Dilemmas in Practice: Keeping a Promise

Wolters Kluwer Health, Inc.

Dilemmas in Practice: Keeping a PromiseAuthor(s): Ellen LeffSource: The American Journal of Nursing, Vol. 82, No. 7 (Jul., 1982), pp. 1136+1138Published by: Lippincott Williams & WilkinsStable URL: http://www.jstor.org/stable/3463154 .

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Keeping A Promise By Ellen Leff

The patient was Philip, a 14-year- old with acute myelocytic leukemia. The dilemma was deciding whose needs came first-one frightened and dying teenager or 30 other sick children on a busy pediatric unit.

The ethical dilemma arose as Philip began to face the reality that he was dying. He was in pain, dependent on others to meet physical needs, angry, and afraid. From the time of his diagnosis, Philip had been promised he would not be left alone or allowed to suffer.

During his several hospitaliza- tions for chemotherapy, he had learned to trust the staff and they had learned to care about him. It had not been easy.

Philip had been living in foster homes and was unmanageable at times. He often tested his nurses and physicians to see if they would keep their promises. Meanwhile, both his natural and foster parents had been withdrawing. By the time Philip re- alized that all possible therapies had failed and that he was dying, his family had virtually abandoned him. The hospital staff was as much of a family as he had.

In the days before his death, Philip's needs for physical care had been increasing. He could no longer walk because of his pain. He was often feverish and suffered from nausea, vomiting, and diarrhea. He feared pain, but not as much as he feared the depressant effects of morphine. He was afraid to go to sleep because he might not wake up.

The evening before Philip died, he had asked for a nurse to be with him, and his primary nurse had wanted to stay-to do what she could to alleviate his pain. But that evening there was not enough staff. If one nurse spent all her time with

Philip, the others would not be able to give the kind of care they wanted to all the other patients on the unit.

From Philip's point of view, the presence of a nurse was neces- sary. Though he refused intrave- nous morphine, measures to comfort and distract him were of some help in relieving his pain. Also, he was very afraid. As his fear and pain increased, he became unable to cope. He was like a whining, demanding toddler. He would beg the staff not to leave and then reject their attempts to comfort him.

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The nurses, and especially Phil- ip's primary nurse, understood his situation and his responses. Some of them also felt strong affection for him and were already grieving over his imminent death.

The ethical problem was one of justice: what is a just or fair distribu- tion of a nurse's time when the many demands for it seem to be equally important?

If no one stayed with Philip, he would feel abandoned. His trust in others would be damaged, and the only positive meaning of his dying

would be negated. For the nurses, the consequences would be guilt feelings, frustration, and anger at being unable to answer Philip's important needs.

But if one nurse stayed with Philip, nursing needs of other patients could not be met. Such a decision would also lead to problems for the staff. Overworked and frus- trated, they would be unable to provide the usual and expected nursing care for all patients.

Reaching a Decision

Ethical principles must be con- sidered in deciding how to set priorities in nursing care. An important one is nonmaleficence-the nurse's duty not to cause harm to patients and to protect them from harm. This principle dictates certain mini- mum standards of care for all patients in order to provide a safe environment. At the very least, nurses' patient assignments must not be so large that it is impossible to provide safe care, including fre- quent observation for complications of therapy or deterioration of a patient's condition. But, as in this situation, even a usually well-staffed unit can have times when there are too few nurses or too many demands.

The ethical obligations of a personal relationship also have rele- vance. Philip's primary nurse felt strongly obligated to fulfill the promise that he would not be left alone. The fidelity of friendship and of a caring nurse-patient relationship also required that Philip receive the care he needed and had been promised.

Based on these considerations, it was decided that Philip's needs should be given priority.

Philip's primary nurse was as- signed to care for Philip and for two other patients, both scheduled for surgery the next day. The other two patients received adequate, if some- what hasty, preparation for surgery

ELLEN LEFF, RN, BS, works as an assistant head nurse at the Medical Center Hospital of Ver- mont in Burlington.

1136 American Journal of Nursing/July 1982



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during the times Philip napped. Philip's care continued to receive high priority until his death the fol- lowing night.

Afterwards, all of the nurses involved grieved; they also experi- enced feelings of frustration, guilt, and inadequacy. Later, the dilemma was analyzed and discussed in nursing grand rounds.

Such analysis both during and after the process of trying to resolve an ethical dilemma is crucial. Its value is not that it inevitably leads us to the best solution. The nature of ethical dilemmas is often such that no solution seems completely adequate. But ethical analysis can help us understand and accept "the solution."

In this case, the decision was actually a value judgment about how to set priorities for nursing care. It was a situation in which both personal and professional values came into play. When those involved decided that Philip's needs were more important than other patients' needs, they were expressing their own values.

Another group of nurses might not have come to the same conclusions in the same situation. Some might have interpreted Philip's overtly rejecting behavior to mean that he wanted to be left alone; others might have judged his fear to be much less intense than these nurses believed it to be.

Even if another group of nurses agreed that Philip's needs were very great, they still might have con- cluded that the other patients' needs, or even their own needs, should take priority over Philip's need to have someone with him.

Priority judgments are value judgments shaped by many factors. Whatever our conclusions, seeing the problem as an ethical one is use- ful because it helps us express our feelings and analyze our actions. If we know our actions are based on careful investigation of the situation, the weighing of alternatives, and our best moral judgment, it will be easier for us to explain these actions to others as well as to ourselves.

),' 1138 American Journal of Nursing/July 1982



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Dilemmas in Practice: Keeping a Promise