Family Member and Nurse

Combining morphine and Ativan (lorazepam) can be deadly, making the Primary Care Physician (PCP) statement seem contradictory to medical ethics. The specific medical ethical issues addressed in this case include patient autonomy, beneficence, and nonmaleficence. However, there are other ethical issues and dilemmas raised by this case. The nurse faces professional ethical dilemmas in terms of the conflicts between Provision 2 and Provision 8 in the American Nurses Association (ANA) Code of Ethics. Provision 2 indicates that nurses have a primary commitment to the patient, followed by Provision 3, which calls for the professional nurse to actively advocate for and protect the "rights, health, and safety of the patient," (ANA, 2015). However, Provision 8 indicates that the nurse also "collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities," (ANA, 2015). This case shows how the nurse's primary obligation to protect the interests of the patients may conflict with the nurse's work as a collaborator with other health professionals with the ultimate goal of protecting human rights and promoting health diplomacy. Therefore, the nurse in this situation should confer with the PCP to discuss reasons for proceeding to the Ativan.

Crucial questions that need to be posed include the patient's stated level of pain. If that level of pain remains suitably high after the administration of the morphine, in spite of appearances, then the nurse may need to accept that the Ativan would be necessary. The patient "appears comfortable," according to the case, but appearances can be deceiving. Plus, the patient may be saving face by avoiding the appearance of pain to prevent worrying family members. The nurse is obliged to ask the patient directly and confidentially about the level of pain being experienced and whether the patient would like additional pain relief via medication. Although the input from the family member is helpful, it is not necessarily relevant because the patient is the person who the nurse answers to ultimately. The International Council of Nurses (2012) also suggests that nurses advocate on behalf of patients by providing as much information as needed for the patient to make informed decisions related to healthcare. In this case, the nurse needs to tell the patient of the potential outcomes of combining morphine with Ativan. If the patient is not in a state of mind conducive to making choices, the nurse can confer with the family member and the PCP by citing evidence showing the potential harm of the drug interactions. The possibility for harm needs to be weighed against the ethical push towards beneficence -- providing for the needs of the patient for pain relief. The patient's body weight and medical history may also need to be taken into account when making an informed decision based on evidence rather than a knee-jerk response to the assumption that the patient is experiencing pain and would benefit from the additional drug.

It is an ethical obligation of the nurse to communicate clearly her concerns with the PCP and family member. Section 4 of the ICN (2012) Code of Ethics, for example, advises that nurses take "appropriate action to support and guide co-workers to advance ethical conduct," (p. 4). Similarly, the nurse's primary obligation to the patient cannot be overshadowed by deference to the perceived authority of the physician. The nurse's obligation is "to safeguard individuals, families and communities when their health is endangered by a co-worker or any other person," (ICN, 2012, Section 4, p. 4). Moreover, the patient has the right to refuse medical treatment "even if it is recommended by their physician," according to the Patients' Bill of Rights ("Patients' Bill of Rights," n.d.). Just because the PCP recommended the Ativan does not necessarily mean it should be administered. If it were administered without consulting the patient first and informing the patient of her rights, then that would constitute an egregious ethical violation of patient autonomy. Similarly, the nurse is obliged to speak with the patient in private to protect patient confidentiality and privacy in communications.

The principle of non-maleficence applies to this case, too. Doing no harm means refraining from offering the patient the Ativan if it is suspected that the interaction between the Ativan and the morphine might result in a fatality. The DNR order has nothing to do with physician assisted suicide and if the PCP knows of the potential interaction and still goes ahead with administering the Ativan, then the physician might be complicit in maleficent acts leading to the patient's death. Therefore, there are several possible course of action in this situation. The following three courses of action would occur simultaneously to ensure that all ethical standards are being met.