Download Ethical Considerations in Transplantation

Ethical Considerations in
Transplantation
Marci Andrejko, RN, BSN, OCN®
Sharon Flynn, MS, RN, ANP-BC, OCN®
National Institutes of Health
Clinical Center Nursing Department
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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®
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Objectives
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.
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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
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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
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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
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Ethical Considerations in Clinical Care
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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
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Case Presentation
Patient 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
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Patient Background
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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
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Is this patient a candidate for a stem cell transplant
giver her psychiatric history?
1. Yes
2. No
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Which of the following factors make a case for
transplantation in this patient?
1. Patient has a matched related donor
2. Psychiatric issues were directly related to chronic
health conditions and situational event
3. CGD is a transplantable disease
4. Unethical to deny a transplant based on a co-morbid
condition
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Transplant Regimen
• Campath® (alemtuzumab) - monoclonal antibody
• Busulfex ® (busulfan) - alkylating antineoplastic agent
• Rapamune® (sirolimus) – immunosuppressive agent
• 4 week inpatient hospitalization
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Care Planning
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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
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Daily Nursing Assessment Questionnaire
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How are you feeling today?
**How depressed are you feeling today?
**How worried are you feeling today?
**How hopeless are you feeling today?
In the past 24 hours, have you had any thoughts
about hurting or killing yourself?
** Rating scale: 1=“not at all” and 5=“extremely” **
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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
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What would your #1 ethical concern be while caring
for this patient?
1. Patient care takes time away from other patients
2. Personal disagreement with taking patient to
transplant
3. Patient won’t be compliant with care during
emotional instability
4. Lacking expertise to adequately assess and care for
the patient’s psychological needs
5. No ethical concerns
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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
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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
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Plan of Action and Key Factors
• Accessing the organizational infrastructure
• Availability and accessibility of resources
• Mentorship embedded in a culture of collaborative,
interdisciplinary communication
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Key Factor
Organizational 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
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Key Factor
Availability 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
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Key Factor
Mentorship 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
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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.
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Questions?
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