Ethical Dilemmas In Nursing

Legal-Ethical Decision Making Dilemma

Acute Hemodialysis Nurses and Advanced Practitioners with the Long Term Acute Care Facility (LTACH), are often faced with legal-ethical situations that require informed healthcare decisions. Patients within these facilities are often severely sick, non-verbal, non-responsive, and unstable, which places decision making on the next of kin/patient's family. Invasive procedures, such as dialysis are often ordered despite the hemodynamic stability of the patient. Families and loved ones who consent the patient for hemodialysis, typically for preservation of life. Hemodialysis can produce excessive stress on the body when combined with issues such as low blood pressure, elevated temperature, cramping, increased

Though a patient’s lab values indicate a need for hemodialysis treatment, the vital signs and hemodynamic stability may not support the treatment. For example, the patient with a hemoglobin less than 6 could be considered hemodynamically unstable since a unit of blood is removed from the body immediately upon treatment initiation. Even though, blood can be given with hemodialysis should the patient receive a unit of blood prior to treatment initiation? This scenario could be compared to the surgical patient in need of surgery with an elevated PT/INR of 4. Would this surgery be performed knowing that there is an increased risk of bleeding? So, the question remains, Should treatment be initiated considering the risks of hemodynamic instability, and possibility of injury or

From the Nurse Practitioner’s standpoint, ordering/continuing the treatment in spite of a presenting low blood pressure, low hemoglobin, elevated temperature, etc. that results in injury or death could indicate negligence if injury or death is resulted. A negligent claim would be supported if the Nurse Practitioner failed to perform a comprehensive assessment. This assessment would also need to include a review of the history and physical for any contraindications prior to ordering the hemodialysis