Research question and annotated bibliography

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Original Article

The patient suicide attempt e An ethical dilemma case study

Lin Jie

Suzhou Health College, New District, Suzhou, Jiangsu Province, China

a r t i c l e i n f o

Article history:

Received 19 December 2014

Received in revised form

26 January 2015

Accepted 29 January 2015

Available online 19 February 2015

Keywords:

Ethical dilemmas

Suicide attempt

Ethical theory and principles

E-mail address: [email protected].

Peer review under responsibility of Chinese http://dx.doi.org/10.1016/j.ijnss.2015.01.013 2352-0132/Copyright © 2015, Chinese Nursing article under the CC BY-NC-ND license (http

a b s t r a c t

Case description: Nurses face more and more ethical dilemmas during their practice

nowadays, especially when they are taking care of the patient at end of life stage. The case

study demonstrates an ethical dilemma when nursing staff are taking care of an end stage

aggressive prostate cancer patient Mr Green who expressed the suicide thoughts to one of

the nurses and ask that nurse keep secret for him in Brisbane, QLD, Australia.

Ethical dilemma identification: The ethical dilemma is identified as “if the nursing staff should

tell other health care team members about patient's suicide attempt without patient's

consent”.

Analysis: To better solving this case and making the best moral decision, the ethical theory,

the ethical principles and the Australian nurses' code of ethics values statement, the

associated literature relative with this case are analyzed before the decision making.

Ethical decision making: After consider all of the above factors, in this case, the best ethical

decision for the patient is that the nurse share the information of Mr Green's suicide

attempt with other health care professionals.

Results: In Mr Green's case, the nurse chose to share the information of Mr Green's suicide

attempt with other health care professionals. The nursing team followed the self-harm and

suicide protocol of the hospital strictly, they maintained the effective communication with

Mr Green, identified the factors which cause patient's suicide attempt, provided the

appropriate nursing intervention to deal will these risk factors and collaborated with other

health care professionals to prefect the further care. The patient transferred to a palliative

care service with no sign of suicide attempt and other self-harm behaviors and passed

away peacefully 76 days after discharged with his relatives and pastors accompany.

Copyright © 2015, Chinese Nursing Association. Production and hosting by Elsevier

(Singapore) Pte Ltd. This is an open access article under the CC BY-NC-ND license (http://

creativecommons.org/licenses/by-nc-nd/4.0/).

Nurses face more and more ethical dilemmas during their

practice nowadays, especially when nurses have re-

sponsibility to take care of patients with terminal diseases

Nursing Association.

Association. Production ://creativecommons.org/

such as cancer [1]. The case study demonstrates an ethical

dilemma faced by a nursing staff taking care of an end stage

aggressive prostate cancer patient Mr Green who confided to

and hosting by Elsevier (Singapore) Pte Ltd. This is an open access licenses/by-nc-nd/4.0/).

i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 2 ( 2 0 1 5 ) 4 0 8 e4 1 3 409

the nurse his suicide attempt and ask the nurse to keep the

secret for him. This essay will present the clinical case regard

to Mr Green's attempt to suicide, identify the ethical dilemma arise from this clinical case, discusses ethical theory and

principles apply to this case, apply the western countries' nurses' code of ethics values statement to this case, analyze the opinion in the associated literature and give some sug-

gestions on how to solve this ethical dilemma.

1. The case description

The patient Mr Green is a 57 year old gentleman with

aggressive prostate cancer who is took care of by the nursing

team in the oncology department of a general hospital in

Brisbane, QLD, Australia. Mr Green was diagnosed with pros-

tate cancer seven years ago but refused medical and surgical

treatment at the time. He chose to seek alternative treatment

and did not follow up with the urologist over that seven year

period. Mr Green has now presented with anemia and hypo-

proteinemia. After several diagnostic tests over a period it was

discovered that the cancer had metastasized to his bones, it

had spread locally to his lymph nodes and the primary tumor

was invading the bladder and partially obstructing the left

kidney. Mr Green had several admissions over a two month

period for various reasons. On the last admission Mr Green

was told that he may only have 4e6 weeks (previously it was

6e12 months) to live after a cystoscopy showed further

extensive growth of the tumor, it was determined that any

further surgical/medical intervention would not be appro-

priate in this case and that a palliative care regimen was the

next step. At this point the patient reported to the health care

team that he had resigned himself to the fact that he was

going to die. Mr Green pulled one of the author's colleagues aside and confided to the nurse that he planned to kill himself

and that is was a secret that the nurse was not to tell anyone.

2. The ethical dilemma arise from this clinical case

According to the patient's case, the patient Mr Green with end stage aggressive prostate cancer who had been

confirmed that he only have 4e6 week to live expresses the

suicide attempt to a nursing staff and asks nurse do not tell

others. The behavior of patient put the nursing staff in a

difficult situation, which can be identified as an ethical

dilemma. Beauchamp and Walters [2] defined an ethical

dilemma as a situation happens when person must make a

choice among mutually exclusive alternatives. According to

Chally and Loric [3], an ethical dilemma always occurs when

“a moral problem involving two or more mutually exclusive,

morally correct actions” (p. 17). In Mr Green's case, after the patient confided the suicide attempt, the nursing staff has

two exclusive, morally correct choices. If the nurse chooses

to keep secret as patient required, this behavior will respect

patient's own decision. However, the nursing staff's decision may cause the patient actually commit suicide without any

healthcare intervention. If the nursing staff chose to tell

other health care team members about patient's suicide

attempt, the health care team would be involved in moni-

toring, prevention and avoiding suicide, but the patient's autonomy, confidentiality would be violated. Therefore, the

major ethical dilemma of this case can be identified as ‘if

the nursing staff should tell other health care team mem-

bers about patient's suicide attempt without patient's consent.’

3. Analysis of the ethical dilemma

3.1. The ethical principles apply to this case

Some research identified the relationship between the ethical

dilemmas and ethical principles. According to Johnston [4],

the logical incompatibility between two principles can cause

the ethical dilemmas, especially in the moral situation that

two different ethical principles can be applied, but using one

principle must violate the other principle. In the Mr Green's case, the ethical principle autonomy and beneficence can be

applied equally, but none of them can be chosen without

violating other one. The significant logical incompatibility

between autonomy and beneficence in this case is the major

reason which causes the ethical dilemma about ‘if the

nursing staff should tell other health care team members

about patient's suicide attempt without patient's consent’. In addition, the ethical principle non-maleficence is considered

in this moral situation which infringes autonomy principle

but gives support to beneficence principle. Therefore, when

considering Mr Green's case, three ethical principles are in conflict: respect for autonomy, non-malefience and

beneficence.

Bate [5] defined beneficence as “the quality of doing good,

taking positive steps to help others, or the notion that one

ought to do or promote action that benefits others” (p. 343). It

can be referred as actions which mainly focus on benefiting

other people [6]. In the health care area, one of the most

important obligations of nursing staff is take the positive

action to promote health and wellbeing of patients [7]. It

means that the nursing staff has to consider which actions

will be better for patient. Applying beneficence to ethical

dilemma in Mr Green's case, the nurse has to consider the question which choice will be better for Mr Green. Depart-

ment of Ageing Disability and Home Care stated that the

beneficence principle requires nursing staff do everything to

promote patient's health and maintain patient's safety. It is obvious that the nursing staff tells other health care pro-

fessionals about Mr Green's self-harm attempt, thus the health care intervention can be involved to prevent the actual

suicide will be a better choice and will fit the beneficence

principle.

Beside beneficence principle, “Non-malefiecence invokes

the obligation not to harm others”. Refer non-malefiecence to

health care area, it emphasized that the health care staff has

to make sure their actions would not cause harm to patient [8].

In Mr Green's case, the non-malefiecence principle requires the nurse take an action to ensure patient not to harm himself

instead of ignoring patient's potential self-harm. Therefore, the action of telling others ensures no further self-harm

i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 2 ( 2 0 1 5 ) 4 0 8 e4 1 3410

behavior of patient corresponds with non-malefiecence

consideration.

There is an issue which needs to be noticed. It is important

that when applying the beneficence and non-malefiecence

principles, the patients' own perspective about benefit and harm of themselves needs to be assessed [9]. Therefore, in Mr

Green's case, Mr Green's own perspective of benefit and harm need to be considered. Mr Green's concept of greatest benefit would be to be allowed to die. And nurse's behavior of keeping silent would not be considered as harmful from his

perspective.

Friedman [10] defined Autonomy as “a form of personal

liberty of action in which the individual determines his/her

own course of action in accordance with a plan chosen by

himself/herself” (p. 450). It means that the autonomy principle

respects competent patient's right to make their own de- cisions. In the meantime, autonomy also required nursing

staff to respect patients' confidentiality and ensure nursing staff's actions have informed consent of their patients [11] Applying this principle to Mr Green's case, the choice of keeping secret respects patient's right of self-determination and informed consent.

But the choice of keeping secret would ignore patient's potential suicide and would lead to patient's self-harm behavior. According to Howard, Fairclough, Daniels and

Emanuel [12] the cancer patients would be more likely to

seek assistance with dying. One type of assisted dying

behavior of health care staff is “refraining from interventions

to prevent or dissuade the patient from taking his or her life”.

In Mr Green's case, the choice of keeping secret can be clas- sified into assisted dying. Sneesby [13] pointed that “the

ethical principle of autonomy is not upheld in law regarding

euthanasia and assisted suicide, ‘as people do not have the

right to be assisted to die at any time they choose’ ” (p. 456).

Therefore, although Mr Green's autonomy should be respected, but it can not override the common law which

identifies that professionals' behavior of assisted dying are prohibited restrictedly.

Some research also pointed that if patient in some special

situation made the irresponsible decision which would cause

severe consequences to themselves or/and others, the health

care professionals should override their wishes in order to

minimize and prevent these consequences [14]. In Mr Green's case, the suicide attempt can be identified as a decision

which causes the serious self-harm result. Therefore, Mr

Green's autonomy can be overridden in order to avoid his suicide attempt. In addition, the assessment of Mr Green's current situation when he made the decision is needed,

because some research emphasized that patient with mental

disorder or unstable emotional condition can not be

considered as a competent person who can make decision

for themselves.

3.2. The ethical theory apply to this case

Besides the ethical principles, one of the consequentialist

theories, utilitarianism, can be used in above case to deter-

mine the better moral decision. Singer [15] indicated that

utilitarianism emphasized the good action is the action

which maximizes pleasure and minimizes pain to most of

people. The principle of utility becomes the fundamental

principle of ethics. According to this principle, the moral

right action is the action which creates the best outcomes for

greatest number of people [16]. The patient, his family and

health care staff are involved in Mr Green's case, thus the ethically correct choice should be an action which benefits

for most of them.

Comparing the two options of the nurse in above case,

the choice of ‘keeping secret’ would cause the patient

commit suicide. This outcome only benefits Mr Green

because this action satisfies his desire to die. Moreover,

some research stated that suicide has negative impact on

family and health care staff especially emotional impact. For

instance, the people who have lost family members to sui-

cide are more likely to feel guilty, shame and upset. There-

fore, it is obvious that ‘keeping secret’ would not be the

moral correct action.

In contrast, the possible outcome of the action “telling

others” is the patient's suicide behavior would be prevented and avoided by health care professionals' intervention. This outcome lengthens Mr Green's life and maintains his safety which makes both his family and health care professionals

feel happy. Some research indicated that most family mem-

bers would be gratified and satisfied if they could spend more

time with their dying relatives [17]. In the meantime, as the

health care providers, one of the duties of them is maintaining

patients' safety [18]. Health care givers will be satisfied when duty is fulfilled. Therefore, the choice of ‘telling others’ will be

the ethical correct choice because it benefits most people in

Mr Green's case.

3.3. The western countries' nurses' code of ethics values statement apply to this case

This is an ethical dilemma case which happened in Australia,

therefore, the considerations of the Australian's National Code of Ethics for Nurses and Midwives is significant for case

solving.

The National Code of Ethics for Nurses and Midwives

published in 2008 is a new guideline for ethical and profes-

sional behavior of nurses and midwives in Australia. It con-

tained eight value statements which focus on assisting nurses

on moral decision making [19]. Some of the statements can

apply to Mr Green's case in order to make the most appro- priate ethical decision.

First of all, ANMC [19] indicated that “Nurses value

informed decision making” (p. 8). That means that nurses

have to respect patients' right to involve and share the deci- sion of their own health care and treatment. According to this

ethical value statement, Mr Green's decision of suicide should be respected. But ANMC emphasized that “Nurses also value

the contribution made by persons whose decision making

may be restricted because of incapacity, disability or other

factors, including legal constraints” (p. 8) when they explained

this statement. Therefore, the assessment of Mr Green's cur- rent condition became necessary for nurse to determine if his

decision should be respected. Moreover, as the legal consid-

eration, the option of ‘keeping secret’ to respect autonomy

which can be identified as letting people die by not acting is an

illegal action according to Australian law [20]

i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 2 ( 2 0 1 5 ) 4 0 8 e4 1 3 411

Secondly, ANMC pointed that the first and the most

important value statement of nurse are providing the quality

of health care. Besides this statement, the fourth statement

indicated that “Nurses value access to quality nursing and

health care for all people” [19]. These two statements expect

nurse to do no harm, to do good and fair things to all people.

They also require nurse to create the quality and safe practice

environment and minimize the harm to patients. Considering

these two statements in Mr Green's case, nurses have obliga- tion to ensure Mr Green's safety and ensure safe practice environment. Therefore, it is obvious that the action of

sharing information about Mr Green's potential suicide with other colleagues would support to create safe surroundings to

monitor his following behaviors and reduce the risk of actual

suicide.

In addition, according to ANMC, nurses have re-

sponsibility to value ethical management of information.

According to this value statement, nurses should respect

patients' wishes about with whom information may be shared and their confidentiality and privacy. Applying this to

Mr Green's case, the nurse should respect his wishes to not to share information with other professionals. But ANMC [19]

also emphasized that if these information have “signifi-

cantly compromise or disadvantage the health or safety of

the person or others” (p. 9), nurse would use their profes-

sional judgment to make decision about whether they share

these information with other professionals [21]. Applying this

to Mr Green's case, although the nurse should respect his confidentiality and privacy, but Mr Green's requirement of “keeping secret” would have negative effects (suicide) on his

safety and health. Therefore, the nurse in this situation can

use own judgment to decide whether they keep secret for

him.

3.4. The opinion in the associated literature analyze with this case

The opinions of contemporary literature can be considered in

order to further analyze the ethical dilemma from the above

case. Research indicated and evaluated nurse’ feelings and

attitudes when they are faced the situation similar to Mr

Green's case. Leiser et al. [22] stated over half nurses in their study expressed professional and individual ethics prevents

nurses from assisting with suicide and encourages nurses to

take positive action in suicide prevention. According to Sun,

Long and Boore [23], nearly 40% nurses in their study insisted

that “It is the professional duty of the nurse to prevent any

suicidal client from dying” (p. 260). That means more nurses

would take the positive actions in order to avoid suicide under

both ethical and professional consideration.

Some other research emphasized that patients having

suicide attempt are usually trying to get sympathy from

others. They are seeking help from health care givers [24].

Therefore, nurses should provide assistance such as effective

communication to resolve patients' suicide attempt. In addi- tion, some nurses expressed that other health care pro-

fessionals such as physicians played an important role in

suicide prevention; thus they should be told first when nurses

noticed patient's suicide attempt. It is obvious that the opin- ions from contemporary literature agreed nurses to take

positive action and told other health care professionals in

order to prevent suicide. In Mr Green's case, the choice of telling others corresponds with the opinions from contem-

porary literature.

3.5. The ethical decision making

After consideration of all ethical principles, utilitarianism

theory, value statement, legal concepts and opinions in

contemporary literature, it would be neither ethically nor

legally permissible for the nurse to keep the secret of Mr

Green's suicide attempt. The action of sharing this infor- mation with other professionals fits the ethical consider-

ation of non-malefience and beneficence principle. It creates

benefits for most people in this case; thus it becomes the

moral right choice according to utilitarianism theory. Be-

sides these, nursing ethical value statement emphasized

nurses' responsibility to provide quality of health care and to value access to quality nursing and health care for all people

which support nurses to take positive action to avoid sui-

cide. Moreover, the opinions in contemporary literature

agreed nurses to take positive action and tell other health

care professionals in order to prevent suicide which sup-

ports the choice of ‘telling others’. Therefore, the best ethical

decision for the patient is that the nurse share the infor-

mation of Mr Green's suicide attempt with other health care professionals.

4. Results

In Mr Green's case, the nursing staff made the best ethical decision for the patient. She chose to share the information of

Mr Green's suicide attempt with other health care professionals.

Once the nurse noticed Mr Green's suicidal tendency, she provided the psychological comfort to the patient first in order

to stabilize patient's mood and prevent patient's immediately suicidal behavior. In the meantime, the nurse manger was

informed by that nurse. The nursing team which was

composed with 2 nursing staff and the head nurse of the

oncology department was established immediately after that.

The nurse manager was the leader of this team who guided all

team members' work. She followed the self-harm and suicide protocol of the hospital strictly, In Mr Green's situation, she divided the suicide prevention protocol into three step. At the

first step–effective communication, one of the nurses

continued to responsible for maintaining the effective

communication with the patient, stabilizing Mr Green's mood to prevent suicidal or self-harm behavior. This nurse also

initiated an open conversation with Mr Green to identify the

facts which may be precipitating thoughts of suicide. During

the conversation, the nurses found that Mr Green complained

repeatedly about the unbearable renal pain and his daughter

have not contact with him for a long time. Therefore, the

unrelieved pain and lack of family support should be two

factors which cause patient's suicidal thoughts. At that point, the nursing team initiated the second step of the suicide

prevention protocol—purposeful nursing intervention. In this

case, a systematic pain assessment was processed on the

i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 2 ( 2 0 1 5 ) 4 0 8 e4 1 3412

patient by nursing staff and the physician was informed to

adjust the pain medication for Mr Green. After the head nurse

ensured that the renal pain of Mr Green was relived gradually

and the patient was on a stable mental and physical condition,

the third step of the suicide prevention protocol—collabora-

tion with other health care providers was processed. In this

case, psychologist and social worker were noticed to partici-

pate in the suicide protection work. The psychologist con-

ducted a psychological evaluation to address the other risk

factors and symptoms associated with patient's suicide thoughts. And the further psychological nursing plan was

made by the psychologist and nursing team. Moreover, the

social worker contacted with Mr Green's daughter and arrange the family member to visit Mr Green. After the series of

intervention, the Mr Green physical and emotional states

were stabilized, he did not expressed any willingness to

commit suicide or had any self-harm behaviors. One week

later, Mr Green was transferred to a palliative care service in

Brisbane, QLD, Australia. According to the follow-up visit, Mr

Green passed away in the palliative care service 76 days after

discharged. During the two and half months in the palliative

care service, he did not have any deliberate self-injurious

behaviors and passed away peaceful with his relatives and

pastor's accompany.

5. Conclusion

In nursing practice, cases of patients expressing their suicide

attempt or other self-harm thoughts are becoming more

common. Therefore, contents regarding ethical issue such as

Mr Green's case, needs to be attached great importance to. Nurses have a professional responsibilities to be aware of the

moral and ethical complications which relate to their profes-

sional practice. There are some key points which ensure the

ethical dilemma regard to patients' suicide attempt could be solved efficient and rational.

First, to better resolve these kind of ethical dilemmas, the

assessment of patient's current situation when they make the decision is necessary. Because it helps nurses to decide if

patient is competent to make the suicide decision and further

consider to take the correct action to deal with the ethical

dilemma.

Moreover, to better solving the case and making the best

moral and ethical decision, the ethical theory, the ethical

principles and the national nurses' code of ethics values statement, the associated literature relative with this case

should be analyzed comprehensively before the nursing staff

makes their ethical decision.

In the meantime, once the best decision is made by nursing

staff, the effective response should be initiated immediately

to handle patient's suicide attempt. Hospital's self-harm and suicide protocol is one of the efficient instruments for nursing

staff to deal with the situation like Mr Green. It provides the

guide line for nursing staff to handle the patient's suicide attempt.

In addition, collaboration with other health care providers

is another key point, the other health care professionals such

as psychologist, social worker and physician are able to work

with nursing staff to conduct a comprehensive care plan for

patient.

Author contribution

The author Jie Lin makes all contribution associated with this

article. The author sets up the conception and design of the

study, collect and analysis the data, drafting and finish the

article, and approves the version to be submitted.

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