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Jessica has been a nurse practitioner for nearly two decades. She has been providing primary care services to home bound and home limited patients since 2013 with an organization known as MD2U in Evansville, Indiana. In viewing the documentary, The Invisible Patient, Jessica presented herself as a disruptive innovator. According to Hamric, Hanson, Tracy, & O’Grady, “disruptive innovation transforms an existing market or creates a new market by making processes simpler and improving access” (2014). Jessica took pride in carrying for individuals in the community that were faced with challenges. In viewing the documentary, I was able to see many of them live in difficult situations. Some are unable to travel to see a clinician at a doctor’s office for a lot of different reasons. They all had multiple chronic conditions, and all faced some form of poverty. Jessica mentioned several times that there are only a handful of people currently reviving primary health care in their homes. Jessica background was in renal and telemetry medicine at Yale New Haven hospital. Prior to joining MD2U, she cared for the adult and geriatric population with dementia. She also spent a decade in traditional family practice prior to branching out. If Jessica did not provide her services many of her patients would have frequent admissions to the hospitals or require long term or skilled rehab services. During the documentary, Jessica displayed respect and empathy to her patients while delivering high quality patient centered care. Per Jessica, her services are also more cost efficient for the patients, especially since they were on a fix income.
The ethical dilemma that stuck to to me the most while watching the documentary was the care Jessica provided to the 34-year male Roger Brown. He was diagnosed with muscular dystrophy at four years old. “Muscular dystrophy is a group of diseases that cause progressive weakness and loss of muscular mass” (“Muscular dystrophy”, 2018). According to “Muscular dystrophy”, the genes are abnormal, and they mutate interfering with the production of proteins needed to form healthy muscle (2018). This disease is very common in young males. There is no cure, but medications and therapy can try to help manage symptoms and slow the course of the disease. The normal life expectancy is approximately twenty years, Roger exceeded this. Symptoms may include, “frequent falls, waddling gait, walking on the toes, large calf muscles, muscle pain/stiffness and respiratory complications” (“Muscular dystrophy”, 2018). The ethical dilemma faced here was informed consent, “Concerns that patients and their families have not been fully informed about there treatment or clinical prognosis is a common ethical concern for nurses” (“Muscular dystrophy”, 2018).
Often, patients feel more comfortable asking a nurse to decipher what their doctor say because of comprehension, especially with end life decision making. In one party of the documentary Jessica is faced to discuss end of life care with Roger and his mom due to the progression of his disease especially impacting his respiratory status. Jessica conflict was Rogers age. Normally treating a person of his age, you would take aggressive measures. But regarding Rogers health, his EF is 20%, fluid buildup, heart failure, kidney stones and generalized pain. He had multiple co-morbidities that Jessica knew if his heart stop beating, performing CPR to prolong his life would cause more harm to him. At first Roger wanted to continue aggressive measures so he could continue his life if he could. Jessica had to find another approach to assist Roger and his mother to understand the progression of his disease. She helped him understand that he wasn’t getting better regardless of his treatment. Aggressive measures and hospice/palliative care services are two different treatments. Jessica had a difficult time discussing this because she was fully aware Rogers time was near. She did a great job explaining to Roger and his mother what would happen once he starts to transition. Many people are faced with difficult decision regarding code status, hospice and palliative care services in their lifetime. End of life should be a smooth transition, but it is often difficult because people find it hard to accept.
One important factor that affects ethical decision making is your personal belief system (Hamric, Hanson, Tracy, & O’Grady, 2014). Your life experiences over a period may change your personal values Hamric, Hanson, Tracy, & O’Grady, 2014). My personal beliefs are inline with Jessica with this ethical dilemma. I feel end of life patients should have pain and symptoms management. I would also assist the patient and family through the dying and death process, so the anxiety and fear can be decreased like Jessica did. Advocacy for the patient is key to me. For a person to give great end of life care appropriately, effective communication should take place.
Becoming an adult gerontology nurse practitioner, I will be the spokesperson for my patient and honor their rights and give them dignity. I will ensure my patients are informed on what advance directives and living wills are in case they ever are unable to make a sound decision and they wouldn’t want to put that burden on there love ones. Everyone should honor a patient wishes as it is not causing any harm. Through education with end of life, DNR, palliative care services, hospice services and advance directives the tales will be eliminated, and anxiety/fear will be decreased (Hamric, Hanson, Tracy, & O’Grady, 2014).
One mechanism to overcome barriers is recognizing a patient needs and making
patient and families aware of additional services such as palliative care. It is for patient with life threatening illness. “Patient have better quality of life and live longer and cost the health system less”, with palliative care services (Perrin & Kazonowski, 2015). Barriers to palliative care consultation for patients in critical care include misunderstanding. Palliative care undermines the focus of saving the patient life is what some feel. Providers often have difficult time determine when critically ill patients are approaching the end of life, often causing patients to die in pain. According to Perrin & Kazonowski, palliative care is an approach that improves the quality of life of patients and their families facing problems associated with life threatening illness (2015). APN can emphasize to families that symptom management care to the patient can improve a patient outcome.
When the dying process is detected earlier, comfort focused treatment goals are initiated sooner. When appropriate, patients are moved to lower intensity care site (Perrin & Kazonowski, 2015). Length of stay in the intensive care unit is decreased (Perrin & Kazonowski, 2015). Cost of care is reduced because realistic goals are established. Staff would receive support for patients and families. The need for repeat admission could be reduced because treatment goals have been clarified. And lastly, with palliative care the patient and families would have continuity of care with familiar faces because they would be followed from the hospital, to skilled/long term care or home.
In the documentary The Invisible Patients, Jessica, a nurse practitioner for home-limited patients, is faced with several ethical dilemmas. For example, Jessica provides care for an elderly couple named Wink and Patty Sherrill. Both Patty and Wink are prescribed narcotics to manage their arthritis pain. During a routine urine drug screen, it is discovered that Patty does not have any trace of her pain medication in her system, yet she is still having her narcotic prescription refilled regularly. This obviously raises concerns for medication diversion. Patty is presumably giving her narcotics to her husband or selling her narcotics, which is a clear violation of her pain contract. She is banned from her primary care MD’s practice, which causes her great difficulty in finding another healthcare provider. Jessica feels that it is her responsibility to provide care for this couple.
This scenario raises the ethical dilemma of beneficence versus nonmaleficence. The principle of beneficence is “the duty to do good and prevent or remove harm" (Hamric, Hanson, Tracy, O'Grady, 2014, p. 337). Prescribing narcotics to those experiencing chronic pain and disability is a necessary and beneficent act of healthcare providers. The principle of nonmaleficence is “the duty not to inflict harm or evil” (Hamric et al., 2014, p.337). Prescribing narcotics to a patient who is suspected of narcotics diversion has the potential to cause harm to the person who is taking the narcotics illicitly. Jessica must now decide which principle to follow and which principle to potentially break. Jessica decides that even though Patty is abusing her prescription, she does in fact still need her narcotics and continues to prescribe the pain medicine.
In this scenario, I would not continue to prescribe Patty narcotics. Since she is not taking her pain medications but still seeking refills, she is abusing her prescription and the trust placed in her. If she is diverting her narcotics to her husband and/or selling them on the street, this places Wink and/or the narcotic abuser at risk for health complications such as respiratory depression, constipation, drug dependence, increased tolerance, and narcotic withdrawal in the future. I believe Wink has a legitimate need for pain medications, but he should be honest and open with Jessica about the need to increase his pain medications or try different modalities if his pain is not properly controlled. Regardless of motive, illegally diverting narcotics is a breach in contract and should not be overlooked.
If I were presented with this scenario, I would have talked with Patty and Wink about Patty’s narcotic diversion and sought an alternative solution to continuing to prescribe narcotics. If Patty were in fact giving her narcotics to her husband to help control his pain, I would adjust Wink’s medications and pain management strategy. If they were selling their excess narcotics on the street to help pay for their bills or health insurance (which Patty frequently mentioned), I would consult a social worker to help Patty and Wink manage their finances and review insurance options. Narcotic abuse is an epidemic in America, and nurse practitioners must use wisdom when prescribing narcotics (CDC, 2017). Pain management is certainly a responsibility of the nurse practitioner and should always be considered when providing care.
Personal Beliefs and Values: Costs and Benefits
I believe that individuals should be held accountable for their actions. Though it is sad to think that some individuals feel they must break the law to “make ends meet”, that does not make it right. I tend to see things as black and white, and I realize that this is a barrier when facing ethical dilemmas. Ethics and medicine have many grey areas, and I must be cautious to not let my personal views affect how I care for my patients. One may argue that Patty felt she had no other choice, and it was a necessary means for Patty and Wink for them to survive on such a limited income. Though I disagree with this argument, I must still be willing to consider the opposing view before making my final decision. By pausing and considering the opposing viewpoint with an open mind, I can begin to overcome my personal bias when faced with an ethical dilemma.
A potential cost to my barrier of being a dichotomist thinker is that I may fail to see an alternative solution. There are often more than just two solutions to a problem, and I need to actively seek creative, alternate solutions before coming to a decision. A potential benefit to my beliefs is that I do not tend to ruminate over past decisions. Working in healthcare is often emotionally taxing and can lead to burnout if you let it consume your thoughts.
According to our text, disruptive innovators are individuals who provide a cost effective, convenient service to a customer who is less demanding than the typical customer (Hamric et al., 2014). This creates competition between the disruptive innovator and the larger corporations and often drives down prices of the larger corporation. Nurse practitioners, such as Jessica, can provide excellent care to patients at a cheaper price and deliver this care conveniently at home. Providing care to homebound patients such as those in The Invisible Patients is an excellent example of a service that is competitively priced and convenient for the less demanding patient population.
ANA Code of Ethics
The ANA Code of Ethics is a grouping of morals and values that nurses are expected to adhere to during their career (ANA, 2015). Nurses must use this code when faced with difficult ethical dilemmas. An example of a barrier regarding the ANA Code of Ethics could be found with Provision 3: “The nurse promotes, advocates for, and protects the rights, health, and safety of the patient” (ANA, 2015, p.8). For example, if a nurse is caring for a patient that confesses to elder abuse, the nurse must now report that patient to the police and fail to protect the patient's right to confidentiality. Most nurses would agree that this is the correct action to take, but some may mistakenly believe that Provision 3 prohibits reporting the incident to the police. This is a barrier of the ANA Code of Ethics as well as a barrier due to simply a lack of understanding. The Code of Ethics is a great tool for nurses but also has the potential to be a barrier in healthcare if misunderstood.
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