Final Discussion regarding Patient Advocacy

Over the course of these last three weeks we have reviewed the basic principles of patient advocacy. In synopsis, a patient advocate is someone who speaks out for someone who is powerless or in a vulnerable situation who is for whatever reason unable to speak for themselves. According to the American Nurses Association (ANA) being a patient advocate is a major role for the nurse. It is important as we practice to remember the four main ethical principles of ethics, non maleficence; beneficence; autonomy; and justice. Violations of these principles usually indicates a situation in which the patient/client needs someone to advocate for them. Advocating for your patient/client is not without its barriers as described in the article previously mentioned (link was provided). An example is lack of support from the rest of the multidisciplinary team. If a patient centered approach to care and ethical principles adhered too than ideally such situations should be minimized. Advocating for your patient is an essential function of being a professional nurse.

Follow up on discussion

What ethical principles were involved in the YouTube scenario? You could most likely apply all four principles. Non maleficence refers to health care providers doing no harm, was Nurse A causing harm to the patient by wanting to give her the transfusion even though the patient did not want transfusions? Beneficence refers to how patients want to be benefited, Nurse B was looking out for the patient in this regard as she was honoring her wishes and going to coordinate with the physician for palliative care and discharge home with hospice, this was also respecting the patient's autonomy. And finally the last principle is that of justice, which means that every person should be treated fairly and have equal access to care. Nurse B ensured that this patient received the care she needed even if she refused the blood transfusion as she was just as entitled to care as anyone else.

YouTube Patient Advocacy Discussion

You were asked a couple posts ago to view this video:
http://www.youtube.com/watch?v=zfS3q0v4U4E

Now that we have reviewed patient rights and basic medical ethic principles. What did you notice in the scenario where the patient did not want the blood transfusion? Initially the two nurses discussing her case stated that she was confused, and nurse A stated that since she was "out of it" they should give her the blood transfusion since she would not realize what they had done anyway and it would be a life saving measure. Nurse B stated that from her previous admissions she had not wanted nor had she consented to any previous blood transfusions and that they should honor her wishes. Who is correct? Well, first you do need informed consent prior to transfusing blood. The patient has to understand that there are potential risks in blood transfusions and the risks and benefits should be discussed; ideally this should be done by the physician and nursing staff can reinforce the information given by the physician. So who do you go for consent if the patient is unable to sign for themselves? Patient's may have appointed a health care agent within documents such as the Health Care Proxy or Living Will, or patient's next of kin may be able to give consent if the patient did not appoint anyone in case of such a scenario. It is important to note that in the case the patient had an established behavior of refusing blood transfusions (and contrary to the family wishes, they wanted her to have the transfusion) so sometimes what a family may verbalize may not necessarily be what the patient would have wanted, these situations can get very complicated if the patient did not make any official documentation of what there wishes were. Going back to the scenario the patient was able to answer all of Nurse B's questions to determine her level of orientation, and she was oriented and capable of making her own decisions and thus refused the transfusion. It is not our place to pass our beliefs on to that of the patient (Nurse A felt she should have the transfusion) our job is to respect and follow the wishes of the patient regarding their treatment and care. It is in the Patient Bill of Rights that patients have the right to decisions regarding their medical care. Reflect further on this scenario and tomorrow we will discuss what ethical principles were upheld or potentially violated in this scenario.

Resolution

Last we were discussing a case scenario in which an elderly couple (husband was being admitted to the hospital) told the physician they wanted everything done in case patient deteriorated and the physician despite this wrote orders for DNR (Do Not Resuscitate). You have had time to consider your actions. You could do nothing, or you could advocate for your patient as delegated in most nurse practice act. This is not only a scenario but an experience I had several years ago. After the physician handed me the admitting orders and I saw the DNR order I asked if he (the physician) had gone back and discussed advance directives with the couple again and he replied that he had not. At this point I had told him that it was my understanding that they had declined the DNR and that I would be more than happy to go back with the physician to see the couple to clarify this. The physician replied that it was not necessary and that they did not understand. Informed the physician that if they do not understand how did they consent to a DNR. The response I received was that they were elderly and he should be a DNR. It is not our place as health care professionals to pass judgment on the decisions patients and families make; our responsibility is to ensure that their rights are upheld and their decisions honored; regardless of our personal opinion. I went back and spoke with the couple and indeed they understood what CPR entailed and what a DNR was, and they wanted full resuscitation at this point in time. At this point I notified the charge nurse and nursing supervisor of the situation and the medical director was than contacted and he spoke with this physician and made him go back and speak to the couple and than he had to rescind his DNR order and write in the chart that the patient was a full code. Sometimes advocating for patients can be intimidating as you may have to speak up to someone you view as powerful; however, remembering that you are protecting your patient can help alleviate some of this fear (it does for me). So can you see in this scenario where the patient's rights were not being upheld by the physician? Where there any ethical problems that you saw when the case scenario was first presented? When we began this course we looked at the basic principles of medical ethics as well as the Patient's Bill of Rights, if you understand and know these you will be able to recognize situations in which you may need to act as an advocate. Always follow your chain of command as able. As you progress through your nursing career being an advocate may not get any easier, as some situations can be quite complex, but your experience will help you become more effective. Advocating for patients and families is the most important aspect of being a nurse; whether you work at the bedside or conducting research to improve outcomes you are advocating.

Case Scenario

Thus far we have reviewed articles about patient advocacy that identified obstacles, we have reviewed the Patient's Bill of Rights, foundations of medical ethics, and viewed a YouTube video depicting various scenarios of advocating for patients. Now we will review a case scenario.

You are coming on shift in a busy emergency department, you go to the nurse's station to sign in on the computer to check your assignment and to get a quick report; while doing this you over hear a physician discussing advance directives with an elderly couple. The husband is the patient and his wife is sitting at the bedside discussing DNR status with Dr XYZ. You over hear the elderly couple explicitly tell the physician that they want everything done that is possible. The physician soon excuses himself as he is going to write admitting orders and tells them it should not be too long before they get moved to the medical unit. Approximately a half hour later the physician hands you this patients chart and reviews the admitting orders in case there is any questions. You are surprised to see that the physician has written the patient's resuscitation status as DNR. What is your first step?

Video

Class, take a look at this Youtube video.
http://www.youtube.com/watch?v=zfS3q0v4U4E

Patient Advocacy

The American Nurses Association is a well known and respected nursing organization that represents millions of nurses (ANA, n.d). They bring the nursing profession to higher standards and lobby congress for change. Of the many position statements; they also address the nurse as a patient advocate. Go their link and explore what you can find about their views on advocating for patients.
http://www.nursingworld.org/default.aspx

NURSE PRACTICE ACT

Each state has their own nurse practice act; and as such may have slight deviations in the expectations of the registered professional nurse. Explore these four sites of each different state and examine what, if any, is discussed about being a patient advocate.

NYS practice act
http://www.op.nysed.gov/prof/nurse/article139.htm
Vermont practice act
http://www.leg.state.vt.us/statutes/fullchapter.cfm?Title=26&Chapter=028
California practice act
http://www.rn.ca.gov/regulations/npa.shtml
District of Columbia practice act
http://hpla.doh.dc.gov/hpla/lib/hpla/nursing/nurse_practice_act.pdf

Patient Bill of Rights

To be an effective patient advocate we have already discussed the importance of being knowledgeable of basic ethical principles as many times an ethical dilemma is precisely when a patient may need assistance from you, and you have to step in and advocate for the patient. You must also be familiar with the Patient's Bill of Rights. Please review this power point presentation.
https://docs.google.com/leaf?id=0B1wGQQ6SBKvANmVlNzg4M2MtOGNmMi00NmFjLWIyMTUtZjRiYTJhZTYzNmQ5&sort=name&layout=list&num=50

<iframe width=100% height=560px frameborder=0 src=https://docs.google.com/viewer?a=v&pid=explorer&chrome=false&embedded=true&srcid=0B1wGQQ6SBKvANmVlNzg4M2MtOGNmMi00NmFjLWIyMTUtZjRiYTJhZTYzNmQ5&authkey=CIjW87MC&hl=en></iframe>

Patient Advocacy Article

Please go to the following link and read about patient advocacy, it provides an overview as well as identifying some obstacles as perceived by nurses in adequately advocating for their patients.

http://nursinglink.monster.com/training/articles/929-patient-advocacy-barriers-and-facilitators

Week Two

Hello everyone, to start out with I thought we would review the basics of medical ethics, as some situations in which one may be advocating for a patient may also be one that is an ethical dilemma. I think it is important to review the basic principles of ethics before we continue, please review the attached Power Point Presentation.

You will have to go to the following link (I am posting the two links in case one does not work and you will have to download the presentation)

<iframe width=100% height=560px frameborder=0 src=https://docs.google.com/viewer?a=v&pid=explorer&chrome=false&embedded=true&srcid=0B1wGQQ6SBKvAZTdkZTUwOTctYzA2NS00MzE2LTgwNTktNDhiMTRjNTJmY2Iw&authkey=CNyc4dUH&hl=en></iframe>

https://docs.google.com/leaf?id=0B1wGQQ6SBKvAZTdkZTUwOTctYzA2NS00MzE2LTgwNTktNDhiMTRjNTJmY2Iw&sort=name&layout=list&num=50