Application of bioethical decision-making model
Mr. Braze (pseudonym) is an Africa American Jehovah Witness patient aged thirty-five years. He present to the emergency room with acute massive bleeding that cannot be urgently stopped, and the physician recommends lifesaving blood transfusion. Mr. Braze is awake, alert, and competent and has refused to have a blood transfusion because his religion does not allow it. He is informed of the benefits of blood transfusion and the consequences that may follow if blood transfusion is not done. The physician explained to him that blood transfusion would increase his chances of survival and resolving the underlying bleeding problem. He is also informed that he is likely to die if the blood transfusion is not done urgently. Despite having all this information, he still refused the lifesaving blood transfusion and did not sign informed consent to allow blood transfusion. Mr. Braze began to deteriorate, and the bleeding seems not to stop. The physician is set to violate his autonomy and wants to initiate a blood transfusion. He is reassured that all will be well with a blood transfusion but still refuses. The physician insists on initiating a blood transfusion and begins to get set to start the intervention.
Application of bioethical decision-making model
Mr. Braze’s scenario raises an ethical dilemma regarding how to balance his autonomy with his safety and wellbeing (beneficence). He understands the benefit of blood transfusion, and the consequences of not having a lifesaving blood transfusion still refuse it because it will violate his religious beliefs. The physician appears more concerned with ensuring he is okay and increasing the chances of treating his underlying cause of acute bleeding than respecting Mr. Braze’s autonomy to the extent that he set to violate his autonomy by initiating blood transfusion. The nurse, as the patient advocate, is with the physician and the patient in this ethical dilemma and comes in to help resolve the situation as both patient advocate and quality health advocate. The significant ethical issue here is whether to respect Mr. Braze’s decision and preferences or to violate it to warrant his wellbeing as the physician insists (Sanderson, 2018).
Understanding the medical facts on acute massive bleeding allows accurate risk prediction, estimation of prognosis, adverse effects, the burden of treatment, relative risk reduction, and amount of treatment (Stone, 2018). Massive bleeding is a blood loss of more than the overall circulating blood volume in twenty-four hours, a blood loss of fifty percent of circulating blood volume in three hours, a blood loss of more than 150ml per minute or blood loss that requires urgent transfusion of platelets and plasma (Kendigelen, Kamalak & Abat, 2016). However, there is still no universal definition of massive bleeding. Bleeding is often critical and does not have to meet the above criteria to be termed as critical.
According to a study, about sixty-three percent of patients that had blood loss, about thirty-seven percent of them had a blood loss exceeding two circulating blood volumes (Irita, 2011). Additionally, over fifty-one percent have a blood loss of more than 120ml per minute. Studies show that healthcare professionals should consider the volume and speed of the blood transfusion when they want to save a patient’s life in case of massive bleeding. Similarly, studies show blood loss of less than 120 ml per min or one circulating blood volume can be responsible for critical hemorrhage. This confirms that a patient must not have a blood loss that meets the general definition to be critical and every blood loss should be considered possibly critical and dealt with appropriately. Also, a patient’s blood loss maybe not critical, but his ischemic comorbidity delayed blood transfusion or underlying anemia or other conditions may make it critical. Delay in making a decision on initiating blood transfusion, for instance, is attributed to about seven percent of critical events following massive bleeding. The major causes of this delay are ethical dilemmas, policies, lack of or shortage of transfusion apparatus, among others, which may lead to life-threatening hypovolemia. The prognosis is acute massive bleeding, and the primary diagnosis is not yet confirmed.
Mr. Braze, as stated earlier, is a Jehovah’s Witness believer who believes that he will have failed his religion by accepting to have a blood transfusion. He has no Advance Healthcare Directive and makes a verbal preference stating that he should not have blood transfusion despite the risk that comes with not having it. He can afford the highest care available because he has an insurance cover.
Patients have the right to autonomy, and healthcare providers must obey their decisions, preferences, and needs (Vonderhaar & Snyder, 2019). It is a patient’s right that is protected in the medical law, and all healthcare professionals are legally required to seek a patient’s informed consent before initiating any procedure. The patient must be competent and give consent. The doctor and other healthcare providers must provide all the necessary information to the patient, including the benefits of having a blood transfusion, its risks, consequences of not having a blood transfusion, and the alternatives, as seen in Mr. Braze’s case. This is to enable the patient to weigh all the available choices and make an informed decision about his health and treatment.
The federal law requires that inadequate disclosure of information, carrying out a procedure, or an intervention that is different from the consented the law treat one of negligence (Vonderhaar & Snyder, 2019). This law implies that healthcare providers can only educate Mr. Braze but not coerce him or make the decision for him. Hospitals implement the same policy and must promote respect for patient autonomy. Similarly, the nursing code of ethics and the medical code of ethics state that nurses and physicians must respect patient autonomy after they are convinced that they have disclosed all the essential information to them. It emphasizes that no healthcare provider should, in any case, make a decision on behalf of a competent patient. Hence it means deciding to initiate a blood transfusion in Mr. Braze’s case if a breach is a breach of duty.
Certain aspect necessitates clarification to be sure of specific medical issues that will inform the decision. For instance, Mr. Braze presented to the emergency room, and his extent of bleeding or speed has not been confirmed. The physician is assuming that the bleeding may be critical, thus insists on urgent blood transfusion; however, this is common in a clinical setting, which leads to a violation of certain aspects of patient’s rights. Though any blood loss may be critical, there is still need for confirming certain parameters to see if there are other alternative to achieve the same goal while respecting the patient autonomy. An alternative in this case is administration of tranexamic acid.
Moreover, Mr. Braze’s medical and demographics are not well known, meaning that it is possible to make a rush judgment, which may be unnecessary because of the sight of blood loss. It is appropriate to access to Mr. Braze’s health information to give insight into his blood loss. Lastly, Mr. Braze appears alert, awake, and competent according to assessment; however, blood loss may present with decreasing mental processes, which may influence reasoning and decision-making capacity. It is appropriate to continually confirm whether he is competent or whether the blood loss has affected his competency through brief and quick mental health assessment.
Mr. Brief is a competent adult and can make an informed decision regarding his health and treatment according to the initial assessment. However, there is a likelihood that acute massive bleeding may progressively influence his competency (Vonderhaar & Snyder, 2019). He denies involving any other person in deciding his management. He insists that he is awake, alert, and competent enough to decide what he wants and how he desires to be treated. Thus he remains the only decision-maker in this case, and no one, including the healthcare provider, can decide on his behalf.
As stated earlier, Mr. Braze’s case presents an ethical dilemma on how to balance between autonomy and beneficence. Mr. Braze is competent and can make informed decision about what he wants. His autonomy must be respected by everyone regardless of the harm it present to him (Vonderhaar & Snyder, 2019). On the other hand, beneficence requires that healthcare professionals provide the best care and services that best meet Mr. Braze’s needs. However, in this case, beneficence conflicts with principle of autonomy which means the healthcare provider will automatically violate the other to achieve another which creates an ethical dilemma. Mr. Braze do not want to have blood transfusion despite its benefits (principle of autonomy). The physician on the other side, believe that blood transfusion would save his life (principle of beneficent) and insist to initiate it against his wishes. It is apparent in the nursing code of ethics regarding the four main principles of ethics that healthcare providers must respect the patient’s choices, even if the treatment could provide the most significant benefit. Respect for autonomy outdoes the respect for beneficence as long the patient is competent.
An alternative to blood transfusion in Mr. Braze’s case is the administration of antifibrinolytic agents; tranexamic acid followed by administration of iron supplements and dietary advice to replenish the lost fluids. This can arrest the bleeding (achieve beneficence) while meeting the patient’s desires (autonomy). Tranexamic acid will inhibit the activation of plasminogen to plasma. Mr. Braze should receive 20mg/kg within three hours. He should carefully be monitored and persistent bleeding, hyperfibrinolysis according to the kaolin activates TEG Ly30 of less than four percent, should necessitate a further tranexamic acid administration based on his weight and dynamic of the breathing. Administration of tranexamic acid will resuscitate him and allow for treatment of the underlying cause, and if need be iron supplement are given. This meets the patient desires, cost-effective, efficient, and does not burden the patient.
Implementing this alternative requires an objective evaluation of Mr. Braze’s bleeding to determine the speed and volume, which will require a multidisciplinary approach (Kendigelen, Kamalak & Abat, 2016). Mr. Braze will be educated on the alternative, its benefits, risks, and what will follow, such as the administration of iron supplements to meet his blood volume needs. He will then be left to make an informed decision, after which he will sign an informed consent form. The intervention will then begin and through a collaborative approach with Mr. Braze as a key participant and decision-maker throughout the process. A therapeutic relationship between Mr. Braze and the healthcare team will be established and maintained to ensure close monitoring and effective communication.
Conclusion on nursing advocacy in a clinical environment
Nurses aim to deliver high quality, safe, and evidence-based care to their patients. However, high-quality care does not only mean knowing the disease, its pathogenesis, and management. Nurses are great patient advocates in clinical settings (Vonderhaar & Snyder, 2019). Their direct interaction and maximum stay with patients put them in an excellent position to understand patients and be their advocates. Nurses help ensure that patients make informed decisions about their health and treatment. Also, they assist the patient in navigating the usually complex healthcare system while simplifying the tough medical terms into languages that patient understands to aid their ethical decisions. Additionally, nurses will often collaborate with other healthcare providers to ensure that patient autonomy is observed in the clinical setting and will often be patients’ spokesperson during these times. Adequate and successful advocacy for patients promotes the healing process of patients and thus leads to quality as well as health restoration.