Case Studies: Alexandra and Carolyn

Alexandra DeMarco

You are precepting with Devoreaux, a nurse practitioner at a family practice clinic. Today, Alexandra DeMarco, a 15-year-old girl, comes in. Devoreaux has seen Alexandra since she was baby and gets permission for you to be present for this visit. Her mom is also here today.

Transcript

If you were Alexi's health care provider, what would you say to her mom? “I am not able to talk about this over the phone; however, if you come into the office, we can discuss the visit.” “I cannot discuss the visit due to privacy regulations; however, I encourage you to talk to Alexi about the visit.” “Alexi is pregnant and needs to see an OB-GYN as soon as possible.”

Correct!

This is inappropriate; it is a violation of Alexi’s privacy to discuss her care with her mom without permission.

Correct! This maintains Alexi’s privacy, as requested.

This is inappropriate; it is a violation of Alexi’s privacy to discuss her care with her mom without permission.

Correct!

More principles apply. Please revise your answer.

Autonomy should guide your decision making. This principle includes:

Respecting a patient’s right to privacy and confidentiality
Providing the information necessary for patients to make an informed consent. Informed consent in minors should be a part of your decision making. This involves:
Whether the hospitalization or treatment is emergent and lifesaving (trauma, suicidal ideation).
Whether the minor is legally emancipated.
Whether the minor is seeking care regarding sexually related issues (contraception, pregnancy care, or STIs).
Whether the parents of the patient are themselves minors. The grandparents may give consent for their grandchildren in this case.
Respecting a patient’s choice to accept or decline care
- Informed consent during pregnancy should also be a part of your decision making. A pregnant woman has the right to refuse health care even if her decision poses a risk to the unborn fetus.

Beneficence should also guide your decision making. This principle includes:

Asking whether an action that is done for the benefit of others
Promoting the welfare of patients
Preventing and removing harm
Weighing and balancing possible benefits against possible risks of action

Justice does not apply in this scenario. Justice requires that healthcare practitioners act in ways that treat people equitably and fairly. Actions that discriminate against individuals or a class of people arbitrarily or without a justifiable basis would violate this basic principle.

Balancing Autonomy and Beneficence

Some of the most common and difficult ethical issues arise when a patient’s autonomous decision conflicts with the healthcare provider’s beneficent duty to look out for the patient’s best interest.

Let’s examine this conflict in Alexi’s case. Alexi chooses not to tell her mother about her pregnancy. The autonomous choice of the patient (Alexi) conflicts with the nurse practitioner’s duty of beneficence (informing Alexi’s mother about the pregnancy so that she can receive needed support).

Following each ethical principle would lead to different actions. Which one should you choose if you faced this? As long as the person meets the criteria for being able to make an autonomous choice, you should respect their decisions even if you tried to convince them otherwise.

Carolyn Brown

Carolyn Brown, an 89-year-old woman, was hospitalized three days ago for weakness and fever. Yesterday she was diagnosed with lung cancer. You are the nurse practitioner on the hospitalist's service preparing to visit Carolyn this morning.

As you gather pertinent information from the patient chart outside of the room, her daughter, Lisa, asks to speak with you. You agree and walk to a private area for the conversation. Lisa tells you that the family held a meeting last night. "We decided not to tell Mom that she has cancer. We’re just going to tell her she has pneumonia, and she just needs a few days of antibiotics to get better. We want you and any other staff to say the same thing. Mom has always been afraid of cancer. We know she will just give up if we tell her the truth.”

Correct!

This is an appropriate response. People have a right to be told the truth about their medical care. This is the ethical principle of veracity, which requires that healthcare providers be honest in their interactions with patients.

This is an inappropriate response. It violates the ethical principle of veracity (truthfulness), and ultimately violates Carolyn’s ability to make medical decisions for herself (autonomy) based on factual information.

This is an inappropriate response. Competence to make healthcare decisions can only be assessed by a court of law.

Correct!

More principles apply. Please revise your answer.

Justice should govern your process. Justice is usually defined as a form of fairness or maintaining obligation, equity, and fairness through the application of moral principles, rules, and established standards.

Autonomy should govern your process. Autonomy is characterized as allowing an individual freedom of choice and action. In healthcare, it is the choice of the patient to determine their own medical decisions.

Fidelity should govern your process. Fidelity is defined as acting with integrity and trustworthiness, but also, in the professional context, nurses and other healthcare professionals are expected to act in the best interests of their patients or clients.

Summary

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