DESCRIPTION OF THE CASE: Ralph is a recent widower in his midi-60, who was diagnosed with metastasized colon cancer. He is a home health agency patient, and his primary caregivers are his two daughters. Ralph is unaware of the severity of his condition and wanted to know what his state of health and prognosis was. The nurse evaded his questions initially, and his daughters did not want to tell him that his cancer was terminal. The nurse’s position was not to continue providing care for Ralph, as she would be deceiving him by not telling him the truth. When the nurse consulted with Ralph’s physician, he agreed with the family’s decision, as he felt that they needed time to accept their mother’s recent death and Ralph’s impending death. The doctor ordered the nurse not to oppose him and not to disclose any further information to Ralph.
THE PRINCIPLE: TRUTH-TELLING & DECEPTION (Should be “FIDELITY”). In most cases, a rational person has a right to truthful information and avoidance of deception, which will allow him to decide which course of treatment to follow. A patient’s right to decide includes the right to know the truth, not be brainwashed, and not be lied to or deceived by having information withheld that is relevant to his own health. There is a moral standard that condemns lies, deception, and withholding of relevant information. To tell Ralph that “everything was all right and he would be up and around the house in no time at all” is deceptive, as his condition is terminal, although he does not yet realize it. The ANA Standards of Clinical Nursing Practice states that clients should be educated about their illness, which is subsumed within Standards of Care (p3).
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In Standard V-Ethics (p15), measurement criteria #3 states that “the nurse acts as a client advocate” and #5 states the “nurse delivers care in a manner that preserves and protects client autonomy, dignity and rights”. The “Patient’s Bill of Rights” cites some cases that justify overriding a patient’s autonomy rights, however. Considering that Ralph has recently lost his wife and that he is still working through his own grief may present a morally compelling reason for withholding information and considering Ralph’s best interests. His emotional status may need to be assessed to assure that he would not be suicidal or lose interest in the remaining quality of his life, also to determine his ability to cope, before telling him the truth, and prevention of harm overrides autonomy rights.
If I were involved in Ralph’s care as his nurse, I would have great difficulty with deceiving or withhold information from him, but considering the impact of his wife’s death, combined with the knowledge of his own inevitable demise, I would take into consideration his emotional state first, as his advocate, and work with his daughters in establishing a set time to inform him of his condition, assuming that he has at least a few months to live. This will hopefully allow the daughters more time to accept their mother’s death and their father’s condition. We would have to agree not to lie to Ralph outright, but to encourage him to participate in his own care as much as possible, as well as perform his own ADL’s as tolerated. By so doing, Ralph would be able to maintain his dignity, his daughters would be placated, and a lawsuit hopefully avoided.
- American Nurses Assoc (1991). Standards of clinical nursing practice. American
- Nurses Publishing. Washington, DC.
- Bandman, E. & Bandman, B. (1995). Nursing ethics through the life span. Appleton & Lange. Norwalk, CT.