Arthur and Nancy Johnson were happily married for 45 years before Nancy developed Alzheimer's Disease. Nancy has previously stated that she never wants to go into a nursing home and in moments of insight pleads with her husband to look after her at home. Arthur wants to honour Nancy's wishes but finds it difficult to care for her alone because she has dementia and wanders; she is also doubly incontinent with an unfortunate habit of daubing faeces on the walls. To be able to get a few hours to sleep at night Arthur sometimes ties Nancy into the bed. He also needs to do the shopping and banking and loves nothing more than the occasional game of bowls and to spend an hour with friends at the bowling club. Unfortunately, Nancy's behaviour is not appropriate for the bowling club but if Arthur leaves her alone in the house she is incontinent and makes a terrible mess. Arthur's only solution to prevent the wandering and to save a mess from the incontinence is to tie Nancy to the toilet while he goes out.' (pp. 191-192)
1.What ethical issues do you think are important in this case?
2.What ethical principles do you think are relevant in considering this case?Briefly explain what each of the principles is. What about the case leads you to choose these principles?
3.Imagine that Nancy has been admitted to hospital and you are a registered nurse working in the ward. During a conversation, Arthur discloses the details of his approach to caring for Nancy at home. What standards of practice, ethical principles, or legal principles are relevant to this case? Briefly explain what each of these principles is. What about the case leads you to choose these standards or principles?
4.Describe what you would do and the outcome(s) you hope would be the result of your actions?
The paper discuses about Arthur and Nancy, who had been happily married for 45 years before Nancy developed Alzheimer disease. Nancy has got habits of wandering and is doubly incontinent and has got the habit of daubing faeces on the wall. Nancy had to be tied in to the bed as Arthur had to go out for doing shopping or banking or to spend an hour with the friends at the bowling club. Unfortunately Nancy cannot be taken to the Bowling club due to her inappropriate health condition and if she is left alone in the house, she is incontinent and makes a terrible mess throughout the house. Thus, Arthur often ties Nancy to the toilet to prevent the wandering and incontinence. This essay will discuss about the different ethical issue that has been withheld in this case study. The ethical principles that are relevant to the case, the ethical principle related to this case and rationale behind choosing the following ethical issue. Furthermore, the paper had also provided information about the nursing standards of practice, relevant to this case, the rationale behind choosing the principals. Furthermore, the essay would also provide information about the recommendations that are required in part of a registered nurse.
Ethical can be defined as sets of values or morals that contribute to the betterment of one’s life. The main components of ethics that should be present in a human being are- honesty, trustworthiness, respect , responsibility and being a person of integrity (Nursing and Midwifery Board of Australia., 2018). Is the morality and the ethical beliefs of a person that guides whether one person treats there other person with integrity and dignity. Some of the ethical underpinnings that a person should follow while providing care to someone are beneficence, truthfulness and confidentiality, autonomy, informed consent, beneficence, non-maleficence and justice.
The ethical issue that can be found in this case is that Arthur put restraints on Nancy due to her habit of wandering around and incontinence. Nancy is also not appropriate for being accompanied in a bowling club. Furthermore, Arthur also needs few hours of sleep and the freeing Nancy might disturb his sleep. Use of restraints on a dementia patient can be an ethical dilemma.
Looking at the case scenario, one can definitely understand the commitment that Arthur has made to his wife, with whom he had spent almost the whole of his lifetime. Despite of the incontinent problem of Nancy, Arthur never thought to transfer Nancy into any sort of rehabilitation centres Nancy never wanted to visit a nursing home and wants to stay with her husband. In spite of all these it can be seen that Nancy had to be tied on her bed or had to be tied in a toilet sometimes under some circumstances. Whatever, might be the reason, providing restraints to person displays direct breach of the autonomy of person, which is one of the ethical parameters while upholding the interest of a human being. Hence the chosen ethical principle relevant to this case is “autonomy”. Autonomy refers to the right of every individual’s right of self-determination, independence and freedom to make their own choices. In the concept of health care, the concept of autonomy is mainly concerned with the ethical obligation of a practitioners to provide respect to the rights of their clients for making decisions about their own health. Again as per the Universal declaration of the human rights, everyone has got the right to experience freedom and autonomy. In this context, restraining Nancy has led to the breaching of the autonomy of the patient. Hence, the ethical principle of autonomy is appropriate in this case.
Various criticisms are prevalent retarding the principle of respect for the autonomy. The idea that patient should be given with the choices for making voluntary choices about the health care interventions, discouraging the so called paternalistic attitude of the conventional nurses and the other health care professionals has turned to be good for some of the patients (Parahoo, 2014). The concept that patients should be allowed to make informed decisions and also encouraged attention to the patients’ understanding about the different health care interventions and assist the development of the autonomy enhancing patient decision aids.
Now, the ethical dilemma that can be used in this context is that Nancy suffers from a degenerative disease and leaving her free might bring about harm for Nancy itself. Furthermore, it has to be noted that Arthur has also turned old and must be suffering from some frailty due to his old age and hence it can be difficult for Arthur to look after Nancy every now and then. He also needs some amount of peaceful sleep at night and letting Nancy free at night can cause sleep disturbances that can become the precursors of several diseases at old age. Human rights are common on to all the people irrespective of the age, race of religion and are divided in to rights to live, safety, freedom, equality and dignity (Gastmans, 2013). From an ethical perspective it is important to protect certain rights of the human beings. Due to this reason ethical dilemmas are common in managing patient with neurodegenerative disorders (Yamamoto, Mizuno & Aota, 2012). It is the duty of the person taking care of the patient to address the physiological and the psychological needs of the patients, hence putting restraints on a patient with dementia might affect the psychological wellbeing of Nancy, on the other hand putting restraints on Nancy might serve to be beneficial for Nancy itself as that would probably help to prevent harm due to falls and injury.
Ethical issues from the perspective of the registered nurse
Restraints in dementia like conditions are common in clinical practice. Although that can inflict harm and largely contradicts the rights of freedom, respect and autonomy of the patient (Sandman, Granger, Ekman & Munthe, 2012). The health care professionals, especially the nurses taking care of the dementia patients suffer from ethical dilemma using restraints on the dementia patients (Zahedi et al., 2013). From the perspective of the nurse, the breaching of the ethical issue that has occurred in this case is non-maleficence. The term non-maleficence tells one to cause no harm to the patient intentionally or unintentionally for instance abandoning the person in care. The case study reveals that Arthur used to lock up Nancy in the bathroom, whenever he had to go somewhere. It should be noted that although Arthur needs some time to be spend alone or to do the daily shopping, Nancy should not be left alone in a bathroom as the patient might suffer from slips and the falls, turning situations more difficult for Arthur. In fact special homecare supports are there for providing care to Nancy during the absence of Arthur. A proper home based support services can be provided to help out Arthur to deal with the coping stresses ( Boekhorst et al., 2013). Ethical considerations for a registered nurse are important as they understand the legal requirements of the health care practices necessary for the protecting the patient from unjustifiable restraints (Zahedi et al., 2013). Restraints are always provided as the last resorts and practitioners should always find for the alternative interventions for promoting safety and respect to the dignity of the patient (Gastmans, 2013).
Other ethical principles that is relevant to this case is autonomy and beneficence. The definition of the autonomy has already been mentioned in the above section. Autonomy is right of the patient to participate in one’s own decision making process. It also refers to the involvement of the patient in the care regimen (Entwistle et al., 2013). Personal autonomy is widely valued ad and the recognition of the vulnerability in context of the health care leads to inclusion of the autonomy as an important concern in the biomedical ethics. Beauchamp (2016), have opined that the relational concept of the autonomy is to understand both the positive and the negative consequences of the autonomy. Some of them suggest that in most of the cases the nurses practice autonomy not because of the treatment preferences of the patient, but also due to the self-evaluation, self-identity and capabilities for the autonomy (Lindberg et al., 2013). Beneficence is an ethical principle that addresses the concept that the action of a nurse or a caregiver should always be to promote good to the patient. in relation to the therapist- client relationship professionals should always work in favour of the interest of the client that included all the aspects of the relationship and the preclude activities that causes conflict of interest on part of the practitioner (G?mez-Gallego, G?mez-Amor & G?mez-Garc?a, 2012). Beneficence should not be confused with the closely related principle non-maleficence that states that patient should not be harmed (Lusk & Fater, 2013). These two ethical principles are important in nursing as it is these principles that is the foundation of modern nursing. Nursing doesn’t just mean medial competence but also involves adhering to the professional principles and standards. Nursing individuals are constrained by the principles of the professionalism in upholding the wellbeing of the patients (Kim et al., 2013). Beneficence in nursing is important as plays a key role in the outcome of the patient care. It emphasis on compassionate care and advocates a continuous striving of the nursing professional towards excellence. Each and every nurse and the health professionals should have the morality (Kim et al., 2013) Hence, putting Nancy on restraints might be a breaching of the beneficence as restraints sacrifices the autonomy of the patient. It is the important for the nurse to uphold the basic rights of humans – that is autonomy (Lindberg et al., 2013).
It should be mentioned that clients are always in the weak and the vulnerable position due to the needs that cannot be ameliorated by the patient on his/ her own. Hence legislation and regulations have been made to protect the demands of the vulnerable patient.
Restraining patients might present the health care professional under specific lawsuit, but if the restraints are offered correctly; by using the reasonable force or with the trained individuals (Goulet, Larue & Dumais, 2017). Under such situations that patients are normally monitored for a long period of time. A nurse should be acquainted as of when to apply restraints on the patient. In fact not protecting the safety of the patient by not applying the restraint can bring potential liability for the health care professionals.
In this case scenario, Arthur keeps Nancy in restraints whenever he goes outside. As per the section 69 of the Mental health act, a person should not be kept in seclusion or applied any kind of mechanical means of bodily restraints for the patients unless such seclusion or restraint is determined as per the rules of the section 69, that is for the purpose of the treatment or to avoid the patient from injuring herself (Kontio et al., 2013). In this case if Arthur is found to be applying restraints on his wife, when the wife has got the functional capability, then he might be brought under legal lawsuits (Mental health act, 2001). One of the professional standards of the nursing practice is that a nurse is responsible or accountable to provide care within the scope of practice, hence a nurse should be aware of how application of restraints might lead to breaching of the professional standards. As per the mental health act, restraints should be considered as the last resort, only if the other option turn to be useless. Prosecutions against any person who contravenes the section 69 should be brought under the mental health commission (Mental health act, 2001). The Act had also opined the mental health commission shall make rules in relation to the concept of seclusion. Seclusion can be defined as leaving a person in any room alone at any time of the day (Kontio et al., 2013). A registered nurse understands the penalty of leaving a vulnerable patient locked in a room. It has to be remembered that seclusion should be offered by writing by a registered medical professional following the consultation with the consultant physician, accountable to the type of care provided to the patient or the duty of the consultant therapist (Goulet, Larue & Dumais, 2017). A seclusion order shall remain in force, for a maximum of 8 hours from the time of restraint (Kontio et al., 2013). A family member should never put restraints as the nurses cannot delegate legal responsibility to the family members. It was necessary that before applying restraints in patients. They have to consult with the physicians. It is necessary to recognise the rights of the adults for making the decisions regarding the regarding the personal care and the treatment. While applying the restraints it is necessary to document the specific behaviour and patterns, the types of the restraints used, the consent of the client, the exact timing in which the type of the restraints applied (M?hler & Meyer, 2014).
Action and the outcomes
The main factor in the case that led the registered nurse to choose these ethical and legal principles are- Leaving Nancy locked up in a bathroom that can cause probably harm the patient. Hence as a registered nurse, I would refer Arthur to some organisation giving home support that will look after Nancy and would also assist Arthur to manage with the daily chores of life. Arthur should also be informed about any community groups providing financial aid to the elderly people having financial constraints. It is necessary that Arthur should be educated about the adverse effects that can be caused on secluding a dementia patient. Falls, confusion, disorientation and delirium is common in patients with Alzheimer’s (Stern, 2012). People with Alzheimer’s normally have difficulty with the memory and the medications given to them can make them drowsy, dizzy and can lower their blood pressure, thus increasing the risk of falling (Kr?pelin et al., 2013). Arthur should also be educated about the human rights and litigation that can be brought against any person or a health care professional for secluding and putting restraints on an elderly person.
The relative outcome for tis recommendations can be expected as probably Arthur would take the help of home support who would be present for 24 hours to look after Nancy and hence no restraints are required to stop the wandering of Nancy.
In conclusion it can be said that health care professionals are obligated to cat in a particular manner. They have a duty of care that extends to the patients, colleagues and the society as a whole. Any professional who is not aware of these factors are at risk for violating the fiduciary principle of protecting and honouring the patient. This paper has discussed about how autonomy has been breached in this scenario by the application of the restraints on Nancy, where Arthur could have appointed a home support for Nancy. The paper has discussed about the probable litigations that can be brought for breaching the autonomy of the patient (Lindberg et al., 2013).
Beauchamp, T. L. (2016). Principlism in Bioethics. In Bioethical Decision Making and Argumentation (pp. 1-16). Springer, Cham.
Entwistle, V. A., Carter, S. M., Cribb, A., & McCaffery, K. (2010). Supporting patient autonomy: the importance of clinician-patient relationships. Journal of general internal medicine, 25(7), 741-5.
Gastmans, C. (2013). Dignity-enhancing nursing care: a foundational ethical framework. Nursing ethics, 20(2), 142-149.
G?mez-Gallego, M., G?mez-Amor, J., & G?mez-Garc?a, J. (2012). Determinants of quality of life in Alzheimer's disease: perspective of patients, informal caregivers, and professional caregivers. International psychogeriatrics, 24(11), 1805-1815.
Goulet, M. H., Larue, C., & Dumais, A. (2017). Evaluation of seclusion and restraint reduction programs in mental health: A systematic review. Aggression and violent behavior, 34, 139-146.
Kim, Y. S., Kang, S. W., & Ahn, J. A. (2013). Moral sensitivity relating to the application of the code of ethics. Nursing ethics, 20(4), 470-478.
Kontio, R., Joffe, G., Putkonen, H., Kuosmanen, L., Hane, K., Holi, M., & V?lim?ki, M. (2012). Seclusion and restraint in psychiatry: patients' experiences and practical suggestions on how to improve practices and use alternatives. Perspectives in psychiatric care, 48(1), 16-24.
Kr?pelin, T. F., Neyens, J. C., Halfens, R. J., Kempen, G. I., & Hamers, J. P. (2013). Fall determinants in older long-term care residents with dementia: a systematic review. International psychogeriatrics, 25(4), 549-563.
Lindberg, C., Fagerstr?m, C., Sivberg, B., & Willman, A. (2014). Concept analysis: patient autonomy in a caring context. Journal of advanced nursing, 70(10), 2208-2221.
Lusk, J. M., & Fater, K. (2013, April). A concept analysis of patient?centered care. In Nursing Forum (Vol. 48, No. 2, pp. 89-98).
Mental health act (2001).Victorian Current Acts. .Acces date: 2.11.2018. Retrieved from www.legislation.vic.gov.au
M?hler, R., & Meyer, G. (2014). Attitudes of nurses towards the use of physical restraints in geriatric care: a systematic review of qualitative and quantitative studies. International journal of nursing studies, 51(2), 274-288.
Nursing and Midwifery Board of Australia., (2018).New codes of ethics in effect for nurses and midwives.Access date: 2.11.2018. Retrieved from:
Parahoo, K. (2014). Nursing research: principles, process and issues. Macmillan International Higher Education.
Sandman, L., Granger, B. B., Ekman, I., & Munthe, C. (2012). Adherence, shared decision-making and patient autonomy. Medicine, Health Care and Philosophy, 15(2), 115-127.DOI
Stern, Y. (2012). Cognitive reserve in ageing and Alzheimer's disease. The Lancet Neurology, 11(11), 1006-1012.
Te Boekhorst, S., Depla, M. F. I. A., Francke, A. L., Twisk, J. W. R., Zwijsen, S. A., & Hertogh, C. M. P. M. (2013). Quality of life of nursing?home residents with dementia subject to surveillance technology versus physical restraints: an explorative study. International journal of geriatric psychiatry, 28(4), 356-363.
Yamamoto, M., Mizuno, S., & Aota, M. (2012). Ethical dilemma factor in regarding physical restraints to elderly of female nurses with the living together experience. International Journal of Clinical Medicine, 3(05), 328.
Zahedi, F., Sanjari, M., Aala, M., Peymani, M., Aramesh, K., Parsapour, A., Maddah, S. B., Cheraghi, M., Mirzabeigi, G., Larijani, B., … Dastgerdi, M. V. (2013). The code of ethics for nurses. Iranian journal of public health, 42(Supple1), 1-8.