Case Study:

Judy a seventeen year old girl was hospitalised following presenting to the Emergency Department (ED) with acute abdominal pain. Judy has just commenced a job in the retail industry. Judy's provisional diagnosis was Pelvic Inflammatory Disease (PID) while the doctors awaited the results of her tests taken in the ED. Judy was commenced on an IV N/Saline 1000mls q8h with IV antibiotics. No admitting beds were available in the gynaecology ward so Judy was placed in a busy general medical ward. Since admission to the ward that evening Julie complained to staff that she was in a lot of pain and that she needed to 'pee all the time'.

Sue the nurse has just come on duty at 0645 hours (6.45am) and sees that the ward is extremely busy, Julie buzzes once again and one of the night staff (Nurse 1) comments 'not her again, she has been a right pest all night, she never gets off the buzzer, I think she is pretending and attention seeking.' Nurse 2 contributed 'let her wait, she's a pain.' Nurse 3 comments 'she can't be in that much pain, she rolls over to sleep when she thinks we are not watching her, yet soon as she sees us she asks for Morphine......if she is going to get herself an infection then she should live with the consequences, I've told her there is bound to be some discomfort...... we called the doctor during the night to get her pain relief and she's still complaining!'

Sue responds 'it's okay, I'll get the buzzer for you, I have a few minutes before report.' Nurse 1 and Nurse 2 both smirk at each other and comment 'Florence is at it again' in hearing distance of Sue. Sue shrugs it off she knows they have had a 'bad night'.

Sue goes to Judy's bedside and notes that she looks extraordinarily pale, Judy says she needs to use the pan again (there was one sitting beside the bed). Sue takes the covers back and notices the abdomen is rigid and distended, she palpates lightly and Judy cries out in pain. Sue looks at the observation sheet however no observations have been completed since admission to the ward since 7pm the night before. Sue feels her pulse and notes that she is tachycardic 148, she quickly takes her BP and it is 70/40, she also feels clammy to touch. Sue checks the IV is running and looks at her output, there are no recordings of her urine output overnight. She checks her peri pad and notes it is heavily blood stained. Sue puts the bedrails up and tells Judy that she will be back in one minute. Judy's last comment to Sue is that 'no body believes me they think I'm making it up, I'm really frightened'. Sue did not say a word. Sue quickly goes to the nurse's station where the Nurse Unit Manager (NUM) has just arrived and relays the situation to her. The NUM hurriedly goes to Judy's bedside where she assesses Judy. The NUM returns to the nurse's station where she pages the doctor for an emergency review. Judy is prepped for emergency surgery, it is thought she is haemorrhaging internally from an ectopic pregnancy. She is taken to the operating theatre. She returns later in the day to the ward after having removal of her L) fallopian tube from a ruptured ectopic pregnancy and also is diagnosed with peritonitis.

Interestingly the NUM notes that in the patient's file it said Provisional Diagnosis PID however 'ectopic pregnancy needs to be ruled out'. For 4/24 observations overnight, IV fluids as ordered and notify if worried.  The NUM notes that the night Duty Medical Officer (DMO) had reviewed Judy regarding her pain and had ordered her Morphine. The DMO also wrote continue 4/24 observations and IV fluids and to notify if abdominal pain increases. The NUM questions Sue about the sequence of events leading to the situation that occurred. Sue is not sure what to do. She does not want to get her colleagues into trouble, yet she is very distressed about what has occurred for the patient.

Assessment Framework

Use the Kerridge, Lowe and McPhee's (2005) modified ethical decision-making framework below to examine the facts from this case study in light of their ethical and legal issues.

Clearly state the problem/s - note this section here can be tabled i.e. you can use a grid

• Identify all the issues (facts) within the context of the case study and distinguish between ethical and legal issues and any other problems such as health/medical, social, cultural, linguistic, gender.
• Explore the meaning in any value-laden terms identified.
• Identify the facts that support or refute the issues.
• What else would you like to know about (e.g. further information / facts) or consider?

Consider and explore the fundamental ethical principles and whether they were upheld or breached (you will also have to consider whether or not they apply in the case study circumstance)

• Autonomy: how is this concept considered / applied in this case study?
• Beneficence: what benefits have been applied for this patient in the case study?
• Non-maleficence: what are the risks and how can they be avoided?
• Confidentiality /Privacy: what information is private and does confidentiality need to be limited or breached?
• Veracity: has the patient and their family been honestly informed and is there any reason the patient cannot know the truth?

Consider and explore the Law and Professional Nursing standards and whether they were upheld or breached

• Identify relevant legal principles and laws that indicate unlawful/unprofessional behaviour

Consider how the problem would look from another perspective

Consider a range of the following:

• Who are the relevant stakeholders? (e.g. patient, hospital, nurses, doctors)
• What is their interest?
• What do they have to lose?
• How significant are their interests?
• How powerful are they? How legitimate are they?
• How urgent are the problems?
• How would the problem look from an alternative ethical position?

Identify any ethical conflicts in the case study

• Are there any ethical conflicts in the scenario? If so, can you explain why the conflicts occur and how they may be resolved?
• Identify the relevant ethical concepts and how they might guide management
• Identify relevant legal concepts and laws and how they might guide management

State the ethico-legal decision and justify it:

• What decision needs to be made, specify how guiding principles were balanced and why
• Outline how you would communicate the decision and assist relevant stakeholders to determine an action plan