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In the April 2007 issue, I discussed the importance of moral courage in resolving difficult ethical problems (Lachman, 2007a). Moral courage is the individual's capacity to overcome fear and stand up for his or her core values and ethical obligations (Lachman, 2007b). It is the willingness to address a problem that others are ignoring or sidestepping. Clinical practice offers a multitude of opportunities to speak out and advocate for patients, families, new graduates, and the preservation of quality care in your unit.
As promised, in this column four different case studies relevant to the practice of a medical-surgical nurse are analyzed. The first case study focuses on the need for moral courage in the dying patient, where the right action is supporting the patient's expressed wishes. The second case study will center on the management of a disruptive family. Case three will emphasize the ongoing ethical issues of incivility/bullying toward new nurses. The fourth and final case will spotlight the nurse's ethical responsibilities when the new nurse manager is asked to do something unethical. Each example will provide an overview of an actual case, disguised to protect the individual or organization. It will contain the basic description of the case, highlight the ethical issues, and describe the obvious need for moral courage and options for an ethical solution.
Moral Courage with a Dying Patient
Mr. T. is an 82-year-old widower who has been a patient on your unit several times over the past 5 years. His CHF, COPD, and diabetes have taken a toll on his body. He now needs oxygen 24 hours a day and still has dyspnea and tachycardia at rest. On admission, his ejection fraction is less than 20%, EKG shows a QRS interval of greater than 0.13 seconds, and his functional class is IV on NYHA assessment. He has remained symptomatic despite maximum medical management with a vasodilator and diuretics. He tells you, "This is my last trip; I am glad I have made peace with my family and God. Nurse, I am ready to die." You ask about an advance directive and he tells you his son knows that he wants no heroics, but they just have never gotten around to filling out the form. When the son arrives, you...