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Mom deserves the best

Thursday February 20, 2014
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Hypothetical case:

Chibesa and Innocent are two sons from Zambia now working in the U.S. Neither is married, and they are living frugally in an efficiency apartment trying to earn enough money to bring more of their family to the U.S. For weeks they have been celebrating the long-awaited arrival of their mother, Kakande, who is coming to visit. Their father died shortly after Innocent was born and they revere Kakande. When they arrive at the airport to greet their mother, they grow anxious when she fails to appear. After what seems like an eternity, they learn that an ambulance greeted her plane and Kakande was taken to a large medical center. There physicians diagnosed a stroke related to a severe subarachnoid bleed. Kakande is stabilized in the ED and admitted to the neurosurgical ICU.

After initial assessments, it quickly becomes apparent to the nurses and physicians caring for Kakande that recovery is highly improbable because of the extensive neurological damage. They recommend to the family that she be transitioned to purely palliative goals and transferred to hospice. Neither of the brothers, and certainly not Kakande, have health insurance or funds to pay for her hospitalization or hospice care. Both brothers are undocumented workers. They refuse to believe that in a great country like the U.S. something can’t be done to “save” their mother. Chibesa tells the nurses, “Mother spent her whole life taking care of others. Now you must take care of her. She deserves the best.” They refuse to believe that recovery is no longer a realistic goal and grow suspicious of the healthcare team.

What the Code of Ethics says:

Provision 3 of the ANA Code of Ethics for Nurses states, “The nurse promotes, advocates for and strives to protect the health, safety and rights of the patient.” It seems everyone has a different idea about how best to advocate for Kakande and her family. Possibly complicating the response of some are their differing ideas about what rights poor, non-U.S. citizens have to U.S. healthcare, especially since so many hard working citizens still lack access to high-quality, affordable, safe care. Provision 1 of the ANA Code of Ethics for Nurses states, “The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes or the nature of health problems.” Taken at face value, nurses are obligated to respect Kakande and her sons and to create a trusting partnership that will result in the best outcome for all. Let’s consider two possible nursing responses to this challenge.

Scenario 1: Nurses choose to be task- versus person-focused.

Each shift nurse looks at the “work” that needs to be done for the patient. A “good” nurse is one who gets that work done and is busy, not one who makes the critical difference for patients and families in terms of future options and goals. Strikingly absent from consideration is what this means in terms of the big picture, who this person is, what the long-term goals are. Given the fragmentation of care in today’s workplace environments, it is not infrequent that treatment of complications with a goal of stabilizing the patient continues indefinitely with no one coordinating care — until a length-of-stay committee gets involved and decides that action is needed. Nurses practicing this way and their physician colleagues fail to meet the standards of both the first and third provisions in our code.

Scenario 2: Nurses prioritize their advocacy responsibilities and establishing a trusting relationship with the family.

In order to advocate effectively for Kakande, nurses must help her sons understand and accept her medical condition. This hopefully will contribute to the sons believing that the doctors and nurses are as committed to her welfare as they are. If the staff can educate the sons on the advantages of hospice and try to find a way to secure these services, Kakande then will be in a better place. Nurses troubled by the failure to breach this impasse might avail themselves of the services of an institutional ethics committee or consultant. Certainly there should be trusted individuals within the medical center who can be consulted for help. Nothing less than Kakande’s family’s memories of her days in her host country and their ability to trust the U.S. is at stake. Everyday nurses create the memories that families of the seriously ill and dying live with forever.

Visit CE.Nurse.com/Course/ for CE modules on stroke care.

To see what else is trending in stroke, visit www.Nurse.com/Stroke.


Carol Taylor, RN, PhD, is a professor of nursing at Georgetown University School of Nursing and Health Studies, and senior scholar at the Kennedy Institiute of Ethics. Post a comment below or email specialty@nurse.com.