Nursing Roles and Values Task One
Western Governors University

State Regulations and Nursing Standards The State of Tennessee Board of Nursing’s Rules and Regulations of Registered Nurses, Rule # 1000-01-.13-1r states that unprofessional conduct is defined in part by "failing to take appropriate action in safeguarding the patient from incompetent health care practices" (State of Tennessee, 2011). There are a number of arguments in this case study that incompetent health care practices are being performed, from the decision to place a patient on a ventilator for an oxygen saturation of 88%, circumventing the patient’s written and verbal advanced directives, utilizing an unauthorized family member to get consent for a medical procedure, and discussing confidential medical information in a public location and with and unauthorized family member. The nurse clearly violated this rule because the nurse did not take any action at any point to stop the physician from taking these incompetent actions.
Implications
Rule # 1000-01-.13-1r applies because, as mentioned above, the nurse failed to take any action to prevent the physician from performing a number of incompetent acts related to the healthcare of the patient. First and foremost, the patient likely does not even need to be placed on the ventilator. The physician’s decision to place the patient on the ventilator is based on an oxygen saturation of 88%. Although the patient’s oxygen saturation does need to be increased, the physician could consider BiPAP to adequately ventilate the patient without violating the patient’s wishes. BiPAP (bilevel positive airway pressure) is a non-invasive ventilation device that can increase the volume of air that enters the lung when a patient breathes in. Studies have proven that BiPAP has been used effectively to prevent the need for intubation and it is effective for patients with severe respiratory difficulty (Kirkland, 2010). The chief implication here is that there is a viable alternative to intubation, that the physician has ignored or was unaware of that alternative, and that the nurse failed to ask the physician to consider alternatives to violating the patient’s verbal and written wishes. The nurse is also negligent in attempting to utilize the patient’s power of attorney to make a healthcare decision. In the State of Tennessee, a physician or power of attorney may not override an advanced directive. A power of attorney is utilized to make healthcare decisions for a patient when the patient cannot make those decisions for themselves. In this case, the decision was already made by the patient with his advanced directive – he clearly did not want to be intubated, and this was documented both in a legal document and verbally by the patient. If the physician was unable to comply with the patient’s wishes, he should have transferred care to another physician. In any case, the nurse should have notified the physician that the advanced directive must be followed. A relative of the power of attorney is not qualified to make healthcare decisions for the patient (Department of Health, n.d.). The implication here is that the patient’s wishes were completely violated.
Code of Ethics One of the Nursing Codes of Ethics approved by the ANA that applies to this case study is Provision 1 – Section 1.4, “The right to self-determination”. This section describes the patient’s moral and legal rights in allowing or disallowing procedures to be done to them. Patients can be given more information about a certain procedure, but should be allowed to accept or refuse any treatment without any influence or deceptiveness. The nurse is responsible for ensuring that the patient understands the implications behind their acceptance or refusal of care, but is also responsible for protecting the patient’s right to accept or refuse said care (ANA, 2010).

Impact of Code This case is a clear violation of the above-mentioned code. The nurse did not, in any way, protect the patient’s right to refuse intubation. Although the nurse was given several opportunities to do so, the nurse did not intervene in the initial physician contact, in the attempt to contact the patient’s brother, or in the conversation with the niece. The nurse failed to mention the patient’s advanced directive at any point.
Ethics of Putting Patient on Ventilator The chief ethical implication is the violation of the patient’s desire to not be intubated and go on the ventilator. The patient has an advanced directive, a legal document, which clearly states that he does not want to be on a ventilator. The patient does not appear to have changed his mind since the document was drawn up, as evidenced by the patient shaking his head and stating “no” when confronted with the physician’s desire to place the patient on the respirator. Another ethical implication is whether or not the patient will be able to be removed from the ventilator after being placed on it. Studies have shown that patients who are on ventilators for long periods of time become dependent on the ventilator and are unable to be removed from it. For some very ill patients, there is still a risk for ventilator dependence even if the intubation is for a short time. The patient may be at risk for having to be attached for a substantial period of time to the device that he explicitly refused, if he is ever able to come off of it (Purro er al., 2010).
Ethics of Authorizing Ventilator Mr. Y may have a number of ethical considerations to weigh before agreeing to authorize the use of the ventilator. Mr. Y may not have seen his brother much in recent years, as evidenced by the fact that no family was present on Mr. E’s admission to the nursing home. This may present Mr. Y with some unresolved guilt that he may feel could be addressed by prolonging Mr. E’s life, so he may feel the need to authorize the ventilator because of this. Mr. Y is unaware of Mr. E’s wishes to not go on the ventilator. His decision may be swayed by Mr. E’s wishes if he were aware. Mr. Y may also question why Mr. E would make the choice not to be intubated in the first place. Mr. Y may also consider Mr. E’s current situation and be conflicted about whether or not Mr. E should remain on life support. Mr. E has a number of medical conditions and is currently living in a nursing home. Even if Mr. E survives, Mr. Y may be unsure of how good Mr. E’s quality of life will be after this incident.
Analysis of Mr. E’s Advanced Directives The first complication of Mr. E’s advanced directive is that there was no family present at the time the advanced directive was signed, and Mr. Y is unaware of this advanced directive, so it is likely that Mr. E has never discussed the advanced directive with his family. Another complication of the advanced directive is that Mr. Y has been designated a power of attorney and can make medical decisions for the patient – and this is incorrectly seen as an ability to nullify Mr. E’s advanced directive. A third complication with the advanced directive is that Mr. E’s physician is blatantly attempting to circumvent Mr. E’s wishes.
HIPAA
The first HIPAA violation is the discussion of the case with Ms. H, Mr. Y's niece. Ms. H, despite being a relative, is not the power of attorney and has not necessarily been listed by Mr. E as someone who is allowed to receive information about his condition. The second HIPAA violation is the discussion of the case in front of Ms. H's boyfriend, who has nothing to do with the case. The third violation of HIPAA is the discussion taking place in a public area in front of other patients. The fourth violation of HIPAA is the nurse's discussion of the case with other nurses at dinner. These nurses are not part of Mr. E's care team and do not need information about this case.
Professional Conduct The nurse that is caring for Mr. E is violating Mr. E’s self-determination by allowing the physician to circumvent Mr. E’s advanced directive. The nurse is also unprofessional in discussing the case with other nurses not related to the care of Mr. E. The other nurses display unprofessionalism by referring to the patient as "retarded" and stating that "no one pays attention to HIPAA". Although the last nurse did not say anything negative by stating that she did not know anything about advanced directives, she does display unprofessionalism by showing ignorance of a common medical practice.
Steps
The first step that should have been taken in this scenario is that the nurse should have pointed out that Mr. E does have a legal advanced directive in place and that the physician should attempt to educate the patient, but honor the patient's wishes if he continues to refuse. Secondly, the nurse should have suggested BiPAP as an alternative to intubation. A fever of 101 and an oxygen saturation of 88% is not enough to determine that the patient is incompetent to make decisions. The nurse should have made an assessment of the patient's alertness and orientation to determine whether or not he was competent to make a decision. The next step that should have been taken is that the nurse should have mentioned that advanced directive to Mr. Y and asked if he knew anything about it. The nurse should have encouraged Mr. Y to discuss this with his brother before calling anyone else. Mr. Y likely would have been able to determine whether or not his brother was competent enough to continue to refuse the ventilator. After this, the nurse should have politely and tactfully refused to include Ms. H in the decision-making process. If the physician insisted on speaking with Ms. H, the nurse should have ensured that the conversation took place in a private area away from Ms. H's boyfriend and other patients. In any case, Ms. H has no legal authority to make decisions for Mr. E. The nurse should have asked Ms. H to have Mr. Y contact the physician with any additional insight that Mr. Y may have to offer. After Ms. H authorized the ventilator, the nurse should have reminded the physician that Ms. H has no legal authority to do so, and that the advanced directive is still in effect. If the physician continued to ignore this fact, the nurse should have called her supervisor to have administration get involved. Finally, the nurse should not have had the conversation about Mr. E with her co-workers. Although the nurse may feel troubled and may feel the need to vent, discussing confidential information with healthcare workers not involved in the case is illegal and inappropriate.

References
ANA. (2010, November 15). Code of Ethics for Nurses with Interpretive Statements. Nursing World Code of Ethics. Retrieved December 11, 2012, from http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics.pdf
Department of Health. (n.d.). Advance Directives for Health Care Decision Making. Advance Directives: Frequently Asked Questions. Retrieved December 10, 2012, from http://health.state.tn.us/advancedirectives/FAQ.htm
Kirkland, L. (2010, September). Noninvasive Positive-pressure Ventilation. ACP Hospitalist. Retrieved December 11, 2012, from http://www.acphospitalist.org/archives/2010/09/tech.htm
Purro, A., Appendini, L., DeGaetano, A., Gudjonsdottir, M., Donner, C. F., & Rossi, A. (2010). Physiologic Determinants of Ventilator Dependence in Long-term Mechanically Ventilated Patients. American Journal of Respiratory and Critical Care Medicine, 161(4), 1115-1123. Retrieved December 12, 2012, from http://ajrccm.atsjournals.org/content/161/4/1115.full
State of Tennessee Board of Nursing. (2011, November). Rules and Regulations of Registered Nurses. Rules of the Tennessee Board of Nursing. Retrieved December 11, 2012, from http://www.state.tn.us/sos/rules/1000/1000-01.20111103.pdf