Many elderly people want to remain independent even when faced with a health crisis or a deterioration in their general health. Frequently they meet with a health problem that requires hospitalization in an acute care setting. Tliis is the occasion for family members to consider a change in living arrangements.
Ine older adult may have fallen at home and sustained a fracture. The family becomes concerned and begins to question the advisability of the individual to continue to live alone. The possibility of further injury is a concern. Children or other relatives may feel a great deal of responsibility but cannot actually be there to supervise the person.
Everyone's concerns must be considered. How can resolution occur in a situation where there is a difference of opinion among those involved? Nurses work with families in planning for the discharge of patients. It is essential for them to use the nursing process to assess and determine the appropriate interventions which assure consideration of everyone's needs.
A problem-solving approach that includes both ethical principles and family system's theory is useful for achieving a resolution. Such an approach considers the differing viewpoints of the family members. This article presents a case study which illustrates the application of ethical principles and family system's theory. This particular case study focuses on the care of an elderly person. Selected ethical principles are explained and discussed as they relate to the case. Family system's theory is used to reach a resolution.
The nurse responsible for discharge planning at St. Ann's Hospital went to see a patient and her family. The patient is being discharged in one week. The patient, Mrs. S, is 82 years old. She had fallen at home, had fractured her left humerus and was badly shaken. At the time of admission, Mrs. S lived alone in a small frame house. She and her husband, who died a few years ago, had built it for their retirement.
She has three children. The youngest, Anne, lives a block away. Anne works during the day but believes she can check on her mother in the evening. The son, John, is a successful lawyer who lives over 1000 miles away. He feels it is in the best interests of his mother for her to be in a nursing home. That way she will receive care and not be alone if she falls again. He is willing and able to pay for her care.
Lauri, the oldest child lives about 30 miles away from her mother. She wants her mother to come live with her. Lauri 's husband is willing to have Mrs. S live with them since they both believe she is too old to live alone. Lauri has an active social life. In Lauri's absence, a sitter will stay with Mrs. S.
Mrs. S tells the nurse that she wants to continue to live in her own home since she owns it and her friends live close by. She is in good physical health except for her recent fall. She will be in a shoulder immobilizer for 6-8 weeks. However, Mrs. S feels she can manage to take care of herself because she is right-handed.
Mrs. S tells the nurse, "I just wish my children would realize that I can continue to live alone. I have enough money to live on except when I have high heating expenses. My son says he has money to put me in a nursing home. Why can't he help me out once in awhile with my bills? Lauri visits her friends frequently and does her other activities. She wouldn't be there to keep me company. If I stay in my home, my friends can visit me. Anne can check on me every day and I will be just fine."
It is apparent to the nurse that there are very differing viewpoints about the proper care for Mrs. S upon discharge. The nurse needs to examine the ethical principles that will guide her in working with Mrs. S and her family. It is also necessary to decide on a systematic approach to use in trying to resolve the differing family viewpoints. The family must reach a resolution acceptable to all parties.
Ethics has always been an integral part of nursing. Throughout the history of nursing there have been codes of ethics, statements of moral principles, expressions of high ideals, and discussion of moral issues. In the 19th and 20th centuries, ethical discussions and teaching have become an important part of the development of the nursing profession. It was not until the 1970s that ethics became recognized as a part of nursing requiring special attention.
Ethical dilemmas, as presented in this case, occur whenever there is the possibility of good or harm to someone. Empirical data alone does not lend itself to the resolution of an ethical dilemma. The resolution of an ethical dilemma usually has a profound and far reaching effect on one's perception of 1 ) human beings; 2) relationships among human beings; 3) the relationship of human beings to society; and/or 4) the relationship of human beings to the world.1
Nurses, when making ethical decisions, deal within an area called normative ethics. According to Davis and Aroskar2 "normative ethics raises the question of what is right and wrong or what ought to be done in a situation that calls for a moral decision. " A review of norms or standards in the area of ethics is conducted and applied to the specific issue at hand. The American Nurses' Association Standards for Practice and Nurse Practice Acts of the various states give direction for the appropriate action.3
In this particular situation, the discharge nurse could follow a deontological ethical approach which states: 1) All persons must be respected. Their humanity must be recognized and their rationality honored. They must not be interfered with when making choices; and 2) Persons must not be treated solely as the means to an end by others. Individuals cannot be used by others for their purposes.1
Mrs. S is a rational adult who has the ability and right to decide her future. In this particular situation, the discharge nurse has assessed that Mrs. S wants to continue to live in her own home. Unfortunately, the siblings cannot agree to support this decision. Thus the problem or issue is where should Mrs. S live? If the discharge nurse looks simply at Mrs. S's side of the issue, a resolution can be reached by the deontological approach. The difficulty is that the pursuit of an individual's goals within a family can sometimes conflict with a family's goals.4
Encouraging patients to engage in health-promoting activities which are not supported by their families can cause difficulties.1 Behaviors and attitudes displayed by family members may undermine the patient's decision. In Mrs. S's situation, a deontological approach would mean that she stays in her home in spite of her children's concerns. There would be constant friction and unrest in the family system, thus, creating unrest for her.
The discharge nurse may consider a utilitarian approach to help in resolving the dilemma. She approaches the dilemma from the perspective of the greatest good for the greatest number, everyone considered. This approach is consistent with family system's theory.
Family system's theory views the family as a unit or system. "The family is viewed as an organi smic whole, and the treatment is of the impaired functioning of the family system. "5 The family system includes parents, children, significant relatives, and any other people important to the functioning of the family. Satir states that each individual in the family uses their past to contaminate their present. This creates a future that replicates the past and results in a hopeless quagmire.6
Family system's theory directs that the nurse view an individual within the context of his natural support system, the family.7 This family perspective recognizes the interactions among all family members and seeks to mobilize resources within the informal support system.8 Therefore, nurses must assess the capabilities and strengths of family members along with the needs of the patient. This assessment allows the nurse to develop a workable plan of care which meets the needs of everyone involved.
The nurse must identify the ethical principles important in reaching a resolution. The resolution must be ethically correct and support the family system. Respect for persons or an individual requires consideration of each person's uniqueness and equality in relation to every other individual. This principle requires consideration of the individual's own values and goals for the future.2
In deciding where Mrs. S is to live, the nurse is aware that Mrs. S is competent, rational, and able to care for herself. The nurse wants to respect Mrs. S's values and goals. She decides the only way to arrive at an acceptable solution is to have a family meeting.
The second principle of importance is that of autonomy. Cohen9 defines autonomy as "that quality which describes the degree of mastery an individual exercises over his own life." Mappes and Zembaty10 describe an autonomous person as one who makes rational and unconstrained decisions and acts accordingly. Mrs. S is capable of determining her own actions, establishing her goals, and acting on them. Consideration of everyone's goals promotes harmonious family relationships.
The nurse knows the establishment and implementation of family goals will support family autonomy. Paternalism is a principle invoked to justify intervention in an individual's actions or choices with the intent to protect the individual." Cohen9 feels the application of paternalism to the elderly in our society is very harsh. Frequently physicians, nurses, social workers, legal professionals, and family members use paternalism to take advantage of the elderly. Mrs. S's son is presenting a paternalistic resolution. He does not consider his mother's wishes but only wants to do what is "best" for her. Lauri's solution is also paternalistic because she wants her mother to live with her, and is not considering her mother's goals.
The last principle which is important is beneficence. One ought to prevent harm and do or promote good.12 The nurse realizes that the maintenance of independent living and autonomy are important for preventing harm in the elderly. She identified the best way to prevent harm and promote good for Mrs. S. This was to arrive at a resolution which supports Mrs. S's desires and keeps the family system intact.
The nurse called a meeting to give each family member a chance to discuss his/her viewpoint. The goal is to reach a resolution which will keep the family intact so they can continue to function and support each other. The nurse is aware that Mrs. S is in the advanced old age group. This is the time when individuals hope to live out their lives with dignity, remain in control of their lives, and care for themselves. The nurse, in her assessment of Mrs. S, knows she is capable of living alone. There is a division among the siblings in this decision-making process.
Anne agrees that her mother's autonomy is essential. She feels her mother would do fine at home with her help. John and Lauri are looking at their mother's situation from a paternalistic perspective. John is not close enough to actively help his mother. He rationalized he did not have the time. John did not want to worry and felt if his mother was in a nursing home she would receive good care. Lauri was ready to accept the "caretaker role." but on her terms.
It was clear to the nurse that all the family members would have to support a single decision. If they did not support the decision the outcome would not be successful. There would be a negative impact on Mrs. S.
The nurse met with all the family members and identified the possible options. The differing values and concerns were stated and discussed. The role of the nurse in the family conference is to hold everyone's values in creative tension as they proceed toward a resolution. Family members must each state their positions. The nurse can assist the individual family members to identify his/her beliefs, concerns, and ability to support each other.
Family members in this situation have the potential for either limiting or enhancing Mrs. S's ability to remain autonomous. The discussion revealed that John and Lauri were very afraid that their mother would fall again. As a result, she would be unable to truly care for herself. When they realized the strength of their mother's desire to remain independent they agreed she would be safer with an emergency pager. That way she could summon help immediately. This relieved their fears.
John also agreed to provide additional financial support which would further promote his mother's dignity and autonomy. The active involvement of all the family members allowed each of them to maintain their autonomy and support the resolution.
The case and its resolution demonstrate the importance of considering ethical principles and including the family when initiating the nursing process. Assessing only the individual patient, such as Mrs. S, does not provide information regarding the family as a system. Thus, the family remains peripheral to the plan of care for the patient.
Nurses, when developing a care plan for a patient, must remember the family system needs to be included in the assessment. The assessment includes the capabilities and strengths of the family system, and including the system will assure success in achieving positive patient outcomes.
- 1 . Curtin L. Flaherty MJ: Nursing Ethics: Theories and Pragmatics. Bowie. Maryland: Roben J. Brady & Co.. 1982.
- 2. Davis AJ. Aroskar MA: Ethical Dilemmas and Nursing Practice. Norwalk. Connecticut: Appleton-Century-Croft. 1983.
- 3. American Nurses' Association: Standards for Nursing Practice. Kansas City: American Nurses' Association. 1973.
- 4. Bandntan EL. Bandman B: Nursing Ethics in the Life Span. Norwalk. Connecticut: Appleton-Century-Croft. 1985.
- 5. Belew R. Buchanan DM: Family Therapy Origins. In I. W. Clements & DM Buchanan (Eds.), Family Therapy: A Nursing Perspective. New York: John Wiley & Sons, 1982, pp 3-12.
- 6. Nertn WF: Family Reconstitution: Long Day's Journal into Light. New York: W. W. Norton & Co.. Inc.. 1986.
- 7. Eichel E: Assessment with a family focus. J Psychosoc Nurs Ment Health Serv 1978; I6(l):ll-14.
- 8. Couper DP, Sheehan NW: Family dynamics for caregivers. Family Relations 1987: 36(2):I8I-I86.
- 9. Cohen ES: Autonomy and Paternalism: two goals in conflict. Law. Medicine, and Health Care 1985; 13(4): 145-150.
- 10. Mappes TA. Zembaty JS: Biomedical Ethics. New York: McGraw-Hill Book Co., 1986.
- 1 1 . Fry ST: The ethical dimensions of policy for prenatal diagnostic technologies; The case of maternal serum-fetoprotein screening. Advances in Nursing Science 1987; 9(3): 44-55.
- 12. Beauchamp TL, Childress JF: Principles in Biomedical Ethics. New York: Oxford University Press, 1983.