Vol. 18 • Issue 2
• Page 70
The chasm between what can be done and what should be done is ever widening. Healthcare professionals are constantly faced with ethical dilemmas in the treatment of patients with Alzheimer's disease (AD). Appropriate decision making requires the integration of ethics.
"Jane," an occupational therapist, calls "Polly," a nurse practitioner, to the inpatient unit to observe one of Polly's patients, "Mr. S." Polly finds her patient sitting in a wheelchair with two lap buddies (soft cushions that fit between a patient and wheelchair frame to facilitate positioning). The lap buddies are taped down, making it virtually impossible for the patient to get up from the chair. Mr. S has severe AD. He sometimes wanders around the unit and has a propensity toward agitation. He is at high risk for falls. Jan and Polly previously discussed with the nursing staff the need to reduce restraint use, and they explained how taping lap buddies to the chair constitutes a restraint. The lap buddies were removed from the chair. Mr. S was allowed to ambulate under the supervision of staff members.
Ethics in Healthcare
Contemporary healthcare ethics can easily be applied to the case of Mr. S. All patients have rightful access to the best care possible. The principle of nonmaleficence requires that people act to avoid harming others. The staff members providing Mr. S's routine care used physical restraint in violation of patient rights.
Most of the staff members said they were not aware that lap buddies were a restraint. They considered the use justified because they were short staffed and they believed they were actually protecting the patient. Since the incident with Mr. S, Polly and Jane still find patients with double lap buddies, and they continue to report their findings to the nurse manager.
A Need for Education
The staff on this unit continues to require much education for all aspects of care. No formal education has been available for the staff, and the NPs have not been asked to provide any educational sessions.
When treating older adults, especially those with dementia, consider the goals of care and the ethical ramifications of the actions taken. Managing behavioral issues in patients with AD poses medical and ethical dilemmas that require an interdisciplinary approach. Mr. S was allowed to be unrestrained but supervised for ambulation because the staff realized he was at high risk for falls. But increased agitation at being restrained could have resulted in combative behavior and a subsequent fall out of his chair.
Navigating the complex terrain of caring for someone with AD requires understanding the profound implications of this disease. Decision makers must acknowledge the responsibility to make often agonizing choices. For older adults, the focal point of care should change from maximizing survival and extending life to maximizing quality of life and minimizing suffering.
NPs have the responsibility to ensure that each patient's rights are upheld and that each patient receives the best possible care. We also have a responsibility to understand the disease process and patient care laws so that we can apply them in day-to-day practice.
Jody Amazon is a gerontologic and adult nurse practitioner who is co-owner of Horizons Healthcare, an NP-owned adult and geriatric practice in Snellville, Ga. She has a doctorate in nursing science.
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