Ethical Dilemma Case 2

Case 2 is about 56-year-old Tom who has been diagnosed with irreversible brain damage.
The debate in this dilemma is whether or not to keep Tom alive via feeding tube. The main
problem is the niece remembers and believes that her uncle did not want to be kept alive as a
vegetable. She also believes that Tom has an advanced directive that is of private records and
his wife serves as his durable power of attorney. The wife and children want to do whatever it
takes to keep her uncle alive and the physician is a personal friend who is reluctant to discuss
anything with the niece. In this case, autonomy is the nursing ethical principle that will be
discussed. According to the American Nurses Association, autonomy is agreement to respect
anothers right to self-determine a course of action; support of independent decision making
(American Nurses Association, 2011). In this case, do we go with what the power of attorney
decides, or do we dispute the challenge of finding out what the advance directive states, even if it
is under private records?
Evidence
Although the niece is adamant about her uncles wishes, the downfall to this argument is
that she does not have any means of written, tangible evidence that her uncle wishes to not
survive in a vegetative state. Because an advance directive is considered a patient identifiable
document under the HIPPA rules, it will be very hard to obtain a record of it without consent
from the uncle. Moreover, the wife is after all the durable power of attorney. Due to the uncles
vegetative state, the wife will be the sole decision maker. This case would not only involve the
state laws on whether or not to make previously made oral declarations as clear and convincing
evidence, in the case of a patient not being able to communicate for him/herself, but it also
requires the violation of HIPPA law. The nurse who is faced in this dilemma would have to

determine to either act in fidelity (doing what is right and what is expected of you) or deontology
(complying with organizational policies to not reveal personal records). However, as a nurse, I
must also consider the uncles right to autonomy. This is by far, the most important principle of
this dilemma, that as a human being, every person deserves the right to decide for what is best
for him or her, not what is best for everyone else.
Research
Perhaps the most prevalent case of autonomy in US history is the Terri Schiavo case. On
February 25, 1990, 26 year old, Terri Schiavo collapsed in the hall of her apartment due to severe
hypoxia. Terri had no living will, nor a durable power of attorney. Michael Schiavo, Terris
husband, was appointed legal guardian without objection from her parents, the Schindlers. Terri
was placed on a PEG (percutaneous endoscopic gastrostomy) tube for feedings to keep her alive.
By late 1990, Mrs. Schiavo was determined to be in a persistent vegetative state (Perry,
Churchill, & Kirshner, 2005). Numerous tests have been done to further prove that Terri
Schiavos condition will not get any better. Neurological surgeons as well as a variety of
neurologic associations have confirmed that Mrs. Schiavos survival rate would be slim to none.
The tests showed that of the patients in the persistent vegetative state for more than 3 months
after nontraumatic injuries, the probability of moderate disability or good recovery was 1%, but
for patients still in the persistent vegetative state at 6 months, this probability was 0%. No
patient, even those with traumatic brain injury, has been reported to recover after a full year of
being in the persistent vegetative state (Perry, Churchill, & Kirshner, 2005). The debate went
on for years: Mr. Schiavo insisted that his wife would not want to live in a persistent vegetative
state, while Mr. and Mrs. Schindler insisted that their daughter be kept alive through artificial
nutrition and hydration. In the end, after over a decade of court battles, and pulling out Mrs.

Schiavos PEG tube a few times, the courts analysis then shifted to the issue of exercising Mrs.
Schiavos autonomy rights, independently of state, family, or public opinion. After hearing from
all of the witnesses and observing their cross examinations, Judge Greer determined that
testimony from the 3 witnesses recalling Mrs. Schiavos prior oral declarations that she would
not want to live like that satisfied the clear-and-convincing evidence standard (Perry,
Churchill, & Kirshner, 2005).
Synopsis
As the nurse, the three alternatives are: 1) refer the niece to a social worker or
recommend bringing the issue up to an attorney, stating her belief that the uncle had oral wishes
to not continue with assisted living (may need a couple of other witnesses and evidences to back
this statement up), 2) speak with the wife and reevaluate the reason to keeping Tom alive. Is
this decision the best for her and their children or is it best for Tom? Ask the wife, What
would you do if you were in Toms situation? Would you want to be granted what YOU think
is best for YOU? and 3) speak to the physician. Because he is a personal friend of the family,
he still must be reminded of the ethical principle of deontology: what are the intentions behind
the decisions rather than the outcomes that result? (American Nurses Association, 2011). I
would also remind the physician failure to respect a valid advanced directive can result in a
claim for battery being made against the clinician (as cited in British Journal of Nursing, 2013).
These are the limitations to what I will do as a nurse. After all, in the Code of Ethics for Nurses,
the right for self-determination and the primary commitment is to the patients interest are
some of the guidelines that guide nurses to principles of good ethical decision-making (American
Nurses Association, 2001).

References
American Nurses Association. (2001). Code of Ethics for Nurses With Interpretive Statements.
Retrieved from
http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNur
ses/Code-of-Ethics.pdf.
American Nurses Association. (2011). Short Definitions of Ethical Principles and Theories
Familiar words, what do they mean? Retrieved from
http://www.nursingworld.org/MainMenuCategories/EthicsStandards/Resources/EthicsDefinitions.pdf.
Brown, M., & Vaughan, C. (2013). Care at the end of life: how policy and the law support
practice. British Journal Of Nursing, 22(10), 580-583.
Perry, J. E., Churchill, L. R., & Kirshner, H. S. (2005). The Terri Schiavo Case: Legal, Ethical,
and Medical Perspectives. Annals Of Internal Medicine, 143(10), 744-748.