The purpose of this assignment will be to explore legal, professional and ethical issues within a significant episode of practice where these are central to the delivery of care received from a multidisciplinary team (MDT). It will also be exploring the importance of MDTS and inter-professional collaboration and how a different professional perspective may impact the delivery of care. Throughout this assignment the episode of care will be from a student nurses perspective.
The episode of care that will be referred to throughout this assignment was undertaken on an acute stroke ward at a local general hospital. The pseudonym “Brian” will be used for confidentiality and to protect the patient’s identity this is in obedience with the Nursing and Midwifery (NMC) (2015) code as it states a person has right to privacy in all aspects of care. Confidentiality is a legal and professional duty that must be maintained throughout any episode of care, (Dimond, 2008).
Brian a gentleman aged 60 was recently admitted to the ward at the general hospital following a stroke. A stroke occurs when a blood vessel bursts or a blood clot interrupts the blood supply to the brain. During this the brains supply of oxygen and nutrients get cut off which cause damage to the brain tissue, (World Health Organisation, 2018). Consequently, Brians oral fluid and food intake has decreased significantly since this occurred and also since his admission. The nurse and student nurse both decide that after having a discussion with the doctor a dietician referral would be beneficial for the patient. The dietician then does an assessment on Brian to assess his malnutrition and necessity for the ng tube. The dietician recommended that a nasogastric tube is to be inserted to help increase Brian’s fluid and food intake as nutrition and hydration aids patient recovery, (Royal College of Nursing, (RCN) 2018a). Brian initially refused this advice regarding treatment. The student nurse, nurse, doctor and dietician (MDT) decided to all have a more in-depth conversation regarding the NG insertion with Brian explaining to him the benefits, risks and its importance in assisting his recovery. Subsequently, Brian then agrees and consents to the treatment. The different members of the MDT work together to provide interprofessional collaboration to provide integrated care that benefits service users, (Barrett, Sellman and Thomas, 2005).
There are many professional, legal and ethical issues in any episode of practice that are central to the delivery of care. Health care professionals must practice in an ethical manner and law legislations and regulations also provide a minimum code of standards which supports ethical practice, (Kinsinger, 2009). The Mental Capacity Act (MCA) (2005) Code of practice states that you should always assume an individual has the capacity to make specific decisions and the act also states that lacking capacity is when an individual is unable to decide for themselves due to an impairment or disturbance in the mind or brain. However, Dimond, (2008) states that if an individual has a mental disorder it does not automatically mean that a person is unable to make a valid decision regarding treatment. According to the Mental Capacity Act 2005 (Great Britain Parliament, 2005) if there were any concern about a person’s capacity an assessment would be necessary to clarify this. The mental capacity assessment is guided by common law requirements, (Greaney, Morris and Taylor, 2008). Brian is presumed to have capacity to make decisions regarding his treatments as there is no concern. However, in a case of a person being mentally incapacitated and unable to give valid consent such treatment must be in the patient’s best medical interests, when making these decisions the health care professional must act in compliance with a capable body of professional judgement, (Howard, Bogle 2005). The MCA (2005) delivers a checklist of factors that must be considered when determining a decision in best interests, (Great Britain Parliament, 2005). This is seen to be a holistic approach to best interests as it wants to ensure that both the patient’s wishes and also the views of the person caring for the patient are also considered, (Griffith, Tengah, 2014). Nonetheless, The NMC (2015) states that if the individual was deemed to lack capacity they are still to be at centre of the decision process. So, if Brian were to lack capacity in this decision making then he would still be centre to the decision made in best interests by the MDT which would be in accordance of the NMC, (2015).
It is a general legal and ethical principle that valid consent is essential and must be attained before treatment, physical examination, or providing personal care to a patient, (Department of Health, 2009). If valid consent was not obtained from Brain before proceeding it would amount to battery, (UK Clinical Ethics Network,2011). Tingle and Cribb (2007) suggests that obtaining consent before carrying out any treatment is key and plays a critical part in health care. It also helps to build a therapeutic relationship between the patient and practitioners, so this must be gained from Brian before carrying out treatment. This ethical principle also applies to other parts of the MDT including doctors and other medical staff. The British Medical Association (BMA) (2017), states that doctors have to seek consent if they wish to treat or examine a patient. However, Hendrick, (2000) states that consent has two distinct functions, a clinical function and also a legal function. The former function is intended to foster cooperation, trust and assurance between the patient and professional and the latter function being that it is in place to protect practitioners from any civil claim or criminal charges whilst caring for a patient.
Furthermore, it is important whilst gaining consent that the information provided to Brian regarding the procedure is accurate, truthful and is provided to him in an easy and understandable manner, (Hendrick, 2000). The NMC (2015) states that all patients have the right to receive information regarding their condition and treatments and in which you must remain sensitive to their needs and respect their decisions whether they were to refuse. Likewise, Hendrick, (2000) states that mentally competent patients have total right to refuse medical treatment whether the decision is seen to be rational, irrational or even may lead to death. Doctors and other members of the MDT are also required to discuss patient’s conditions and treatments with them making sure it is done in an understandable manner respecting any decisions the patient makes, (General Medical Council (GMC), 2013). Nevertheless, the Department of Health (DOH) (2003) implemented a guidance for the NHS code of practice on confidentiality, this asserts that when a patient is to refuse treatment alternative forms of care or treatment must be explored. In context if Brian refused the treatment offered of NG insertion other treatment options would be explored and discussed.
When Brian was asked for consent from the student nurse and nurse he was given both the positives, negatives and risks of the insertion. Brian firstly refuses the treatment procedure but after the MDT answering any of his concerns or questions and having a more in-depth conversation Brian decided to consent to the treatment. Tingle and Cribb (2007) states that a patient is to give full and effective consent with acknowledgement of the risks that may occur when consenting to a treatment or procedure and if the patient isn’t informed of these risks then the health care practitioner could be negligent. Nevertheless, Howard and Boggle, (2005) express that the UK law is not deemed necessary to detail every possible side-effect of treatment. When Brian did ask questions regarding his treatment they were answered by the MDT but if the practitioner were to fail in answering questions from him this may be in breach of duty of care.
Together with the doctors, dieticians and other members of the MDT nurses also have a legal obligation to abide by the principle duty of care, a principle that was enunciated by Lord Atkin, (Avery,2017). This principle is an obligation in which people have to act a certain way towards others following firm standards. The RCN (2018b) states that this term is both a legal and professional duty. The duty of care exists also as part of contract of employment in the NHS, (NHS, 2018). Howard and Boggle, (2005) state that if a patient has agreed to treatment with awareness of the risks they cannot bring proceedings related to the damaged caused by taking the risk. Consent or its refusal is not legally valid unless it is freely given. Brian does have right to refuse any treatment and this is a fundamental right which is safeguarded under the Human Rights Act (1998), (Great Britain Parliament, 1998). and if he was to refuse his decision is to be respected even if refusing the treatment would result in his death, (NHS, 2017).
There are two main ethical theories Consequentialism and Deontology. Utilitarianism is a well-known example of Consequentialism and this was first proposed by Jeremy Bentham. This theory focuses on the consequences of actions and also decision making on whether do the most good and the least bad, (Bingham, 2012). Whereas, deontology shows emphasis on that certain acts still have a right or wrong regardless of the consequences they lead to, (Bingham, 2012). In context if Brian was to refuse the treatment the consequentialist theory utilitarianism could be used to override this decision based on what the best overall outcome would be. Whereas deontology would contradict this as it would be seen to be fundamentally wrong not to respect a Brians choice regardless of the consequences.
When in a moral dilemma all of Beauchamp and Childress four ethical principles must be taken into account in accordance to the relevance of the moral conflict unless the principles were to conflict against each other these lie at the core of moral dilemmas and reasoning, (Griffith and Tengah, 2014). Autonomy is one of the four biomedical ethical principles which are used in the decision-making process when health care is challenged with ethical dilemmas, (Page, 2012). It is both a legal and ethical duty for all health care and their MDTs to respect a person’s autonomy. Brian has the right to autonomy and to make decisions regarding his treatment and care, this is essential that his individual views and wishes are respected, (Tingle, Cribb 2007). However, Herring, (2010) states that the talk of ‘right to autonomy’ is misleading as the decision of not receiving treatment is protected by law, the decision in what treatment a person would like doesn’t need to be followed and is not protected by the law. He also states that autonomy is when a person has right to body integrity rather than the right to autonomy. Body integrity being a right not to have something done to your body without consent being given, (Herring, 2010). More so, Tingle and Cribb (2007) state that these decisions are not always assumed to be correct for individuals wishes to prevail as an autonomous decision can also be overridden by best interests if the decision in seemed to be. There is ethical debate upon this as the International Council of Nurses (2012) code states that nurses must promote an environment where spiritual beliefs, values and customs of a patient, their family and community are respected. While Paternalism, is the overriding of a persons autonomy due to what is seen to be for their own good, (Hendrick, 2000). However, paternalism is criticised as it is said to degrade a person which brings risks in achieving a result where the illness or disease is treated and not the person themselves, (Hendrick, 2000). Similarly, members of the MDT including doctors also have to abide by the ethical principle of autonomy. In medical law it is seen as a cornerstone in the respect of a patient’s competent decisions. (GMC, 2013).
Another biomedical ethical principle is Beneficence, when using this approach, the actions used must be beneficial to others, (Kennedy, 2004). Although acting in ways to benefit the patient can sometimes conflict with the principle of autonomy, as an autonomous decision made by a patient may not be seen as greatest benefit to them by a health care professional, (Griffith, Tengah, 2014). In context from a legal point of view if Brian is competent and has full capacity in making his own decisions his decision could not be over ridden in his best interests if Brian was to refuse treatment, (UK Clinical Ethics Network, 2011). However, Hendrick (2000) suggests that beneficence is potentially very comprehensive, and it is hard to exactly define what a benefit is. It is also said to generate obligations to all those affected, directly or indirectly.
Non-maleficence is another of the four principles. Non-maleficence is ‘to do no harm’ this principle is deemed to be a dominant principle for all health professionals who undertake patient care, (Saunders, 2017). The NMC code 2015 states that this is an obligation in which nurses must abide by, by making sure nurses don’t inflict harm. Having said that, Pugh, Pugh and Savulescu, (2007) state that this principle is preventing patients from being exposed to unreasonable risks, preventing patients from undergoing beneficial treatment without good reason and reducing the effect of an effective medical intervention. This principle is applied in the episode of care by the student nurse but also the multi-disciplinary team.
The student nurse and other health care professionals provide him with good reason on why the treatment is beneficial to him. Also, if Brian was to not have the treatment he would be seemed to be at risk of a greater amount of significant harm.
The final principle is Justice, at the centre of this principle is equality. It’s the commitment to others by treating everyone fairly and equally, (Griffith and Tengah, 2014). According to Staunton and Chiarella (2004) this is regardless of a persons, wealth, status and religion, all individuals are entitled to the fair access of services. However, Hendrick (2000) states that the principle justice isn’t easy to define as few have the same concepts or interpretations of what defines people as being equal or unequal. Brian is treated fairly and equally by the healthcare professionals in accordance with this ethical principle. He is treated equally with the same treatment options and care provided regardless of his wealth, status or religion.
To conclude, there are many professional, legal and ethical issues that can arise in any episode of practice. All health care professionals and members of MDTs are required to practice in an ethical manner and must abide by the law legislations and regulations, (Kinsinger, 2009). Interprofessional collaboration plays an important part in the MDTs providing integrated health care to service users, (Barrett, Sellman and Thomas, 2005). A person is always presumed to have capacity to make decisions regarding treatment, (MCA 2005) and if there were to be any concern an assessment would be necessary to clarify it, (Greaney, Morris and Taylor, 2008). Consent is an essential legal and ethical principle and must be attained before treatment, physical examination, or providing personal care to a patient, (Department of Health, 2009). It is critical and applies to all parts of an MDT including doctors, (BMA, 2017). All members of MDTs including doctors are required to give accurate but easily understandable information to a patient regarding treatment, (GMC, 2013) and mentally competent patients have total right to refuse treatment, (Hendrick, 2000) and this is to be respected, (NMC, 2015). Together with the doctors, dieticians and other members of the MDT, nurses have a legal obligation to abide by the duty of care, (Avery, 2017). This also both a legal and ethical duty, (RCN, 2018b). When faced with a moral dilemma Beauchamp and Childress ethical principles must be taken into accordance, (Griffith and Tengah, 2014). These ethical principles are autonomy, beneficence, justice and non-maleficence. It is both a legal and ethical duty for all MDT members to respects a person’s autonomy. It is seen as a cornerstone in medical law in the respect of a patient’s competent decisions, (GMC, 2016). All four ethical principles are at the centre of moral reasoning and dilemmas, (Griffith and Tengah, 2014).