Issue Identification
The main problem in the case is to decide whether Valentina’s religious principles are more important than the objective medical need. The second issue refers to patient privacy and disclosure of Valentina’s health information to Marina. Identifying the full-fledged decision-makers is quite difficult due to Valentina’s relationships with her siblings. Overall, the following parties are involved: Valentina (patient), Carlos (brother), Marina (sister), RN Singh/Dr. Petrova (the medical team).
Issue Evaluation
Issue 1
According to E1.1, the nurse’s key professional responsibility “is to people requiring nursing care” (International Council of Nurses, 2012, p. 2). It means that the team is expected to act in the best interests of Valentina and the newborn child, not her relatives. E1.2 states that the nurse should make care decisions that are coherent with “the human rights, values, customs, and spiritual beliefs of the individual” (ICN, 2012, p. 2). Based on that, it would be unethical to simply ignore Valentina’s wishes related to the use of blood products and her religious principles. According to E1.5, the nurse “shares with society the responsibility…to meet the health needs of the public, in particular, those of vulnerable populations” (ICN, 2012, p. 2). Being unconscious, Valentina is vulnerable, and she cannot restate her refusal, knowing that she will die without the prohibited intervention. However, she previously expressed wishes require consideration.
The principle of autonomy applies to the issue; Valentina is unconscious and unable to state her present and updated opinion on the use of blood products. Despite that, Valentina’s previous wishes should be respected to support her autonomy. In terms of beneficence, there is a conflict between Valentina’s medical (minimize harm to health/survive) and psychological (remain a devoted Jehovah’s Witness) interests. As for non-maleficence, performing blood transfusion against the patient’s will would probably do less harm than allowing a preventable death to happen.
As for legal principles, the patient’s refusal of medical treatment should meet multiple criteria to be considered valid. According to the Guardian and Administration Act accepted in 2000, a person demonstrates capacity if he or she fully understands the consequences of the decision and the nature of the question (Willmott et al., 2017). Since she is unconscious, Valentina does not have capacity at the moment. Earlier, she explained to RN Singh that she would not want the use of blood products, but its potential consequences, including death, and any exceptions were not discussed. It involves an incomplete disclosure of relevant information (McGrath & Phillips, 2008). Also, Valentina did not fill out the AHD form to provide specific and unambiguous directions in case she loses capacity (Legal Aid Queensland, n.d.). According to the order of substitute decision-makers, in the absence of well-documented AHD forms, decisions regarding incapable adults can be made by appointed decision-makers (Queensland Government, 2017). They should have the capacity, be older than eighteen, and act based on the patient’s values. Valentina’s sister does not support her views and values. If Carlos is of full age and mentally healthy, he can be Valentina’s substitute decision-maker.
Those involved in decision-making have different values and perspectives. As a long-time Jehovah’s Witness, Valentina would be likely to confirm her initial decision. Healthcare professionals treat Valentina as a patient who needs timely help and value her right to life. Despite his negative emotions, Carlos views the situation from a religious viewpoint and appreciates his sister’s unwillingness to violate her principles. Next, if Marina knew the circumstances of the medical case, she would agree with the medical team.
Issue 2
Based on E1.4, the nurse is expected to “hold in confidence personal information and use judgment” when sharing it with others (ICN, 2012, p. 2). Valentina does not want to communicate with her sister and share information on her health, and the nurse has to respect this desire. Also, judging from E1.7, the nurse has to demonstrate “responsiveness and trustworthiness” (ICN, 2012, p. 2). Earlier, in her conversation with RN Singh, Valentina mentioned that she did not communicate with her sister. It can be understood as Valentina’s unwillingness to see Marina as a decision-maker and even provide her with access to health information. Being obliged to help patients and take their opinions into account, health professionals have to consider the mentioned detail when making a decision.
Concerning ethical principles, the second issue also refers to autonomy. Despite Valentina’s current inability to express her opinion, the fact that she is at odds with Marina cannot be ignored. Speaking about beneficence, in terms of health outcomes, it is in Valentina’s best interests to inform Marina and give her the right to participate in decision-making. At the same time, this decision would cause psychological harm. As for non-maleficence, providing Marina with all details will run counter to Valentina’s wishes, thus causing harm.
According to the Queensland laws concerning information privacy, health information can be disclosed to individuals responsible for patients (parents, children, siblings, spouses/de facto partners, other relatives) (Information Privacy Act, s 26). Importantly, the disclosure should not be contrary to any wishes of the patient (Information Privacy Act, s 26). Valentina’s words about her unwillingness to share information with Marina were documented by RN Singh. Thus, providing Marina with the same details that Carlos knows would contradict the patient’s wishes. However, Carlos can explain the case to Marina since he is not legally obliged to keep it confidential. As for the sides’ values and perspectives, Valentina would probably confirm her decision and refuse to share information with her sister. Carlos’s position on the issue is unclear since his relationships with Marina are not discussed. The healthcare professionals would value Valentina’s right to make her own decisions.
Actions
Issue 1
According to P2.2.a and P2.2.b, the nurse has to respect patients’ values and preferences, as well as recognize the need for subsequent decision-makers promptly (Nursing and Midwifery Board of Australia, 2017). Thus, healthcare specialists are expected to provide care by Valentina’s previous wishes and let people she trusts speak on her behalf.
Three potential options for action and their key consequences are as follows:
- Let Carlos speak on behalf of Valentina. Outcomes: loyalty to religious principles, Valentina’s death.
- Ask for the religious authorities’ advice to help Carlos make an informed decision. The rules for Jehovah’s Witnesses may vary across the world, so some procedures with the use of blood products may be approved locally (Bhardwaj & Bassi, 2019; Olaussen, Bade-Boon, Fitzgerald, & Mitra, 2018). Outcomes: changes in Carlos’s opinion (low probability).
- Apply to the Queensland Supreme Court on an emergency basis and act based on the decision. Outcomes: increase Valentina’s chances to survive, protect her child’s interests.
The third option should be chosen since it allows balancing between the principles of autonomy and non-maleficence. Performing the procedure against the patient’s will without legal decisions would be unethical and put the hospital’s reputation at risk. Also, Valentina’s previous wishes are not documented properly and do not refer to the situation, in which blood transfusion is the only way to save her life. Apart from her right to life, her child’s interests do not allow leaving her to die in the name of faith.
Issue 2
Based on P3.5a, the nurse has to protect and respect people’s privacy and, if possible, seek consent before disclosing health information (NMBA, 2017). Valentina’s conversation with RN Singh contains an implicit refusal to disclose any information to Marina, and this detail should be considered.
The following actions can be taken:
- Update Marina on Valentina’s condition. Outcomes: The patient’s implicit refusal is ignored, conflicts between Valentina’s siblings.
- Encourage Carlos to keep Marina informed. Outcomes: no privacy breaches.
The second option is more appropriate because it does not run counter to ethical principles and Valentina’s wishes. Carlos is free to share information about Valentina’s condition with his sister. Making him the key decision-maker helps to balance between respecting Valentina’s autonomy as a patient and keeping the family updated to encourage dialogue.
Implementation
Issue 1
The medical team or other representatives of the hospital should gather all documentation explaining Valentina’s condition, seek urgent legal advice in the court, and implement the decision. The foreseeable consequences of using the selected option include Carlos’s discontent. To manage it, the medical team can communicate with Carlos and explain that Valentina’s decision does not consider her baby’s interests and blood transfusion as the only life-saving option. The care plan will depend on the legal body’s reaction to the case.
Issue 2
To implement the decision, the team can contact Carlos and ask him to inform Marina about Valentina’s condition. Among the foreseeable consequences is the man’s overly emotional reaction. To deal with it, the team will use professional communication to explain the benefits of shared decision-making. No specific care plans and documents will be needed.
Outcomes
The decision-making process was complicated by several conflicting principles and the need for new information not stated in the assignment. Regarding the first issue, the proposed action allows involving new and more competent decision-makers. It also aligns with my values since I put the client’s life first but want to make sure that people always make informed choices. The option selected to deal with the second issue can also lead to positive results because information about Valentina will not be provided against her will. The need to make this decision has not changed my beliefs about patients’ privacy. Respecting clients’ wishes, including their preferences related to information management is one of the vital professional values that I support. As for the need to skill-up, learning more about prominent medical court cases would not come amiss.
References
Bhardwaj, K., & Bassi, R. (2019). Ethical practices in the area of blood transfusion. GMC Patiala Journal of Research and Medical Education, 19(1), 5-60.
Information Privacy Act 2009 (Qld).
International Council of Nurses. (2012). The ICN code of ethics for nurses. Web.
Legal Aid Queensland. (n.d.). Medical consent. Web.
McGrath, P., & Phillips, E. (2008). Western notions of informed consent and indigenous cultures: Australian findings at the interface. Journal of Bioethical Inquiry, 5(1), 21-31.
Nursing and Midwifery Board of Australia. (2017). Code of conduct for nurses. Web.
Olaussen, A., Bade-Boon, J., Fitzgerald, M. C., & Mitra, B. (2018). Management of injured patients who were Jehovah’s Witnesses, where blood transfusion may not be an option: A retrospective review. Vox Sanguinis, 113(3), 283-289.
Queensland Government. (2017). Substitute decision-makers. Web.
Willmott, L., White, B., Stackpoole, C., Shih-Ning, T. H. E. N., Hongjie, M. A. N., Mei, Y. U., & Weixing, S. H. E. N. (2017). Guardianship and health decisions in China and Australia: A comparative analysis. Asian Journal of Comparative Law, 12(2), 371-400.