DR. HAROLD RAY GRIFFIN

HEALTH CARE POLICY, LAW AND ETHICS-HSA515002VA016-1114-001

In this paper, the writer is taking on the role of manager of a cancer center in a small, suburban hospital. The manager is dealing with a lot: The nursing staff has expressed burnout because of an increase of terminal cancer patients. In one extreme case, Nurse Nancy, feeling empathy for a rapid decline in one of the patient’s health (a 30-year-old single mother), wants to give an extra dose of narcotic that could potentially end the patient’s life – and what Nurse Nancy perceives as her suffering.
Needless to say, concepts including end-of-life rights, death with dignity and right to life apply to this particular case. In examining this particular case, we’ll find that the nurse is trying to act with the purest of motives. However, what she is doing could skirt ethical decision-making, while being blatantly against the law. Additionally, it could provide a negative view of the cancer center. Though many people might support the idea of dying with dignity, others might take a dim view of a nurse who, in her zeal to prevent a patient’s suffering, would deprive children of their mother.
Patient Bill of Rights
The Patient Bill of Rights, sponsored by Senators John McCain, John Edwards and Ted Kennedy (S.1052), guarantees patients the right to access to health care specialists when necessary and requires continuity of care protections to patients so they don’t have to change health care providers in the middle of their treatment (Summary, 2001). The bill, unfortunately, failed, but many of its requirements make sense. For the patients of this particular cancer center, it means their treatment wouldn’t be interrupted if they needed to change employers (and if their new health care plan didn’t cover treatments by the centers’ providers). The Patient Bill of Rights also provides with external appeals processes to address grievances or complaints about health care plans (Summary, 2001). It should come as little surprise that the insurance industry fought against this plan, and many myths surrounding this plan were generated. One such myth was that employers could be sued under the bill’s provisions, which was patently false (Summary, 2001).
Though the bill never passed, there are provisions these days that provide help for pre-existing conditions. Furthermore, the Affordable Care Act of 2010 attempts to fold in some of the points and conditions of S. 1052.
Now, the issue our manager is facing is that of a “rogue” nurse who, depressed by the condition of a 30-year-old mother, is seeking to “help” by giving this mother an extra dose of narcotic that could end her life. Does this violate a patient’s rights? It does, if the mother doesn’t want the drug, or if the mother doesn’t want to end her life. The case study was not clear on whether this terminal woman was suffering from a lot of pain; nor was it clear on whether or not she wanted to end her life. It’s possible that, with children around, she would want to prolong her life for as long as possible.
Ethical Considerations
Even without considering the patient’s right to life, if she wants it, this particular case brings up several difficult ethical considerations.
1) Right to die. There are those who believe that people should choose the time and place of their death. This discussion becomes even more passionate when patients are in terminal situations and are going to die anyway; or even when patients are in comas and are kept on life support for survival. The ethics of these situations point out that it’s not just quantity of life that’s important, but quality of life. In other words, death is preferable to living life as an unconscious lump.
There is some merit to this – the comatose patient whose brain is irrevocably damaged by an accident and can only survive on breathing support is probably someone who has a right to die. The mother with cancer, however, is different. She’s still alive, and only she can define a positive quality of life.
2) Right to life. As mentioned above, this terminal mother has a right to life and, as long as she’s in her right mind and coherent, can, and should, be able to decide what she defines as “quality of life.” For her, quality of life might be the ability to see her children every day. For someone else, a good quality would be the ability to interact with their children. But the concept of quality differs from person to person – and Nurse Nancy doesn’t really have the right to dictate to this patient what is considered “quality of life.”
3) Death with dignity. Having said the above, the ailing mother does have the right to death with dignity. If her pain is unbearable; if she doesn’t want her children to see her suffering; if she’s terminal anyway; if she’s ready to go and doesn’t want to be a drain on her family, she should have the right to die with dignity, rather than being kept alive in an increasingly pain-racked body. If this is the case, than Nurse Nancy would likely be acting out of compassion, rather than in an attempt to ease her own suffering at seeing this woman’s decline.
Legal Considerations
1) Assisted suicide. At this time, only Oregon and Washington permit what is called physician-assisted suicide (Assisted Suicide Laws by State). Thirty-four states have statutes that criminalize assisted suicide, while nine states criminalize assisted suicide through common law (Assisted Suicide Laws by State). Even in Oregon and Washington, however, a patient needs to jump through many hoops to prove he or she is a candidate for assisted suicide. S/he must prove that s/he is terminal, must be judged terminal by at least two physicians (one of whom isn’t treating the patient), and his/her life must be judged as too painful for survival. We don’t know where the cancer center is located – but even if it was located in Washington or Oregon, the patient hasn’t undergone the criteria necessary to be considered eligible for physician-assisted suicide.
2) Euthanasia. Euthanasia is defined as “the intentional killing by act or omission of a dependent human being for his or her alleged benefit” (Euthanasia Definitions). Euthanasia is illegal in the United States (unless the type is physician-assisted suicide, as mentioned above). However, what’s interesting is that “the giving of high doses of pain-killers that may endanger life, when they have been shown to be necessary” is NOT considered euthanasia (Euthanasia Definitions). In fact, providing these higher doses of pain killers are considered “part of good medical practice, endorsed by law, when they are properly carried out” (Euthanasia Definitions). As such, in this particular case, giving this patient more narcotics to relieve pain would be considered legal, even if the potential consequence might be death.
3) Lawsuits from family members. The one thing we need to remember in this scenario is that, while the mother might be single, she no doubt has family members. If somehow the mother “accidentally” dies before her time, and such a death is traced to an overdose of narcotics, the cancer center could be in for a nasty lawsuit. It doesn’t matter that the patient was terminal and would likely die in the near future. The family might focus on the fact that she was given more narcotics than what was called for, and that caused her death.
Business Considerations
1) Lawsuit. Not to sound flippant, but there is nothing like a good lawsuit to put a shadow on a cancer center. Even if the center has malpractice insurance (which it likely does), it’s a sure bet that insurance premiums will increase, meaning fewer resources can be put toward treating patients with cancer.
2) Loss of Reputation. It’s expected people will die from cancer. This is a given. However, if people die from a narcotic overdose given by a nurse (and presumably without the patient’s approval), this raises red flags. It can give the impression that, if nurses believe patients are terminal, the nurses can then kill the patients with little or no retribution. This doesn’t provide a good image for the cancer center. Furthermore, it could hurt a staff that is already suffering from burnout and low morale.
3) Potential investigations. Investigations by regulatory agencies can be disruptive and costly – and this could occur if Nurse Nancy is allowed to have her way. Again, death from narcotics can occur with cancer patients. However, if that narcotic is administered by a nurse, without a doctor’s orders, this can open the door to potential de-certification and loss of accreditation in a variety of areas.
Recommendations and Reasons
Based on the above, the manager should do the following:
1) Put Nurse Nancy on administrative leave immediately. Nurse Nancy is clearly experiencing burnout to the point that she wants to put patients out of what she perceives as their misery. Whether the mother is suffering or not, it’s not in Nurse Nancy’s purview to decide that she needs extra narcotics or not. Nurse Nancy is a danger to her patients.
2) Put into place programs and counseling to help improve morale of the staff. Working with terminal patients is going to have an impact on the staff; there’s no way around this. But the cancer center needs to have some kind of plan to prevent burnout. This plan should include the ability of the staff to talk to trained professionals about their feelings, regular time off so they can get away from death and redistributed shifts so they’re not working long hours, 100% of the time.
In short, Nurse Nancy’s attitude is the result of a great deal of stress on the part of the staff, which is working under difficult conditions. Attempts to alleviate those difficult conditions can help reduce burnout and helplessness. It’s also hoped that doing so will reduce similar Nurse Nancy reactions.

REFERENCES

Assisted Suicide Laws by State (n.d.). Euthanasia.com. Retrieved 2011, June3 9 from http://www.euthanasia.com/bystate.html.

Euthanasia Definitions (n.d.) Euthanasia.com. Retrieved 2011, June 9 from http://www.euthanasia.com/definitions.html.

Summary of the McCain-Edwards-Kennedy Patients’ Bill of Rights (2001). Retrieved 2011, June 9 from http://democrats.senate.gov/pbr/summary.html.