Clinical Reflection Paper on an Ethical Dilemma
March 23, 2012
Clinical Reflection Paper II
Although my senior practicum takes place on a respiratory care unit, I have seen several clients admitted with renal disease. During the course of one of my shifts I cared for a patient with renal disease and was faced with an ethical dilemma. R.W. was a 55 year old male admitted with an infection to the left foot which led to the amputation of the fourth and fifth toes and is therefore non-weight-bearing on that side. The patient had end stage renal disease (ESRD) with a significant past medical history. Among ESRD, R.W. has been diagnosed with morbid obesity, chronic diastolic heart failure, chronic atrial fibrillation, anemia of chronic disease, deep venous thrombosis, type II diabetes mellitus, coronary artery disease, hypertension, and depression. R.W.’s plan of care involved hemodialysis four days a week, wound care, blood glucose monitoring, a 2 liter per day fluid restriction, and a long list of medications. The patient also had a long history of noncompliance with his medical treatment and often binges on food and fluid the night before he is due for hemodialysis.
R.W. was due for hemodialysis the day of my clinical experience with him. I answered his call light and he requested that his pitcher be filled with water before his trip to the dialysis room. As the pitcher holds a liter of fluid, I explained to R.W. that filling the pitcher would not be compliant with his fluid restriction orders; however, I told him that I’d be happy to grab him a smaller glass of water. R.W. quickly became agitated and demanded the water despite my attempts to educate and negociate with him. The patient posed an ethical decision for me to contemplate in terms of balancing the desires of the patient while trying to comply with the doctor’s orders that had the patient’s best health outcomes in mind.
With much deliberation, I decided to give R.W. the full pitcher of water that he requested. In response to his request, I told R.W. that I would need to speak to my preceptor and would get back to him as soon as possible. Initially, I went directly to my preceptor about the situation and asked for her advice. My preceptor responded that R.W. should not get the water because of the fluid restriction. She told me that, on the other hand, nurses regularly provide him with the pitcher of water for him to bring to dialysis. I sought out additional resources for my decision-making process by doing a quick database search on the problem and reviewing the ethical principles that guide the nursing profession. I brought the pitcher of water to R.W. and he left for dialysis about half hour later.
Basis for the Decision
I based my decision for bringing the filled water pitcher to R.W. on many resources. My decision was based on five influences: the physician’s order, my values and beliefs, the patient’s wants and needs, my preceptor’s professional opinion, the ANA’s ethical principles for nursing practice, and evidence-based research. The hospitalist on R.W.’s case ordered a fluid restriction because this is the recommended protocol for patients on hemodialysis as fluid excess is a serious problem. Also in align with the notion to restrict R.W.’s fluid intake were my preconceptions. As a nursing student I value health and professionals in the medical field. I personally enjoy helping people and seeing health improvements. I wanted R.W. to comply with his fluid restrictions because it was in his best interest. The patient was not interested in abiding by the order, but giving him the fluid would not support his need for overcoming the alteration in fluid balance. My preceptor’s professional opinion came into play by reinforcing that giving the patient a full water pitcher would go against the doctor’s orders. She also informed me that nurses often give in and supply him with water for dialysis.
The American Nurses Association (ANA) code of ethics and the ethical principles that guide nursing influenced my decision-making process in this situation. By not meeting R.W.’s request, withholding water from R.W. would neglect to honor his autonomy, or his right to make choices regarding his care. On the other hand, providing R.W. the water would go against the ethical principle of beneficence by doing harm to his health.
There was surprisingly little research on non-adherence to fluid restriction within the nursing and medical literature. The most dated of the three articles found that cognitive variables of the patient led to fluid noncompliance (Schneider, 1991). These cognitive variables also predicted future adherence to fluid restriction orders. According to this research, future compliance is predicted by a patient’s resourcefulness and not locus of control (Schneider, 1991). Dunrose et al (2004) looked at whether knowledge of a patient’s health situation influences compliance among hemodialysis patients. The findings of this research suggested that knowledge does not play a significant role in (Dunrose et al, 2004). These findings suggest that the traditional information-giving of patient education is not appropriate and that motivational teaching may be a more effective tool for promoting patient adherence to care plans. Lastly, Rambod et al (2010) examined dietary and fluid compliance among hemodialysis patients of an Iranian population. This study found that educational level correlated with adherence to fluid and dietary restrictions. The implications of this study suggest that compliance may be improved by using counseling techniques to motivate patients (Rmbod et al, 2010).
The outcome of my decision was R.W. received his full pitcher of water before being transported to dialysis. Through hemodialysis, six liters of fluid were removed from R.W. I was unable to assess the long term outcomes of my decision, but R.W.’s health continues to decline in a downward spiral. My preceptor agreed with my decision but, like me, was not happy about contributing to R.W.’s worsening health status.
Reflection on the Outcome
Overall, I was very disappointed about giving R.W. his pitcher of water that would go against the doctor’s order for a 2 L fluid restriction. Despite my disappointment, I know my decision was ethical. Depriving R.W. of the water would have gone against what he wanted. The nurse’s priority responsibility is to the patient and advocating on his behalf. Although my personal and professional opinions opposed my decision to give R.W. water, I respected his autonomy. Ultimately the patient has the most important opinion on his health care. As the patient’s nursing student it was difficult to allow him to act against what is in his best interest. Since the patient was mentally competent, he had the right to make his own choices even if those choices were wrong from a medical standpoint. I think this situation could have been improved if the patient had some form of long term counseling that could provide him with educational and emotional support. At the time of my interaction with R.W. he was anxious and angry and not in the right state of mind for motivational counseling. This situation reminded me that ethical decisions are not easy but they are a common existence within the nursing profession.
Dunrose, C., Holdsworth, M., Watson, V., & Przygrodzka, F. (2004). Knowledge of dietary restrictions and the medical consequences of noncompliance by patients on hemodialysis are not predictive of dietary compliance. Journal of the American Dietetic Association; 104(1): 35-41.
Rambod, M., Peyravi, H., Shokrpour, N., & Sareban M. (2010). Dietary and fluid adherence in Iranian hemodialysis patients. The Health Care Manager, 29(4): 359-64.
Schneider, M, Friend, R., Whitaker, P., & Wadhwa, N. (1991). Fluid noncompliance and symptomatology in end-stage renal disease: Cognitive and emotional variables. Health Psychology; 10(3): 209-215.