Reo, a 5 foot, 3 inch, 105-lb, 86-year-old retired cleaning lady, was admitted to a general medical-surgical unit in a small rural hospital. She was...
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Mrs. Reo, a 5 foot, 3 inch, 105-lb, 86-year-old retired cleaning lady,

was admitted to a general medical-surgical unit in a small rural hospital. She was diagnosed 3 months ago with metastatic cancer that had spread from her liver to her lungs and bone marrow. She received chemotherapy and radiation therapy for several weeks, but the treatment was not effective. She was admitted to the hospital because she became too weak to walk or care for herself at home. The cancer returned, and the large doses of oral narcotic medications taken at home were having little effect on her pain while increasing her confusion and weakness. Her oncologist decided that further chemotherapy or radiation therapy would not be effective, and she ordered Mrs. Reo to be kept comfortable with medications. A continuous morphine intravenous (IV) drip was started to help control the pain. Even with this medication, Mrs. Reo cried out in pain, particularly when morning care was given, and begged the nurses not to move her. Because she was severely underweight, the skin over her bony prominences quickly became reddened and showed the beginning signs of breakdown. The hospital standards of care for immobile patients require that they be repositioned at least every 2 hours. Mrs. Reo yelled so loudly when she was turned that the nursing staff wondered if they were really helping her or hurting her. To help decide what should be done, the nurses who gave care to Mrs. Reo called a patient care conference. The manager of the unit stated clearly that the hospital standards of care required Mrs. Reo be repositioned at least every 2 hours to prevent skin breakdown, infections, andperhaps sepsis. In her already weakened condition, an infection or sepsis would most likely be fatal. Betsy, who had been a licensed practical nurse for some 15 years, disagreed with the manager. Her feeling was that causing this obviously terminal patient so much pain by turning her was cruel and violated her dignity as a human being. She stated that she could not stand to hear Mrs. Reo yell anymore and refused to take care of her until some other decision was made about her nursing care. Sally, a new graduate nurse, felt that the patient should have some say in her own care and that perhaps some type of compromise could be reached about turning her, perhaps turning her less frequently or providing more pain relief medication. Monica, a registered nurse who had worked on the unit for 2 years, felt that the physician should make the decision about turning this patient, and then the nurses should follow the order. This last suggestion was met with strong negative comments by the other nurses present. They felt that patient comfort and turning were nursing measures.
A) What are the important ethical principles in this dilemma?
B)How does the Code of Ethics apply to this situation?
C)What are the legal issues?
D) Are there ever any situations when a nurse might legally and ethically violate a standard of care?
E) What are some other possible solutions to this dilemma? What types of consequences might they have?

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