N362 Ethics

Myra, Christina, Corey, Kristie

Ethical Dilemma

A woman in a MVA is in a coma and likely will not survive

She has 2 children that are hers biologically, that she has raised with her life partner

Patient does not have a living will or legal plan for care

The state does not recognize gay marriage or civil unions

The parents are recognized by this state as the legal guardians of the patient

Their spiritual beliefs condemn homosexuality and have forbidden the partner from seeing
their daughter and the children

They threaten placing a TRO on the partner if she does not abide by their wishes

They have told you if you let "that woman near our daughter, then you and the hospital
will have a lawsuit on your hands.

Ethical Decision-making Model

According to Cherry & Jacob (2011)

p.195-196 & 202-203

A competent nurse is an ethically sensitive nurse who can deal with the human dimensions of care
that include a search for what is good and right...Nurses must first attempt to understand not just
what they are to do for their patients, but who their patients are...Nurses must make a deliberate
effort to recognize their own value and learn to consider and respect the values of others.
1.
2.
3.
4.

Identify the ethical issues, the nature & complexity of the problem
Identify and analyze available alternatives for action while applying the ANA code of ethics &
the ethical principles required for each alternative
Make a decision on one alternative based on the meshing of ethical theory and identified
ethical principles for each alternative
Justify the selection made with reasons for the action, ethical basis for those reasons, and the
understanding of any shortcomings of the justification

Ethical Overview

Autonomy of the couple has been infringed upon by the law. Patient and partner have
experienced loss of their autonomy with the current situation

Is there greater psychological benefit (theory of utilitarianism) to the children should the
partner retain custody? What would be in the best interest of the children? What would
maintain continuity of care? Which decision would best uphold the principle of
nonmaleficence concerning the children?

What would the patient choose should she be able to? Not respecting daughters autonomy.
Daughter has made her choice as evidenced by years spent with her partner and children.
Denying her time with the partner in the last moments of her life is imposing on/dismissive of
that choice.

Whose wishes are the hospital legally bound to follow? Violation of beneficence as a lawsuit
would not improve the situation. The hospital & staff have a moral duty to the patient,
advocating for the patient and her wishes would uphold the principle of deontology.

Cherry, B. & Jacob, S. (2011). Contemporary nursing: Issues, Trends and Management (5th ed).
St. Louis: Elsevier.

Allow Visitation

According to Hawaiis Modified Uniform Health Care Decision Act of 1999, the life partner may
be elected as a medical surrogate and fight for guardianship. Also, the parents are required to
act with respect to the patients wishes, including her life choice, and may be relieved of
guardianship if they do otherwise (UH 2014).

According to President Obamas 2010 Memorandum, the hospital cannot deny visitation to the
partner or children based on sexual orientation (OPS 2010)

Guardianship and medical surrogacy laws do not specify the power to deny visitation, but
rather involves decision-making to prevent harm to the patient.

The Code of Ethics Provision 1 states nurses must have respect for human dignity and that
requires recognition of patient rights, specifically the right to self-determination (ANA 2014)

Deny Visitation

The patient and life partner did not have an advance directive, living will, or
power of attorney outlining their preferences in care; including the preference of
the patient to have the life partner as a medical surrogate or guardian.

According to the Uniform Parentage Act the partner is not recognized as a mother.
SECTION 201. ESTABLISHMENT OF PARENT-CHILD RELATIONSHIP.
(a) The mother-child relationship is established between a woman and a child by: (1) the womans having given birth
to the child [except as otherwise provided in[Article] 8]; (2) an adjudication of the womans maternity; [or] (3)
adoption of the child by the woman [or (4) an adjudication confirming the woman as a parent of a child born to a
gestational mother if the agreement was validated under [Article] 8 or is enforceable under other law].

Medical surrogates and state-appointed guardians are granted the power to make
medical decisions for the incapacitated patient.

Hospitals must respect the decisions made by the patient, by extension the
guardian, regarding medical care.

Course of Action
A.

Consult with immediate supervisors, ethics committee, and legal department

B.

Allow visitation of the partner and parents at differing times to avoid conflict.

C.

Inform the parents regarding the Presidential Memorandum-Hospital Visitation (2010) and the
hospital & staffs obligation to allow visitors indiscriminately.

D.

Inform partner of her rights as an interested person to apply/fight for position of medical
surrogate of the patient according to the laws of her state.

Justification of Actions

These actions are in accordance with the laws governing the situation, restores patient
autonomy by acknowledging and honoring the daughters lifestyle choices, and provides an
alternative to potential conflict on hospital grounds.

The decision upholds ANA code of ethics provisions 1.1 Respect for Human Dignity & 1.4 Right
to Self-Determination.

A limitation of the decision is that the patients parents wishes are not satisfied.

It is anticipated that the parents will object the hospitals decision, and the nurse involved
will likely be the first to hear the objection as the nurse is the primary point of contact
regarding health care in the hospital. However, the nurse will follow the law and be supported
by the hospital and its officials as she navigated the proper channels by: notifying superiors,
participating in meetings regarding the situation, consulting the legal department and
notifying ethics committee.

ANA Code of Ethics

ANA Position Statement - Approved 5/28/08
The public has a right to expect registered nurses to demonstrate professional competence throughout their
careers. ANA believes the registered nurse is individually responsible and accountable for maintaining professional
competence. The ANA further believes that it is the nursing professions responsibility to shape and guide any
process for assuring nurse competence. Regulatory agencies define minimal standards for regulation of practice to
protect the public. The employer is responsible and accountable to provide an environment conducive to competent
practice. Assurance of competence is the shared responsibility of the profession, individual nurses, professional
organizations, credentialing and certification entities, regulatory agencies, employers, and other key
stakeholders.
The nurse should not act individually. Care must be taken to ensure privacy and confidentiality, while also notifying
superiors and other healthcare team members who are actively involved in the care for the patient. Ultimately, the
ethics committee will be involved and a decision will be made from there regarding an absolute ethical solution.

American Nurses Association (2014). Code of ethics for nurses with interpretive statements. (n.d.).
Retrieved November 5, 2014 from http://www.nursingworld.org/provision-1
Cherry, B. & Jacob, S. (2011). Contemporary nursing: Issues, Trends and Management (5th ed).
St. Louis: Elsevier.
National Conference of State Legislatures (2014). Civil Unions & Domestic Partnership Statutes. Retireved
on November 3, 2014 from http://www.ncsl.org/research/human-services/civil-unions-and-domesticpartnership-statutes.aspx
Paccione-Dyszlewski, M. (2008). Children of same gender parents: What is known. The Brown University
Child and Adolescent Behavior Letter, 24, 1,5-6.
State of hawaii, Department of Health (2014). About Civil Unions. Retrieved on November 2, 2014 from
http://health.hawaii.gov/vitalrecords/about-civil-unions/
Uniform Law Commission (2014). Parentage Act Summary. Retrieved from http://www.uniformlaws.
org/shared/docs/parentage/upa_final_2002.pdf
University of Hawaii Elder Law Program (2014). Health care decision making. Retrieved on November 1,
2014 from http://www.hawaii.edu/uhelp/healthcare.htm
Office of Press Secretary, The White House (2010). Presidential memorandum - hospital visitation.
Retrieved November 1, 2014 from http://www.whitehouse.gov/the-press-office/presidentialmemorandum-hospital-visitation