters of

mercury), healing of the area is likely to be satisfactory.

laser Doppler measurements of the microcirculation of the skin

skin fluorescent studies that also measure skin microcirculation

skin perfusion measurements using a blood pressure cuff and

photoelectric detector

infrared measurements of skin temperature

No single test is highly predictive of healing, but taken together, the results give

the surgeon an excellent idea of the best place to amputate.

Aftercare

After amputation, medication is prescribed for pain, and patients are treated with

antibiotics to discourage infection. The stump is moved often to encourage good

circulation. Physical therapy and rehabilitation are started as soon as possible,

usually within 48 hours. Studies have shown that there is a positive relationship

between early rehabilitation and effective functioning of the stump and

prosthesis. Length of stay in the hospital depends on the severity of the

amputation and the general health of the amputee, but ranges from several days

to two weeks.

Rehabilitation is a long, arduous process, especially for above the knee

amputees. Twice daily physical therapy is not uncommon. In addition,

psychological counseling is an important part of rehabilitation. Many people feel a

sense of loss and grief when they lose a body part. Others are bothered by

phantom limb syndrome, where they feel as if the amputated part is still in place.

They may even feel pain in the limb that does not exist. Many amputees benefit

from joining self-help groups and meeting others who are also living with



amputation. Addressing the emotional aspects of amputation often speeds the

physical rehabilitation process.

(Gale encydopedia of medicine 2001)

3.4 EVALUATION

Bases on findings the decision to do below knee amputation is protecting the

patient from septicaemia. Usually, before the operation (although not always)

the surgeon decides at what level the amputation will be performed.

In the below the knee operation, the bone in the lower leg (tibia) is divided

about 12-15 cm below the knee joint. This produces a good size stump to

which a prosthesis can be fitted.



4.0 RECOMMENDATATIONS / SUGGESTIONS

Patient refused undergone below knee amputation. These are list of recommen-

dation:

Patient condition will become worse if the procedure is not done or delay.

Introduce other successful patient that already went for below knee

amputation.

Explain and introduce prosthesis equipment that is use post below knee

amputation.

In condition of low income or poor family patient will be refer to social

welfare.

Special rehab team is a allocated to follow up patient with post below knee

amputation.

Nurses and health worker team will follow up at home.

According to (Ozana Gajic 2002) Kinesitherapy plays a prominent role in medical

rehabilitation of the person with limb loss. Some kinesitherapeutic techniques used

in all the phases of rehabilitation are presented . The presented kinesitherapeutic

techniques are highly effective on the entire motoric activity as well as on a good

postural adjustment, at the same time giving a number of proprioceptive

information for a successful use of the prosthesis. Immediately after

the amputation exercises are extremely important to prevent contractures

(tightening of the muscles) which, when present, prevent efficient use of

aprosthesis.



Pre-prosthetic Training

Education on shrinkage device use

Reinforcement of residual limb (stump) skin care

Range of Motion activities and positioning

Education on progressive strengthening exercises of all extremities. Goal is to

improve strength of all muscles to their maximum in preparation for prosthetic

training. Active exercises progressing to resistive exercises including a variety of

concentric, eccentric, and isometric therapeutic exercises

Reinforcement of bed mobility skills - patient must be independent moving in

bed in all directions

Mobility on floor training - patient must be able to move in all directions on the

floor

Wheelchair Mobility Indoors and Outdoors

Education and reinforcement on transfers at all levels

Balance and coordination exercises

Endurance training

Reinforce content of Home Exercise Program to patient, family or caregiver as

necessary.



Post Prosthetic Training

Fitting of prosthesis

Education to patient on appropriate use of prosthetic socks

Education on skin care

Education for proper independence in application and removal of prosthesis

Activities of Daily Living Skills with the prosthesis

Transfers training to all surfaces wearing the prosthesis

Balance and gait training with prosthesis. Outdoors and Indoors. Stairs,

ramps, curbs, elevators

Family training as necessary

Reevaluate ambulation skills periodically and "upgrade" assistive device as

applicable.

The rehabilitation of the person with limb loss is a complex process and period of

training to learn how to function using the prosthesis, with the aim of being

independent in all the activities of daily living, vocational and avocational

activities. The final aim is to live, in the way of life which the person used to live

before the amputation.

The purpose of physical therapy is to empower the person with an amputation to

develop the best level of physical and emotional function that can be achieved.

The rehabilitation program should be design to restore a meaningful quality of life

through return to function in the family, community and workplace. We should

focus not only on the prosthesis but on the individual amputee.



5.0 CONCLUSION

Staff nurses make ethical decisions daily. It is important that nurses know how to

manage those decisions appropriately so that clients' ethical rights are honored

without compromising the nurse's own moral conscience. Nurse decide matters

related to management of care.

The process of making thoughtful decisions follow a similar pattern in most

Circumstances. This pattern includes gathering data, comparing options, using

some criteria for weighing the merit of each option, and making choice.

Evaluation of outcomes or circumstances surrounding the choice provides more

data regarding the rightness of the choice.

In this scenario patient should be doing below knee amputation for prevent

worse patient’s conditions and for his live on.



REFERENCES

Raijah A Rahim, Khatijah Lim,& Rohani Arshad (2010). Management and Medical

Legal Studies B ( 6th ed.) Selangor Open University Malaysia ( OUM )

Margaret A.B & Alvita K. N (2002). Ethics & Issues in Contemporary Nursing ( 2nd ed).

Columbia .Delmar Thomsom Learning.

Murray R B (1993) Nursing Assessment And Health Promotion(5th ed.) North Carolina.

HickoryHill Funiture Corporation.

Leddy S F & Pepper M (1993) Conceptual Base Of Professional Nursing (3rd ed) New

York. J.B.Lippincott Company.

Smith K V (1996). Ethical decision making of nursing. [Online]

Available: http://www.ncbi.nlm.gov/pubmed/8576496 [2010, November 18]

Foot gangrene “cut and medicate” treatment: Below knee amputation. (2005). [ Online]

Available:http://www.reversegangrene.com/foot_gangrene_amputation_picture_htm

[2010 November 18]


http://www.ncbi.nlm.gov/pubmed/8576496%20%5B2010

ethical of nurses

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