Every day decisions are made. The majority of these decisions are unconscious and do not require a formal decision-making process. Ethical decisions change that dynamic. Daily ethical dilemmas challenge nurses while caring for their patients. This seemingly simple principle became the cornerstone while caring for a pregnant 17-year-old at 23 weeks and four days gestation with a Traumatic Brain Injury. The patient was the intersection of several specialties, including Neurosurgery, Pulmonary Critical Care, Maternal Fetal Medicine (MFM), Transplant Intensive Care Unit (TSICU), Neonatal Intensive Care Unit (NICU), Ethics, Chaplains, Case Managers, Social Workers, Patient Navigators and the hospital leadership team. Each specialty/discipline needed to voice concerns about the plan of care. Every member of the team contributed to the safety of the patient and the fetus through their individual expertise. All felt comfortable speaking up in order to provide safe, quality care at all times for mother and fetus. Challenging ethical discussions occurred by providing an environment that was supportive and just. Ethically, any other avenue would have been unacceptable. Team members respected each other’s positions and communicated effectively to move towards resolution and consensus.
Ethical decision making requires a clear understanding of ethical principles. The American Nurse Association defined the principles of ethics as: autonomy, beneficence, non-maleficence, fidelity, justice and paternalism. Autonomy is having respect for another’s right to self-determine a course of action supporting independent decision-making. Beneficence is defined as compassion; taking positive action to help others with a desire to do good and is the core principle of patient advocacy. Non-maleficence is the avoidance of harm or hurt and is at the core of nursing ethics. Fidelity requires loyalty, fairness, truthfulness, advocacy, and dedication to patients. Fidelity refers to the concept of keeping a commitment and is based upon the virtue of caring. Justice refers to equal and fair distribution of resources. Paternalism describes healthcare decisions guided by a clinician’s professional belief about what is the best decision for the patient.
The above six ethical principles are essential but two stood out in this case study, autonomy versus beneficence. Beneficence and the autonomy for both the fetus and the mother guided many of the ethical discussions. These two principles were oftentimes in opposition. Ethics discussions have demonstrated that if prolonging the mother’s life is likely to have a positive outcome for the fetus it can be considered ethical to do so. This decision is often influenced by the gestational age of the fetus at the time the mother sustained the injury. In this case, the fetus had just reached the age of viability when the patient sustained a Traumatic Brain Injury.However, many of the nurses caring for the mother and the fetus felt that maintining somatic support was merely using the mother as an incubator and felt that was contrary to the ethical principle of autonomy. This was never more evident then during the daily cleaning of the craniotomy sites which were leaking brain matter. The situation was especially difficult for those nurse believing the mother was being kept alive merely to be an incubator for the fetus. The International Federation of Obstetrics and Gynecology (FIGO) Committee for the Ethical Aspects of the Human Reproduction & Women’s Health established that healthcare providers are first responsible to the mother and then the unborn fetus. So then the question became what would the patient want? This was a recurring topic of conversation with the patient’s family and the healthcare team. Honoring the mother’s wishes and allowing death with dignity were crucial conversations. It required trust of those who knew her best, her parents and boyfriend, when making decisions about her plan of care. Team engagement, communication and collaboration were essential for consensus to be reached. The team collaborated with the family and the Ethics Committee in order to ensure that the family’s wishes were being respected.
The ethical dilemmas faced during the 10½ week journey spanned across nursing units from TSICU to OB to NICU. There were 292 primary nurse interactions with the patient. The nursing emotions ran the gamut from “this is truly amazing” to “this is truly horrible.” All of these emotions needed to be respected and supported. Nurses were relieved of patient care responsibility when asked to be relieved. No viewpoint was left unheard or unsupported. All team members felt free to bring up problems and tough issues. When the ethical issues became bigger than could be handled by the teams the Ethics Committee became involved. The team was committed to creating an environment where people trusted each other and showed considerable respect for one another. The free exchange of ideas was cultivated and communication was a key concept. While there were varying attitudes and a wide-range of emotions associated with this case collaboration, communication and respect allowed for the free exchange of thoughts ultimately providing the best care for the mother, fetus and the caregivers.
Implication for Nursing Practice
There is little information published on the ethics of somatic support after Traumatic Brain Injury. This case study provides the opportunity to see real-life examples of collaboration and communication regarding the ethics of somatic support.
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