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Critical Incidence Analysis

By: Shirin Akbar Ali Tejani

On March 17th, 2008 during my clinical at private hospital in Male Ward (Special Care Unit) I was assigned one patient. My patient is 60 year old male diagnosed with CRF five months back and was advised for dialysis. His co-morbid are HTN, DM, and COPD. Some of the lab results are BUN = 258, Creatinine = 12.5, HB = 8.5 and K+ = 5.2. His GCS remains 14/15 but when I received the patient, he was drowsy. As the time was passing by, he was becoming very restless but because none of his family was present to sign the consent, dialysis was delayed. As his condition was getting worst, doctor advised to pass N/G tube for feeding. I tried twice to insert the tube but patient refused to pass the tube and became very restless. I decided to leave it but the nursing staffs who were on duty forcefully inserted the tube which caused trauma to the patient. Because of the forceful insertion, patent suffered from massive bleeding from mouth and nose. Seeing the situation, I started doing suctioning from the mouth and nose and called the on-call doctor immediately. He checked the patient and a call was given to the ENT Team. A nasal packing was done by the team and one pint PC was ordered for transfusion. Next day, when I went to see the patient, he was unconscious and his HB level was dropped to 7.2 mg/dl.

Evaluation:
Our Oath stated that we shall do no harm to the patient and provide high quality of care. The incident stands out for me for several reasons. Firstly, I think that why paramedical staff did not follow ethical principal and why did they do negligence and malificence? Even though nurses always promise that they will not break the ethical principal at any cost. Secondly, I also think why the nurse did not follow proper NG tube insertion technique. Thirdly, why the nurse did assumed that the patient is not educated and he will not do anything if they insert N/G tube forcefully.

Analysis:
I started wondering all the possible reasons such as why this incident had occurred. Many questions arise in my mind. When I reflect that why the nurse tried to forcefully insert N /G tube? Why they did not follow the doctor�s order when it said to insert NG if possible? Why staff nurse did not respect patient�s autonomy? Who is responsible if patient looses the trust from medical professionals? Who is responsible for innocent patient�s life? Why do nurses forget their Oath before doing their tasks? When I reflect back, I started thinking about the possibilities. I was thinking whether they know the proper technique of N/G insertion? Maybe it is routine for the nurses to insert the N /G tube forcefully for restless patient. Maybe they wanted to prove themselves that they are confident enough to insert the N/G tube. In addition, no explanation was given to the patient by the nurse or the doctor about the significance of the N/G feeding. Adjacent to that patient was worn out by combating with his disease and pain. Maybe he thought that this N/G tube will enhance his suffering. Maybe he was feeling lonely as none of his family was there with him. I feel that before taking any decision patient consent is a must. If the patient is fully conscious and oriented then there is no reason for forceful applications.

Synthesis:
To solve these ethical dilemmas, one must be aware about the ethical principal. According to Taylor & et.al (2001), Autonomy (Self Determination): Respect the rights of patients or their surrogates to make health care decisions. Nonmalefience: Avoid causing harm. Beneficence: Benefit the patient and balance benefits against risk and harm. In this existing situation, patient wish was neglected. According to the Nursing and Midwifery Counsel 2004, �Code of Professional Conduct stated that all patients have a right to receive information about their condition. It obliges nurses to respect patients autonomy � their rights to decide whether or not to undergo a health care intervention � even where a refusal may result in harm or death to themselves, unless a court orders to the contrary.� Respect to patient�s decision is essential, until and unless he is unable to do so. In 1973, the American Hospital Association adopted the patent�s bills of rights, which stated that, �Every human being of adult mind has a right to determine what shall be done with his own body�.( Lark and Gatti, 1999). Incase if the patient�s decision cannot be considered due to any reason, his advance statement made in past about the treatments should be considered otherwise family has right to decide for it according to they think would be the choice of their patient. As the president�s commission for the study of ethical problems, 1883 concluded that, �It is acceptable for a competent patient�s to refuse life sustaining treatment, that an advance statement could be implemented in the event of future loss of decision making capacity, and that a patient�s family has the moral authority to decline life sustaining treatment for an incompetent patient who does not have an advance statement; However, the decision must be based on what they believe the patient would have wanted.� In the current situation, it is necessary to make the decision according to the weight of benefits but if the risk is more than it is better to change the decision as the author mentions, �whenever we try to help others, we are at risk harming them, therefore it is sensible to consider the principles of beneficence and non maleficence together. Caring out our health care intervention to an individual involves being clear about the risk and benefits of that intervention.�(Gillion, 1994, p.59). In Conclusion, I can say that in the above situation it is necessary to make the decision which is beneficial to the patient but the respect of patient�s autonomy has great importance on the principal of beneficence and non maleficence. As Human Rights Act, 1998 declare, �It could be argued that in a grave life threating situation any doubt should be resolved in favour of the patient�s best interest and therefore beneficence outweighs respect for autonomy.� If the situation will occur in future, I will not do anything against the ethical principles because being a nurse it is my responsible to provide ethically accepted care to my patient and I will apply this learnt principle of ethics to solve the dilemmas with the proper counseling and communication skill with patient and family My personal limitation is that in life and death situation, I am not alone to take the decision but the entire medical team is responsible for it.