discover what’s next in nursing nih clinical center nursing department discover what’s next in...

Discover What’s Next in NursingNIH Clinical Center Nursing Department


Ethical Considerations in Transplantation

Marci Andrejko, RN, BSN, OCN®Sharon Flynn, MS, RN, ANP-BC, OCN®

National Institutes of HealthClinical Center Nursing Department


Full Disclosure

• Sharon Flynn has nothing to disclose.• Marci Andrejko has nothing to disclose.

• Special thanks to:– Joan Sorich, RN, MSN, AOCNS®– Frances Cartwright-Alcarese, RN, PhD, AOCN®


At the conclusion of this lecture, participants will be able to:

1. Define an ethical dilemma.2. Discuss and explore the role of the nurse in ethical

decision making in a complex healthcare environment.

3. Analyze response to a complex ethical dilemma and evaluate the impact of response within your clinical practice.

Objectives


Definitions

• Ethics is the discipline dealing with what is good and bad and with moral duty and obligation.

• Ethical dilemma is also known as a moral dilemma. It is situation in which there is apparent conflict between moral imperatives, in which to obey one would result in transgressing another.

Webster’s Online Dictionary, 2013


Bioethical Principles

• Beneficence is to benefit or help other people

• Nonmaleficence is to prevent or avoid harm to persons: “do not harm”

• Sanctity of life is to hold human life in high regard and respect

• Justice is the duty to act with fairness, giving every individual what is owed them


Bioethical Principles

• Personal autonomy occurs when a competent individual or their surrogate decide for or against treatment

• Benefit-Burden is when ethically mandated medical treatments provide more benefit than burden

Hematopoietic Stem Cell Transplantation: A Manual for Nursing Practice, 2013


Ethical Considerations in Clinical Care

• Norms of family life• Relationship between the clinician and the patient• Professional integrity of clinicians• Cost-effectiveness and justice• Cultural or religious variations

Hematopoietic Stem Cell Transplantation: A Manual for Nursing Practice, 2013


Case PresentationPatient Background• Young, adult, Korean, female• Supportive husband• Chronic Granulomatous Disease (CGD)• History of chronic lung infections, left foot

osteomyelitis, and other infections requiring frequent and lengthy hospitalizations

• Anxiety and depression unidentified and untreated until transplant work-up in 2005

• Started on anti-depressant medication


Patient Background • Work-up for matched related PBSCT in 2005• Youngest sister identified as HLA matched donor• Donor killed in care crash before cell collection• Thoughts of suicide nearly every day X 1 year after

her sister’s death• Reduction in suicidal thought frequency 2007 through

2009, despite attempts• 4 attempts: three in 2007 and one in 2009• Self stopped psychiatric medications in 2008• Re-evaluated for transplant in 2009 • Second sister was identified as HLA matched donor


Is this patient a candidate for a stem cell transplant giver her psychiatric history?

1. Yes2. No


Which of the following factors make a case for transplantation in this patient?

1. Patient has a matched related donor2. Psychiatric issues were directly related to chronic

health conditions and situational event3. CGD is a transplantable disease4. Unethical to deny a transplant based on a co-morbid

condition


Transplant Regimen

• Campath® (alemtuzumab) - monoclonal antibody• Busulfex ® (busulfan) - alkylating antineoplastic agent• Rapamune® (sirolimus) – immunosuppressive agent

• 4 week inpatient hospitalization


Care Planning

• Multidisciplinary planning meetings – frequent• Conduct interview and education in primary language• Social worker to see patient daily• Psychiatry to see patient 2x per week• Husband to stay at bedside except for nighttime• Contacted patient’s family to encourage continued

additional support through transplant• Re-stared Effexor® (venlafaxine) 75 mg• Patient signed agreement for medication compliance


Daily Nursing Assessment Questionnaire

1. How are you feeling today?2. **How depressed are you feeling today?3. **How worried are you feeling today?4. **How hopeless are you feeling today?5. In the past 24 hours, have you had any thoughts

about hurting or killing yourself?

** Rating scale: 1=“not at all” and 5=“extremely” **


Day to Day Care Issues

• Making questions a ‘normal’ part of the assessment• High alert moments – underlying fear of how to care

for the patient (outside usual scope of practice)• Higher speculation for drug seeking behaviors when

managing ‘usual’ transplant symptoms• Taking time away from other patients for increased

monitoring


What would your #1 ethical concern be while caring for this patient?

1. Patient care takes time away from other patients2. Personal disagreement with taking patient to

transplant3. Patient won’t be compliant with care during

emotional instability4. Lacking expertise to adequately assess and care for

the patient’s psychological needs5. No ethical concerns


Patient Outcomes• Patient had 2 repeat admissions for viral infections

(CMV) and new onset of cough• Returned to Korea in Sept 2010• Patient is disease free• No graft-versus-host disease (GVHD) or other

infections• Divorced in 2011• No recorded suicidal attempts• Continues on minimal antidepressant medications• Continues yearly follow-up with transplant team


Lessons Learned

• Situational aspects of psychiatric condition can be improved by receiving transplant in some cases

• Psychiatric diagnosis should be assessed on a case by case basis

• Increased awareness of our own ethical issues and its impact on patient care

• Working outside the traditional role of bedside nursing with interdisciplinary teams increases the quality of patient care


Plan of Action and Key Factors

• Accessing the organizational infrastructure

• Availability and accessibility of resources

• Mentorship embedded in a culture of collaborative, interdisciplinary communication


Key FactorOrganizational Infrastructure and Administrative Support

• Access organizational resources to mentor and support the bedside nurse in collaborative ethical decision making

• Develop standards for an ethical interdisciplinary process that includes role definition of team members and procedures to be followed

• Ensure that practices are consistent within the institution


Key FactorAvailability and Accessibility of Resources

• Provide information regarding access to consultative, educational, and advocacy resources in support of patients, families, and interdisciplinary team to foster ongoing collaboration

• Make resources available when staff are faced with complex ethical issues within the clinical area– Journal Club

– Continuing Education

– Schwartz Rounds

– Ethics Consult


Key FactorMentorship Embedded in Culture

• Mentor, coach and support the RN through the process– Embed a Mentorship Continuum relative to ethical decision

making within the culture of your clinical area– Establish regular “Debriefing” sessions

• To discuss complex ethical issues relative to nursing • To manage decision-making skills • To resolve conflicts in a safe environment


Summary

• Nurse successfully engages in ethical decision making as a collaborative interdisciplinary process.

• Nurse practices fully within the respective scope of practice outside of the traditional role.

• Nurse actively seeks opportunities and mentorship to enhance his/her own professional growth and development.


Questions?

discover what’s next in nursing nih clinical center nursing department discover what’s next in...

Documents

nursing practice

discover whats

clinical practice

aocn slide

complex ethical dilemma

ethical decision

moral dilemma

moral duty