Mr. Bowen is 64 years old. He has been very healthy by report and very active working as a farmer. He had a right-sided cerebral vascular accident (CVA) 14 days ago and currently has a moderate leg weakness with a more significant arm weakness, slurred speech, and mild dysphagia (swallowing difficulty). He is predicted to be ambulatory with a cane, though prognosis of arm function returning is more guarded. It is likely he will improve speech function and swallowing ability but will require some specialization of diet to prevent aspiration.
Mr. Bowen has chosen to stop eating, stating that he does not want to live as an invalid. His family is very distressed and wants the nursing staff to force him to eat. The staff cannot imagine why he has made this choice, given that his prognosis is so good compared to others they have seen in the rehabilitation setting with much more severe deficits. He has been evaluated for depression and an antidepressant has been ordered, which he refuses to take, along with all other medications for his newly diagnosed cardiovascular disease. Mr. Bowen is oriented to time, place, and person. He has never had his competence questioned prior to taking this stand on self-determination.
Some of the staff supports his decision and others do not. Discussion with the family reveals that Mr. Bowen has frequently made deriding remarks about persons with disability, including remarks like “If I ever end up that way, just take me out behind the barn and shoot me.” The psychologist comments that Mr. Bowen is clinically depressed and that part of this depression is related to the location of his stroke, which prevents him from going back to working on the farm. He also points out that, in his strong opinion, should the depression be resolved, Mr. Bowen would most likely change his opinion.
The ethical dilemma in the case
Ethical dilemmas in healthcare refer to the situation in which a decision needs to be made to choose between two or more conflicting moral principles. Healthcare workers providing care for geriatrics often experience challenges when faced with doubt. In this case, Mr. Bowen, a mentally competent older adult patient, refuses to eat or take his medications. His refusal resulted from a series of depressions due to the stroke that left him unable to perform everyday tasks independently. The moral dilemma is that the healthcare team must decide whether to honor the patient’s wishes or continue treatment. There is ethical conflict among healthcare staff involved in Mr. Bowen’s case as some support patient decisions while others refute.
Ethical principles that apply in this case study
The ethical principles that apply in this case are autonomy, beneficence, and nonmaleficence. The principle of autonomy is the right of the patient to take control and choose options best for them. Healthcare workers provide the patient with information and education on their health and offer them options to choose from, but any attempt to coerce the patient into making decisions violates the principle of autonomy. In this case, the healthcare team has provided medications for patient illness and food to aid in quick recovery. However, Mr. Bowen has decided to refuse treatment and food against the recommendations. Even though it may not be in his best interest, he has the right to have control over his body.
The beneficence principle states that healthcare practitioners must undertake all that is in the patient’s best interest with kindness and compassion. According to Mauk (2018), caring for the elderly demands a holistic and integrative approach. In agreement with the psychologist, Mr. Bowen is depressed, and the best action possible is to resolve the depression to help the patient make the right decisions. Therefore, the nursing staff must improve Mr. Bowen’s health by doing what is best for his current condition.
The principle of nonmaleficence state the healthcare workers must not harm the patient. Healthcare professionals must consider whether their actions by omission or commission may endanger the patient. Forcing the patient to take medication may cause harm to them, just like neglecting to provide the medication. In this case study, the clinical team has identified that not harming the patient requires going against his wishes as his altered state of emotion is the reason for his lack of self-care.
Does Mr. Bowen have the right to refuse to eat and take medications when he is not in an end-of-life situation?
Mr. Bowen would have the right to maintain his autonomy in most situations and refuse to eat or take his medications. However, the patient cannot exercise autonomy because he has clinical depression, which affects his judgment and decision-making. Healthcare staff must apply therapeutical interventions to avoid any harm that the patient may get due to the medical condition. Mr. Bowen would only decline if he were in a stable, logical, and rational state of mind.
How does the team resolve the situation when his depression is so evident, and he refuses treatment?
Mr. Bowen should be referred to a clinical psychologist to treat his medical case. For example, the psychotherapist can provide cognitive behavioral therapy to counter his depression, and eventually, he will value medication and food. CBT has been found to alter thought patterns to change moods and behaviors (Holland, 2018). Mr. Bowen may be more inspired and inclined to see the benefits of self-care and appreciate the importance of taking care of himself due to behavioral therapy. The care team may proceed with further medical treatments for the client to address other comorbidities once the depression has been resolved or controlled.
How would the nurse approach and direct the care for Mr. Bowen?
As the nurse, I would first gauge the risks of the medical situation. Mr. Bowen cannot be obliged to take drugs or eat because he is not actively trying to hurt himself. I would work with the psychiatrist to encourage the client to finish Cognitive Behavioral Therapy (CBT) and seek treatment. Education is also essential because it will help the client understand how important it is to take their medications and engage in care.
What elements (provisions) from the code of ethics come to mind preparing to care for Mr. Bowen?
There are a few provisions from the code of ethics in Mr. Bowen’s case that stand out and extend to the patient’s care. For Mr. Bowen’s case, provisions 1, 4, and 8 apply. Provision 1 states that “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person” (Gaines, 2020, para 17). Since each client is distinctive, as in Mr. Bowen’s case, each scenario requires special treatment and consideration. Provision 4 states that “The nurse has authority, accountability, and responsibility for nursing practice; makes decision; and takes action consistent with the obligation to provide optimal care” (Gaines, 2020, para. 17). Nursing is a complex field, and a nurse must do everything possible to provide the best possible care. Provision 8 states that “The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities” (Gaines, 2020, para. 17). The nurse in this situation must work with other healthcare team members of different specialties to provide the best possible care to Mr. Bowen.
Can a theory related to the concept of grief be applied to the care of Mr. Bowen?
For this case, the Kubler-Ross Model of grieving can be applied. The model describes five stages of grieving, including denial, anger, bargaining, depression, and acceptance referred to as DABDA (Gregory, 2020). Mr. Bowen has reached the fourth stage, known as the depression stage of grief. The patient expresses hopelessness following cerebrovascular accident complications, including limb weakness, slurred speech, and mild dysphagia. This situation depresses him to the point he demonstrated fear of disability and said, “If I ever end up that way, just take me out behind the barn and shoot me”(Mauk, 2018, p. 663). Mr. Bowen tends to withdraw in those moments as his grief grows.
Gaines, K. (2020). What is the nursing code of ethics? Nurse.org. Web.
Gregory, C. (2020). The five stages of grief: An examination of the Kubler-Ross Model. Psycom.net. Web.
Holland, K. (2018). Cognitive behavioral therapy for depression. Healthline. Web.
Mauk, K. L. (2018). Gerontological nursing competencies for care (4th ed.). Jones & Bartlett Learning.