Legal, ethical, and professional issues of medical incident

Legal, ethical, and professional issues of medical incident

Legal, ethical, and professional issues of medical incident

Synopsis

            In the world of medical practice and health care, there are many more practical issues than ordinarily meet the eye. The provision of care facilities involves issues pertaining to the context of legal, ethical and professional domain, that are integral to the well-being of both the patient and the health care provider. This paper shall endeavor to dwell upon certain areas of influence in the same realm, and help establish certain working parameters for professionals.

Introduction

            Centuries ago, while the science of medical care was in its technical evolution stage, the prime area of reference was only the provision of health care. However, in today’s world, where the scientific world has come of age in its standing vis-à-vis disease  care and prevention, subsidiary issues have emerged that are considered to be of prime importance in the realm of health care. The changes in society and life all around the world have brought about considerable changes in the lifestyles of people. Similarly, the profession of health care has seen its development through the ages, and many additional factors like ethical, legal and professional concerns need to be understood better.

Relationship of assignment to achievement of learning outcomes

The learning outcomes associated with this course are crucially linked to the integral understand of clinical issues and practice. This paper in turn shall go a long way in reestablishing the norms that were to be established by the goals for this course. Understand the domain of every prong individually is of vital importance:

a)        Application of knowledge of Australian law to clinical issues

As was mentioned earlier, knowledge of legal issues to the cause of clinical practice has now become imperative. Though universal laws for humanitarianism and morality remain constant for humans, yet there are certain legal implications that are different for certain countries and even states within countries. It must be understood by a practitioner, that the legal clauses are not a matter of burden, but actually a facilitating and binding factor that ensures that the provision of health care would be unequivocal and just for all. It is further understood, as to how can a certain health care provider find oneself in a tight corner due to legal concerns, simply due to lack of awareness, and mere complexity of the science of medical health.

b)                Recognizing and supporting the pivotal role of documentation in clinical practice

The current face of health care is largely a product of the advancement made during and after the World Wars. However, despite the magnitude and quality of work that was done at that time, the obvious constraint due to the war was that a systematic procedure for providing health care cannot be established. Much has changed since then, and the corporate face of the organizations in the changing world has brought about a new shape to the domain of clinical practice. With the inception of concepts like quality and the ISO standards, what the world of today has realized, is that documentation, for any system of work, is not only essential, but is a must.

This assignment has gone a long way to establish all this. Specifically focusing on the ethical, legal and professional issues, it has enabled to understand all the paraphernalia that are associated with the direct science of health care. Documentation is as important as giving of medicine to the patient. No scientific treatment in the contemporary world is possible with out the necessary documentation throughput the process. Archival record, current and past medications, and future preventions, all are possible simply because of efficient records.

c)                  Recognizing and analyzing legal, ethical, political and professional issues

Though the importance and significance of the three major issues has been established, yet appropriate working with these concerns in minds is still easier said than done. For a new practitioner, it is extremely important to properly identify with the issues. The ethical and legal concerns are very similar to the medical ones in their dynamics. For one, the first thing that needs to be done with a disease is appropriate identification with respect to the symptoms. Only a sound knowledge of the traits of a disease and its patterns can help identity for the practitioner as to what is to be done with it. Similarly, with legal and ethical concerns, the first step is to identify any anomaly in the normal proceedings that are likely to produce a problematic response.

Secondly, the step of a disease is to be properly analyzed so that the appropriate medication and treatment course can be established. Much the same, in ethical and legal concerns, it has to be ascertained as to what is the error on judgment or practice, which would ultimately be taken care of in due course. The correct analyses before hand no only makes the life and treatment of the patient easier, but the process of provision of health care also finds a comfortable discourse. This is exactly what this assignment has endeavored to achieve. By looking at the example from other papers and cases, one can establish as a bystander as to what were the real loopholes in the process, and what could possibly have been done in order to rectify them.

d)        Defending personal stance on legal, ethical, political and professional issues, using logical argument, clinical examples and reference to appropriate authority and precedent

This is probably the most important element of the assignment, which helps the participant in preparation for the future challenges. This is one factor alone that differentiates the follower from the leader. The fact of the matter is, that many people in all professions tend to believe what is taught and practiced in front of them. They do not have the ability, urge and background to question – which is the most important feature in the development of science. Henceforth, the most credible feature of this assignment is that it would help in the preparation of analytical insight of the healthcare providers.

This means, that one would be able to have not only the necessary ability to accept the norms of science, but more importantly, it would generate the ability to logically criticize the same. Reading and evaluating scientific papers is one of the most important tools that help in making this possible. Therefore, this assignment as a whole is not only helping in providing better insight into issues of legal, ethical and professional concern, but also help in the maturation of professional outlook.

e)         Implementing strategies to resolve legal and professional issues arising in clinical practice

Adaptive and innovative behavior is the need of the hour in a professional as dynamic and ever-changing as the medical profession. So, when the moment of truth arises, it becomes very difficult for the problem to actually be managed by the book at all times. More often than not, there would be instances where people would be required to think out of the box, and to make decision that resolve issues in the betterment of both the patient and the practitioner. For this purpose, one needs to be well-versed with the professional requirement, ethical parameters, and legal concerns that concern one’s areas of work. Only then, would one be able to see beyond the clouds and help establish a working domain that can yield progressive results.

This assignment helps in doing just the same. Although nothing can be projected definitively for the future, but this mode of research and working helps us understand as to what are the real challenges in this profession, and what modus operandi have other established over the years in order to resolve the complexities that arise therein. This may well be the first step in the correct direction, but as long as the vector for professionalism is well defined, nothing else seems to be a formidable barrier.

f)         Be accountable for clinical practice in terms of the legal, ethical and professional implications of that practice

Responsibility is not only a professional virtue, but a moral one. In the profession that has long been associated with messiahs for the ease that it provides to the needy, a sense of accountability is ever increasing. One has to understand, that working with humans, where is humanistically rewarding, also entails a level of responsibility that surpasses any other profession. This is because the margin of error is very less, and the damage done is to a living human being, much like us.

This feeling must not develop a feeling of confinement on this profession; much the contrary, it should help o the realization as to how fragile and complex is the nature of work. Therefore, extra caution is required, and the people must be their first priority in this line of work. Thus, this assignment also helps in generating a feeling of accountability and responsibility within the health care provider.

g)        Demonstrate skills and knowledge that indicate competency in management of personal professional practice

This of course is an applied level of knowledge and skill that is desirous of all new professionals in any fields. Managerial level vision not only helps one to understand the situation at hand, but also gives one the overall insight that ordinary workers do not conceive of. These skills can only show their presence of and when they are learned at first, and then later on practiced. The assignment helps us in identifying these traits, and envisions as to how they could possibly be utilized in the future. Though hand-on practical orientation is not possible in written work, nonetheless, the required theoretical impetus is provided by the paper which helps in triggering the thought process in the correct direction.

Event description (Rewritten)

Synopsis

This paper will look into a case study especially related with nursing industry. It would also deal with the legal aspects involved. It shall endeavor to discuss, as to what ways are the professional duties of a nurse affected. There would be aspects of ethical issues involved in the case study as well.

Introduction

It is increasingly important for healthcare professionals to develop their knowledge in health care ethics and law, which are pertinent to their area of clinical practice and the delivery of patient care. This is because the science is medical care has become ever more complex, and in the contemporary world, it not only pertains to the provision of medicines to the needy, but also an all-encompassing care provided in terms of ethical, legal and professional concerns. The understanding of ethical and legal issues helps one to balance and assess the validity of ethical and legal arguments in relation to particular cases. This assignment will present a case study which provides with succinct descriptions and analysis of a range legal, professional, and ethical issues pertaining to the case.

Description of critical event

This incident happened when I worked as a registered nurse in the Emergency Department (ED) for an night shift in one of Taiwan’s hospital.

Miss Lee had been working on the maternity department for years and felt comfortable and confident with the unit’s procedures and her own skills. One Saturday night the nursing supervisor stopped her just before the beginning of her shift and explained that the Registered Nurse on my unit (ED) had called to say that she was going to be late because of a family emergency. Because of the overall short staffing on weekends at my hospital, Miss Lee would need to be pulled to the Emergency Department for no more than 2 hours to cover the Registered Nurse position until the regular nurse could arrive for her shift.

Miss Lee hurried to the Emergency Department and received a concise report from one of my coworkers, who was waiting to go home. All the patients were stable and the only potential problem was a patient in the Emergency Department who was waiting for a bed in ICU and had multiple injuries on his body and brain swelling, but still conscious. After a concise initial assessment of the patient, Miss Lee recognised that she did not have the skills or experience to provide safe care for this patient.

            Miss Lee called the nursing supervisor and explained that she would need a nurse who is more competent in the domain of Emergency medicine to help care for this patient. The supervisor responded that another side of Emergency Department was in the middle of CPR performance, the whole hospital was short of nurses and she had no one she could send. Miss Lee would just have to do her best until the regular Emergency Department nurse arrived. However, she could not document this discourse with the supervisor.

Two hours later, the regular nurse of the Emergency Department arrived for her shift and did an initial assessment to the patient with the following results: blood pressure 70/30; pulse 134, GCS: E2V3M5, Right Pupil was dilated and did not have the reflection to the light. One incident report was presented by doctor which is Miss Lee calculated a wrong IV drip rate and missed an oral order. In other words, the patient who had been ill, but not critical, was now acutely unwell and unstable.

Identification of issues

Given the specifics of this case study, there are certain issues that arise with the scenario in question. The areas that shall be discussed, under the light of critics by reviewers falls primarily into the three domains of legal, ethical and professional.

Analysis of critical event

Legal issues– The High Court of Australia has adopted standard of care applied to medical professionals, that requires for every registered nurse to have a particular level of skill, knowledge and expertise (Forrester & Griffiths 2005). The nurse supervisor failed in her ‘duty of care’ towards the patients and staff. She did not know what Miss Lee’s current knowledge and skills were. As an Emergency room nurse, has a duty of care to any field of acute patient. Inadequate staffing should be avoided. In addition, the nursing supervisor was also not an emergency room nurse. Otherwise, at this critical juncture for the patient, she could surely have rendered her expertise.

Miss Lee’s actions also appear to be negligent. Professional negligence is a civil wrong or tort which can be a source of potential legal action. The patient who can establish he suffered harm as a result of a nurse’s failure to meet an appropriate standard of care may bring a negligence claim against the nurse as well as the care facility (Tracey et al, 2005). Since Miss Lee was the one who was monitoring this patient, she was accountable legally for not doing the follow-up constantly of the patient’s vital sign and consciousness, and doing wrong drug administration to her patient, considering that her negligence in the case affects the life of the patient. Though she endeavored to do as much was she was professionally capable of, the problem aggravated because she failed to give true perspective to the consequence of her actions.

Finally, it is obvious that this patient needed to be followed up aptly the in the intensive care unit since he had brain swelling.  However, he had been hold in a busy Emergency Department. This delay in patient’s admission did not meet the standard of care which is described as “Quality of care encompasses the adequacy of the total care that patients receive from health care professionals” (Robert ; Simon, 2005, p. 1). This entails that the total health care involves much more than just medicines; ethical and management concerns are vital to his wellbeing.

Professional issues– According to Emergency Department procedure (Çelik et al, 2004), in the case of any head injury, close observation is essential for every half hour to an hour, for at least 6 hours after injury. Further neurological evaluation is mandatory when patient’s Glasgow Coma Scale decreases to a score of 13 or less. In this case, Miss Lee should not have failed to observe and evaluate patient’s consciousness during her charge. It was within the professional domain of Miss Lee, to have report the changes to the surgeon so that appropriate care could have been provided.

Steven’s review article (2005) indicates that nursing actions include knowing the system, verifying drug orders before administration, confirming the patient’s identity, independently double-checking calculations, questioning inappropriate orders or dosages, listening and following up on patient concerns, and having thorough familiarity with medication administration devices. The above mentioned principles were not strictly followed by Miss Lee. As drug administration is vital part of the nursing profession, and adverse drug effects directly affect quality of patient care, every registered nurse is presumed to have drug administration knowledge and should be cautioned of the consequences of certain breach.

Ethical issues– The ethical issues of benenficience, non-maleficience, and justice are clearly reflected in this unfortunate incident (Berglund, 1998). Beneficence is a positive act. In this case, Miss Lee did not detect the changes of patient’s condition; a direct consequence of the fact that she did not have the [professional expertise to do so. Also, she missed an oral order, she did not provide quality nursing care to the patient. While, non- maleficience tells us not to do any harm. By calculating a wrong IV drip rate was unethical in her practice resulting in harm to the patient. She needs to be very attentive to doing procedures correctly in order to prevent harm. In the justice realm Miss Lee should have been ethically justified to refuse the supervisor when she recognized that she was not equal to the assignment.

Conclusion

In conclusion, this case raises questions of violation of rules and regulation, lack of professionalism, ethical concerns in some instances. It not only deals with the life of a person but also the legal aspects involved. Therefore it becomes very evident that, apart from being aware of professional duty, as a nurse we should also be aware of legal liabilities and the ethical issues concerned with this industry.

Articulation with current literature

Three scientific papers are presented hereunder, which directly represent a link into the study of legal, ethical and professional concerns in the realm of medical care.

Case 1 – Concealment of drugs in food and beverages in nursing homes: cross sectional study (Appendix A)

This particular paper examines the practice of concealing drugs in patients’ foodstuff in nursing homes. It is concluded that, “The covert administration of drugs is common in Norwegian nursing homes. Routines for such practice are arbitrary, and the practice is poorly documented in the patients’ records.” (Kirkevold and Engedal, 2005). This is a very interesting case that presents all the three dimensions in question. Firstly, as concerns the ethical domain, even though the health care professional is providing the medicine in good faith, but as the patient is himself not knowledgeable about the medication, then this definitely invokes an ethical debate. This is also due to the fact that more often than not, this condition arises when the patient himself has declined to take the medication on an earlier instance, and therefore is now being given it indirectly.

Legally, this is an issue because the patient is being ‘tricked’ into taking something that he is not willing to consciously. Though done with positive intent of treatment, yet the conscious patient can later on easily decide to file against these proceedings, on account of having been mislead with in comparison to evidence available on paper. On a professional note, this also shows that the practitioner is using the easy way out in order to achieve the desired goals. One could always make use of the IV line, with would of course make the patient knowledgeable about the event. However, the easier means have been adopted in this case.

Case 2 – From Quinlan to Schiavo: medical, ethical, and legal issues in severe brain injury (Appendix B)

This paper discusses various examples in the realm of brain injury, where a final decision had to be taken. Fine concludes by admitting, “At the end of all of the medical, legal, and ethical argument, it is most important to remember that no matter how certain any of us may be of our analysis, decisions near the end of life should never be easy. We must remind ourselves that true wisdom comes with the acknowledgment of uncertainty and admitting that we cannot know all there is to know” (2005). So, for a researcher to have worked in this discipline and to admit that there is a very thin line to crass, one can surely make conclusions about the complexity of the scenario.

The issues of professionalism, ethics and legality are very simple here. Firstly, how can a clinician be ever certain of the fact that the patient is beyond treatment? The concept is that the person is beyond cure for that specific practitioner with his specific knowledge. The person might well be treatable in different circumstances by a different person. Secondly, the ethical concerns do put many questions when the conscious decision of taking one’s life is being asked about. This never an easy decision to make. And finally, whoever is the adversary in this case would be liable to make a legal issue about the case, on the pretexts mentioned above. This is more or less a no-win situation.

Case 3 – Discontinuation of ventilation after brain stem death (Appendix C)

A similar instance is presented in this case, wherein the decision of life and death is to be made. A living person, whom the current definition of science entails as ‘unrecoverable’, is at the mercy of family and health care providers who can ‘pull the plug’. Here, it is mentioned that, “Sensitive and thoughtful explanations from medical and nursing staff combined with a better understanding of the nature of this condition will help grieving families cope with this difficult situation” (Swinburn, et al. 1999). The importance of appropriate intervention is displayed here, while proof of brain death being factually given.

The writers believe that when a medical decision is to be made, it is only possible with the helps of all healthcare providers keeping all the dimensions in mind. The legal and ethical case here is built on the same grounds as in Case No 2. However, here, the professional grounds are vehemently supported and argued by the practitioners. Who believe that the scientific process of brain death is real, and that the patients’ families should be adequately advised about the same.

Reflection on dialogue

The dialogue has been a very fruitful inclusion in this assignment. For one, it has given the true meaning to the concept of ‘constructive criticism’. It has made one realize, that communication with fellow professional is not only essential, it is mandatory. The most important reason for this is that human perceptions are very different. Regardless of the years spent in a particular profession, a fresh mind can come in and provide a totally new perspective to the situation at hand. Similarly, with people in the same profession, the most important thing is that they are current with the same sort of challenges, and it is quite possible, that they have been able to chalk out a scientific methodology to a problem that has a different approach.

Similarly, in this particular instance, some valuable input was received from the feedback made by the colleagues. For instance, the two most important factors highlighted by the first person were, “What was the outcome for Miss Lee? Was she reprimanded, counseled?” and “What was the outcome for the patient?” These are extremely vital to the reader as without them, no definitive solution is provided to the problem. Though the case presents clear indications of ethical, legal and professional concern, yet without the outcome, one cannot assimilate the true essence of the incident. Without the outcome of the events being considered, the ultimate goal of learning remains vague and unclear.
Furthermore, the second person highlights an interesting stance on the same case, “Did the doctor realize that a medication was missed and a wrong IV drip rate calculated at the time? If so, why didn’t he/she take action to draw attention to it at that time?” it is important to appreciate this, because the nursing staff does not work in isolation at any hospital. Where the mistakes and shortfalls in Miss Lee’s work are undeniable, it also needs to be evaluated as to where were the emergency doctors on duty at that point in time. After all, it must be considered that nurses only mage the treatment; it is doctors who administer it! Therefore, whatever legal and ethical consideration may erupt, the doctor is equally (if not more) responsible for the proceedings.

Recommendation for changed practice

In all, in my perspective, the biggest lesson I have learnt from this assignment is to have a greater an in-depth vision of my profession. Earlier, the focus was primarily on the medical and treatment side of the issues, but now, I have a greater appreciation for the ethical, legal and professional concerns that are integral to the care of every patient. The change in practice will not be of procedures or methods, but of attitude. A greater feeling of responsibility and self-accountability would en sure efficient management and enhanced quality of work. It is clear that where the importance of the academic knowledge in this holy profession cannot be undermined, the most important point is the correct appreciation of a holistic picture, wherein the general well-being of the patient is under consideration, and not just the medical one.

Conclusion

Inter-disciplinary and multi-faceted studies in studies always tend to generate a greater sense of insight in an individual. In the profession of medical health care, it is all the more important to consider such facts in the consideration for the benefit of the patient. This assignment helps establish learning patterns on the very same lines, wherein one is able to appreciate the dynamics and complexities involved in the science of patient care, while giving due consideration to the ethical legal and professional issues simultaneously.

References

Berglund, C 1998, Ethics for healthcare, Oxford University Press, London.

Çelik S, Güler A and Neriman A 2004, ‘Nursing Role on Preventing Secondary Brain Injury’, Accident and Emergency Nursing, 12 (2), pp 94-98

Fine R, From Quinlan to Schiavo: medical, ethical, and legal issues in severe brain injury, Proc (Bayl Univ Med Cent). 2005 October; 18(4): 303–310.

Forrester K ; Griffiths D 2005, Essentials of Law for Health Professionals, 2nd, edn, Elsevier Mosby, Sydney.

Kirkevold Ø ; Engedal K, Concealment of drugs in food and beverages in nursing homes: cross sectional study, BMJ  2005;330:20 (1 January), doi:10.1136

Leape L, Reporting of Adverse Events, Health Policy Report, Volume 347:1633-1638.

Robert I ; Simon, MD 2005, ‘Standard-of-Care Testimony: Best Practices or Reasonable Care?’ The Journal of the American Academy of Psychiatry and the Law, 33(8–11), pp: 1-4

Steven M 2005, ‘Medical Liability, Risk Management, and the Quality of Health Care • REVIEW ARTICLE’, Seminars in Fetal and Neonatal Medicine, 10 (1), pp 3-9

Swinburn J, et al, To whom is our duty of care? BMJ 1999;318:1753-1755 ( 26 June ).

Tracey M. ; Nola M. R 2005, ‘Legal Issues in Patient Safety: The Example of Nosocomial Infection’, Healthcare Quarterly Special Issue, October, pp 140-145

Audit Commission. The coming of age: improving care services for older people. London: Audit Commission; 1997.

Lipley N. Nurse-led elderly care wards to free acute beds. Nurs Stand. 2000;14:5.

Audit Commission. The way to go home: rehabilitation and remedial services for older people. London: Audit Commission; 2000.

Department of Health. The NHS plan: a plan for investment, a plan for reform. London: Stationery Office; 2000.

Steiner A. Intermediate care: a good thing? Age Ageing (in press).

Steiner, A. Intermediate care: conceptual framework and review of the literature. London: King’s Fund; 1997.

Griffiths P, Wilson-Barnett J. The effectiveness of ‘nursing beds’: a review of the literature. J Adv Nurs. 2000;27:1184–1192.

Alfano GJ, Hall LE. The Loeb center for nursing and rehabilitation: a professional approach to nursing practice. Nurs Clin North Am. 1969;4:487–493.

Pearson, A. The clinical nursing unit. London: William Heinemann Medical Books; 1983

Appendix A

http://bmj.bmjjournals.com/cgi/content/full/330/7481/20?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=legal+ethical+nursing&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT
Appendix B

http://www.pubmedcentral.gov/articlerender.fcgi?tool=pmcentrez&artid=1255938

Appendix C

http://bmj.bmjjournals.com/cgi/content/full/318/7200/1753?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=legal+ethical+nursing&andorexactfulltext=and&searchid=1&FIRSTINDEX=10&sortspec=relevance&resourcetype=HWCIT



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