Table 5 Examples of ethical challenges discussed

Case

Site I

 1

A patient living in a nursing home. An elderly patient, with a severe reduction in cognitive and functional capacity, was admitted on suspicion of a hemorrhage in the intestinal tract. The physician prescribed taking a blood sample, but the patient resisted and removed her arm – strongly and repeatedly. The nurse was in doubt if the patient had been informed about and agreed to the procedure – and to what extent she was supposed to try to convince the patient to accept the blood sample.

 2

The bricklayer continued to work. A bricklayer was working at a big construction site. Some building materials fell from high above, hitting him on the head. Fortunately, he was wearing a helmet, and for a while he continued to work. But then he started getting a headache and some pain in his neck. When the ambulance took him to the emergency room, he was – in line with the clinical guidelines – placed on a spine board and told not to move. Suddenly the bricklayer needed the bathroom, but as he was at risk of having an unstable neck fracture, he was not permitted to leave the spine board. In order not to violate the guidelines, the nurse tried for a long time to persuade the bricklayer to urinate in a bottle, but he could not. The nurse was in doubt about the limits of her responsibility.

 3

Every day a new physician was responsible for the ward round. As a consequence, a nurse experienced different assessments of her patient by the physicians; one day more intensive treatment was prescribed, the next day further treatment was regarded futile. Torn between loyalty to the physicians and solidary with the patient, the nurse was in doubt about how to act.

Site IIA and IIB

 4

Reduction in antipsychotic medication? A patient asked the nurse for a reduction in the dose of antipsychotic medication because the patient wished for some of the psychotic experiences to return. The nurse was in doubt whether it would be accepted by the physician to increase psychotic symptoms on the request of a patient, or if she had to try to persuade the patient to continue on a high dose, although she understood and respected the wish expressed by her patient.

 5

Continuation of treatment although cure is unlikely. A clinician experienced organizational pressure to end treatment of a patient he had been treating for a long time. The patient was mentally ill, he was an alcoholic, and the patient was often suicidal. Adherence to treatment was poor. Although the patient was not cured, treatment prevented a deterioration, and the relation to the clinician offered alleviation and comfort. The clinician assessed their relation to be of utmost importance to the patient, and he feared the patient might slowly die if their relationship ended.

 6

The staff was frustrated by a patient constantly calling for assistance. A patient was suffering from both mental illness and alcohol abuse. The patient was annoying – to both fellow patients and the staff. Therefore he was told to stay in his room. But then he started constantly calling for assistance by ringing the bell in his room. The staff was frustrated and tried to avoid the patient.

 7

Fluctuating patient wish for termination of treatment. A patient disabled by severe personality disorder asked, with varying intensity and conviction, to end her treatment. The clinicians felt certain that ongoing treatment could help the patient. The patient was in doubt whether she wanted to continue or terminate treatment. At the same time, the clinician experienced pressure from the managers to end treatment because resources on the ward were already tight. Also, there was doubt whether termination or continuation of treatment would be in the best interest of the patient.

 8

Involvement of a vulnerable relative. A psychotic very aggressive patient insisted that he would only take the prescribed medicine if it was administered to him by a close family member. The family member accepted to do so, but at the same time she witnessed aggressive actions done by the patient. The family member was vulnerable too, suffering from mental illness.

 9

Was it all right to transfer the patient? A patient severely affected by mental illness needed specialized treatment in a hospital in a neighboring city. It was decided to go through with the transfer of the patient although the patient refused to cooperate and was transferred not sufficiently dressed.