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A Discussion of Placebos: Autonomy, Veracity, and Virtue Ethics Discussion Forum Submission for NURS 324: Introduction to Professional

Nursing Posted by Amy Johns, RN on 4/2/13 7:31 PM

Case Study: Mrs. Loriz suffers from severe chronic pain, the cause of which has not been definitely diagnosed. Her husband has brought her into the emergency department for the fifth time this month asking for narcotic relief from the pain. In tears, she states, A shot of Demerol is the only thing that takes the edge off. She threatens suicide if she is sent home without some help. The physician has ordered a placebo. What is the nurses responsibility?

Ethical Decision-Making Model The nurses responsibility can be clarified by using an ethical decision making model. Our text enumerates 6 steps in this process and compares them to the nursing process in Table 5-1, to develop and suggest a model that is discipline-specific to nursing. (Chitty and Black, 2011, pg. 114) I will apply these 6 steps to Mrs. Lorizs case. 1. Clarify the Ethical Dilemma It is natural to feel frustration for many reasons in a case like this. First of all, it is natural to question whether Mrs. Loriz is dependent on narcotics and/or is exploiting the ED. It is also natural to be frustrated with the lack of a definite diagnosis related to the origin of her pain and attribute it to emotional causes. It is the responsibility of the nurse (and the physician) to recognize frustration and look beyond it to professional behavior. It also needs to be acknowledged that there are many unknowns here for us as readers. After taking the preceding factors into account, the issues become: the patients uncontrolled pain, the threat of suicide, the ethical nature of the order for administration of a placebo by the physician, and the safety and liability associated with (the possible)

discharge the patient with no further intervention. Specifically for the nurse, the dilemma is whether or not to give the placebo without question and whether or not to follow through with discharging the patient.

2. Gather Additional Data The assessment of a patients pain should remain objective. Nurses are charged with taking the report of pain at face value. The standard definition of pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does (McCaffery, 1968, p.95). (Bernhofer, E., 2011, para. 2) This provides evidence to support that this patients pain requires further investigation. The official position statement of the ANA regarding placebos is states, Placebos should not be used 1) to assess or manage cancer pain, 2) to determine if the pain is "real," or 3) to diagnose psychological symptoms, such as anxiety associated with pain. Nurses should not administer placebos in these circumstances even if there is a medical order. (ANA, 2013) To administer a placebo for pain control requires several assumptions about the patient and the nature of the pain which violate a number of ethical principles. It violates the principle of autonomy in that the patient is stripped of the right to make her own decision. It violates the principle of veracity in that misleading the patient about the nature of the mediation she is receiving is dishonest. (Chitty and Black, 2011, p. 108-111) Mrs. Loriz threatened suicide if she received no help with her pain. Most institutions have policies dictating what to do in this case. To discharge a patient with a placebo after a threat of suicide incurs incredible risk for liability and is extremely complicated. A precedence-setting case is that of Cowan v. Doering. In this case, the plaintiff, Cowan, had an extensive self-destructive behavior history. Following an overdose of medication, she was admitted to a hospital for treatment and observation. During this admission, she jumped from a second-story window and was severely injured.

New Jersey Superior Court Appellate Division held that: Where it is reasonably foreseeable that a patient by reason of his mental or emotional illness may attempt to injure himself, those in charge of his care owe a duty to safeguard him from his selfdamaging potential. This duty contemplates the reasonably foreseeable occurrence of selfinflicted injury regardless of whether it is the product of the patient's volitional or negligent act.(14) (Welch, B., 2001, para. 22) Should Mrs. Loriz harm herself at after discharge, the hospital, physician, and nurse could all be charged with malpractice for ignoring this since it was a clearly foreseeable risk. 3. Identifying Options There is a lot of missing information that would further clarify what options realistically exist for this situation. Options for the nurse include whether or not to comply with administration of the placebo and whether or not to discharge the patient. In my opinion, the nurse is completely negligent if she gives the placebo. She should discuss this further with the physician and if she were to get nowhere, she should talk to her charge nurse and continue going up the chain of command until she is heard. With regard to discharge, I believe the same options exist. The patient should not be discharged after only having being given the placebo. The nurse can discuss this with the physician and then her charge nurse if discharge looks eminent. There are a lot of options for the physician (including the option to order Demerol) but they are not our focus. 4. Make a Decision I believe the decisions are already made and include discussing concerns with the physician with the intent to not administer the placebo even if it remains the order. The decision to discharge the patient after administration of the placebo is also something I believe the nurse needs to be prepared to

refuse to do. Discharge of the patient if the physician orders Demerol is far from ideal but a little bit safer.

5. Act Page the physician. Have the discussion. Be prepared to contact the charge nurse. Be prepared to refuse to administer placebo. Be prepared to refuse to discharge the patient. Document the incident. 6. Evaluate Review the outcomes of this patient. Review the collaboration with the physician. Recommend to the charge nurse or resource clinician that more education be provided to all staff regarding ordering placebos and also for policies and protocol for threats of suicide. Virtue Ethics I would make use of the ideas virtue ethics in this case. Virtue ethics is the manifestation of virtuous character traits in work and life behaviors. It illustrates how a person who has high standards of integrity, honesty, courage, kindness, respect and fairness might use these traits as a basis for decision making. (Chitty and Black, 2013, p. 107) In this case, the most basic tenets of respect are violated by the physician in ordering a placebo. Placebos violate the principles of autonomy and veracity. A nurse who has a strong sense of virtue ethics would probably instinctually know this was wrong. He/she may be driven by an intuitive sense of what is right for the patient.

American Nurses Association, (2013). Placebos for Pain Management in Patients with Cancer, ANA Position Statement-12-1996. Retrieved from http://nursingworld.org/MainMenuCategories/Policy-Advocacy/Positions-andResolutions/ANAPositionStatements/Position-Statements-Alphabetically/Placebos-for-PainManagement-in-Patients-with-Cancer.html Bernhofer, E., (2011). Ethics and Pain Management in Hospitalized Patients. OJIN: The Online Journal of Issues in Nursing 17(1). doi: 10.3912/OJIN.Vol17No01EthCol01 Black, B. P. (2011). Ethics: Basic concepts for nursing practice. In K. K. Chitty & B. P. Black (Eds.), Professional nursing: Concepts and challenges, 6th ed. (pp. 99-125). Maryland Heights, MO: Saunders Elsevier. Welch, B., (2001). Suicide watch: liability for negligent psychiatric care, The Free Library. (2001). Retrieved from http://www.thefreelibrary.com/Suicide watch: liability for negligent psychiatric care.-a075348661