Ethical discussion response assistance please.
-200 word minimum
– 2 references
Early in my nursing career, I encountered an ethical dilemma involving patient consent and capacity. I was working on a skilled nursing unit and was assigned to care for, an elderly patient with dementia who also had occasional moments of lucidity. The patient’s son held her power of attorney for healthcare decisions. When she first arrived on our unit, her son insisted we use physical restraints on her wrists to keep her from getting up out of bed and potentially falling. He was worried about her safety. However, when she experienced moments of lucidity, she would become extremely upset about being tied down. She would plead with me to remove the restraints and let her move about. She clearly expressed a desire not to be confined to the bed.
I brought up my concerns about the restraints during rounds with her physician and the interprofessional team. I explained that while the patient at times appeared confused and delirious, at other brief moments she seemed clearly competent and expressly stated she did not want to be restrained. I raised an ethical concern about whether we were violating her autonomy and consent by keeping her restrained against her expressed wishes when competent. Her physician pointed out that her son had the legal right to make these care decisions on her behalf given the power of attorney paperwork. He sympathized with my concern but said ultimately it was the family’s choice since the patient was deemed incompetent most of the time.
I understood his point, but continued to feel conflicted about ignoring the patient’s clearly stated wishes when she was in a lucid mental state. I worried we were prioritizing beneficence and nonmaleficence, in the sense that restraining her protected her from potential harm and falls (Rainer et al., 2018). However, this came at the expense of her autonomy and caused her significant emotional distress when she was aware of the restraints. I brought up alternatives to consider at our next care plan meeting. I suggested we use restraints only as needed for procedures and high fall risk situations, but avoid continuous use. I proposed keeping her bed in the lowest position and using a bed alarm to alert staff if she tried to get up. I also recommended reassessing her mental status at least every 2 hours and asking her again about her restraint preferences when she appeared lucid.
The team agreed this was a reasonable compromise. We explained the plan to her son, though he remained skeptical. In implementing the plan, I made sure to engage the patient in conversation every time I entered her room to establish her mental status. When she seemed oriented and able to appropriately answer questions, I asked if she remembered the restraints and whether she wanted them on or off at that time. Sometimes she said she did not remember the restraints at all. Other times she immediately asked for them to be removed. I would comply with her requests in those lucid moments, while continuing to keep her bed low and using the alarm for safety. Engaging with her in this way showed respect for her autonomy.
This experience taught me important ethical lessons. I learned the importance of continuously re-evaluating consent and capacity with patients who have fluctuating or unclear decisional capacity. Even if they have been deemed legally incompetent, they may have windows of lucidity where their voice should be honored (Askren & Leslie, 2019). As nurses, we have a duty to advocate for our patients’ rights and preferences when we can discern them. I also learned the value of bringing ethical concerns to an interprofessional team. Other disciplines like social work or medicine may have insight and help find solutions, like the compromise we reached. In complex situations like this particular one with competing principles, collaboration is key.
Finally, this dilemma reinforced how crucial it is that we repeatedly assess patient response and adjust care to balance beneficence/nonmaleficence with autonomy. There are rarely perfect solutions, but we can aim to honor the patient’s voice as much as possible when competent, while protecting their safety when not. This experience had a profound impact on me early in my career and shaped my approach to ethical patient care.