Four Box Method Application

Clinical Indications and the Principles of Beneficence and

Nonmaleficence
At my hospice community clinical site, a female patient was
admitted with congestive heart failure (CHF) diagnosed three years
ago. CHF is chronic and progressive with life expectancy of five years
(Osborn, Wraa, Watson, & Holleran, 2014). Complications included
anasarca, kidney failure, and liver damage. GCS score was 7 with pain
withdrawals to touch. The hospice provider reported she would pass
away in days without improvement. Needing proxy consent, morphine
could be expected to control pain and reduce shortness of breath
caused by pulmonary edema without respiratory depression. Other
opiates are used if morphine is unsuccessful. With pain control, better
nursing assessments can manage clinical decline. During assessment, I
experienced anxiety as any touch prompted contorted grimaces and
loud groans. I worried about disturbing nearby patient rooms. A
hospice value is performing care so comfort is not disrupted without
greater beneficence, such as efforts against infection.
Patient Preferences and the Principle of Respect for Autonomy
The patient was not legally competent and unlikely to improve. If
responsive, I believe any reasonable patient would request some
medications for relief from similar pain. The daughter to be proxy was
informed of benefits and risks of opiates. She said her mom hated
pain medications and was consistently hostile against consent. She
stated opiates would kill my mom, that the hospital lied, and also
the hospice staff lied. Single dose consent was given when painful
verbalizations became loud and regular. There were no known
Advanced Directives but a DNR was transferred from the hospital. A
professional proxy was under consideration to administer more
immediate care. I was sad treatment chased the pain and felt
apologetic to other families hearing my patients cries. The patient had
a right to limit pain medication at end of life, as professed through the
daughter.
Quality of Life and the Principles of Beneficence and
Nonmaleficence and Respect for Autonomy
The patient was expected to pass away in several days without
regaining consciousness. The daughter and patient appeared as
exclusively codependent with consistent hostility by daughter against
pain relief. Multiple providers agreed my patient was at end of life.
Continued life would be considered increasingly undesirable by a
reasonable patient in similar progressive pain with low mentation and
consistently downgraded clinical evaluation. CHF complication resulted

in hospice referral for the explicit mission of palliative care but without
daughters full appreciation of full abandonment of curative care.
Contextual Features and the Principles of Loyalty and Fairness
Patient and daughter had relative social isolation except for
church on Sundays. Hastening death may be perceived as akin to
suicide. Mothers income was relied upon to supplement a part-time
job for living costs. Regardless of personal finances, hospice services
maintain consistent comfort measures without hastening death to
allow for unforeseen clinical improvement. Wrap-around hospice
services apply for financial assistance. Hospice care is cheaper than
hospital curative care (Guido, 2014). The rationale for palliative care
was explained relative to available diagnostic and clinical information.
Three inpatient hospice facilities in Pasco County provide plenty of
beds.
Summary
I felt frustration for patient to receive delayed comfort readily
purposed. My belief is all hospice patients should be able to receive an
immediate evaluation for third party proxy to give blanket approval for
treatment of progressive pain. The daughter attempted to use
mothers prior antipathy against opiates without appreciating the
unchanging clinical decline, infringing on the patients ability to
experience full benefit of opiates. Delaying treatment based upon
patient preference prior to incapacitation serves no function in a
terminally progressive disease such as CHF, as brief improvement is
unlikely and suffering is substantially increased.
References

Guido, G.W. (2014). Legal & Ethical Issues in Nursing. (6th Ed.). Pearson
Education: Boston