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Ethical dilemmas in healthcare are inevitable, and it is crucial to use a particular decision-making algorithm to ensure the beneficence of the moral choice. According to Grote & Berens (2020), implementing machine learning algorithms in healthcare contributes to diagnostic accuracy but often lacks normative justification for the medical assessment made. Therefore, the “Four Topics Approach” seems more reliable for ethical decision making. The case analyzed in this paper is about a 60 years old female who was admitted to hospital with stage four of Chronic Kidney Disease (CKD), caused by high blood pressure. The patient was refusing to undergo the recommended hemodialysis treatment due to her needle phobia; however, neglecting her medical condition would be life-threatening. This paper discusses a case from personal nursing experience and applies the “Four Topics Approach” to it.
The Principles of Beneficence and Nonmaleficence consider patient’s medical indications. The problem was chronic and irreversible and needed prompt action to avoid kidney failure. If dementia or ischemic heart disease were the case, dialysis would not have been an option. However, they were not and, if the CKD progressed to stage five, the other possible treatment would be kidney transplant, from which the patient had previously refused. Given the patient’s high blood pressure and the fact that her GFR was gradually approaching 15 mL/min, starting a hemodialysis treatment at that point would help her to decrease fluid in her body. Therefore, the goal of treatment was life extension and reducing the chance of complications from kidney failure.
As per The Principle of Respect for Autonomy Patient, patient preferences were to be considered. The patient had been informed of benefits and risks but had not given her consent for the treatment. As per the Re C test, she was mentally capable to decide. However, the patient was not acting in her best medical interests and was unwilling to cooperate with treatment. The reason for that was primarily in her fear of needles and general hospital atmosphere.
The third Principle of “Four Topics Approach” considers the quality of life. Without treatment, the patient would develop stage five of CKD and depend on dialysis to live, potentially experiencing physical, mental, and social discomfort. Alternatively, a kidney transplant was an option, but the patient had previously expressed her discontent for it. In case of successful treatment, the quality of the patient’s life would improve, as it would most likely prevent rapid complications. At the same time, it would help the patient to avoid surgery, dangerous with complications. However, the ethical issue arose concerning the patient’s denial to undergo any treatment.
Finally, contextual features were assessed, according to The Principles of Justice and Fairness. There was a conflict of interest in the clinical treatment of the patient and her family member. Her daughter, who learnt about the situation from the patient herself, supported the doctor’s recommendations. The patient realized the risks of poor quality of life and wanted to avoid them but was scared of the treatment suggested to her and chose not to be assisted medically. It appeared that religious, legal, and financial issues were not the case, so ethical decision needed to be made by the doctor, considering the patient’s best interests.
Ultimately, applying the “Four Topics Approach” helped the care team members to assess the situation and find the most reasonable solution. Since it was the nurse’s responsibility to support the patient, in this situation, it was advisable to discuss the best outcomes with the patient and free her from the fear stopping her from receiving appropriate treatment. In particular, applying a numbing medicine was discussed with the doctor and later suggested to the patient. As a result, gradually, the patient became more cooperative and agreed to undergo the hemodialysis procedure, which was beneficial for her physical and, eventually, mental condition. It can be concluded that the “Four Topics Approach” is a valid technique to use in nursing practice.
References
Grote, T., & Berens, P. (2020). On the ethics of algorithmic decision-making in healthcare. Journal of Medical Ethics, 46(3), 205-211.
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