Patient Autonomy Pain Relief

Johnson & Potter’s (n.d.) case study “Walking the Tightrope” demonstrates how different ethical obligations like patient autonomy, beneficence, and non-maleficence often conflict during delivery of care. Pain management is especially difficult, given the problematic side effects and potential for abuse of some pain management interventions. The patient in the case in question has been described as a “complainer,” but there is no indication of dementia (Johnson & Potter, n.d.). Therefore, there should be no reason to allow the family members to continue in their overbearing manner preventing the patient from making her own decisions regarding pain relief. The case illustrates the doctor, the sister, and the brother making decisions on the patient’s behalf, clearly impinging on her autonomy.
The disparate voices are also pulling in opposite directions, leading to a piecemeal and haphazard approach to pain management that could cause further complications and even medication errors. This would also open the healthcare institution for possible malpractice suits, given the level of experimentation being done with interventions like Nalfron causing the patient distress. It would be most helpful in this case to create a healthcare team that can make evidence-based decisions, albeit with some input from the patient and her family members. In this case, the nurse has a moral responsibility to serve in an advocacy role, mediating between the needs of the patient for pain relief, and the equally important needs for providing relief that does not interfere with her health prognosis. The nurse might learn that from the patient’s perspective, being “doped up” is a far better alternative to being in constant pain or experiencing adverse reactions to other types of pain management interventions. There is also a moral obligation to offer the patient additional non-pharmacological interventions ranging from mindfulness meditation to supervised long walks outdoors.
Healthcare workers in this case are in a difficult position because they will be expected to ascribe to different ethical frameworks and professional obligations at the same time. As Maumus (2015) points out, too, “the physician is in the precarious position of needing to make decisions in the best interest of the patient while receiving pressure from system administrators to reduce lengths of stay or clinic visit time,” (p. 124). If the patient had been abusing prescription opioids, then the healthcare workers do need to find a feasible solution to pain management that precludes narcotics. As Smebye, Kirkevold & Engedal (2016) also point out, paternalism may in this case override the importance of patient autonomy in that “paternalism could be justified in light of beneficence and non-maleficence and within an ethics of care,” (p. 1). The textbook also points out how balancing the needs of patient autonomy and advocacy with the needs of beneficence and non-maleficence requires astute competency in bioethics and communication.
Therefore, in this case the primary objective is to manage the patient’s pain in a way that is in accordance with evidence-based practice. Pain management techniques are not limited to medications and should also include ancillary support including therapy, meditation, exercise, and social stimulation. However, the medications the patient receives should be commensurate with her pain. There are too many competing and conflicting voices vying for power over the patient, who has lost autonomy in critical ways that undermine the ethical polities of the institution. Complaining and being irritable should be viewed as symptoms of the underlying pain and being neglected, not as problematic patient behaviors. Nurses in this case have an ethical obligation to listen to family members and doctors, but more importantly, to the patient. The patient’s medication preferences should also be balanced with the outcomes such as physical symptoms. Healthcare decisions related to pain management should be made in a team-based fashion, led by nursing staff rather than the primary care physician.






References

Johnson, L. & Potter, R. (n.d.). Walking the tightrope. Center for Practical Bioethics. http://practicalbioethics.org/case-studies-walking-the-tightrope
Maumus, M. (2015). Bioethics in practice. The Ochsner Journal 15(2): 124-126.
Smebye, K.L., Kirkevold, M. & Engedal, K. (2016). Ethical dilemmas concerning autonomy when persons with dementia wish to live at home: a qualitative, hermeneutic study. BMC Health Services Research 16(2016): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4717656/
Textbook.