Childhood Immunizations
There are a multitude of ethical questions that come up in daily practice, including:
Whether or not to disclose to a patient that the nurse practitioner or someone else at the practice made a mistake regarding the patient’s care.
Whether the availability or lack of reimbursement should determine whether or not a service is provided.
Whether participation in a research study is the best thing for a patient.
Whether a promise to a patient or family member not to disclose information to a family member or patient best serves the patient or family.
Whether and when curative treatments should be stopped.
When and how to terminate a relationship with a patient.
Whether or not to accept a gift or meal from a vendor or pharmaceutical representative.
Whether to discuss the deficiencies of a patient’s insurance coverage with the patient.
Whether and how to tell a patient you are moving to another practice.
Whether and how to inform a patient that you believe the surgeon he or she has chosen is not competent.
▪ Examples
Consider these four situations.
Situation 1
While standing in line at the grocery store, you hear “Help! This lady is having a seizure!” Behind you, a woman is on the floor, jerking around in a way you know is characteristic of a grand mal seizure. Several people are standing over her, calling out for help. You feel compelled to help, but worry that you will a) get sued, if something goes wrong, and b) be accused of practicing medicine without a physician collaborator.
Situation 2
You get a letter from a pharmaceutical company inviting you to participate in a round table discussion hosted by the company. There will be 15 attendees, all nurse practitioners who provide women’s health care. The topic will be treatment of hypercholesterolemia in the older woman. The company has a prescription product for reducing cholesterol. The letter offers you $500 plus a gourmet dinner. The writer wants to send you a consulting contract.
Situation 3
You are arranging the annual conference for NPs in your state. You have heard from past conference chairs that some pharmaceutical manufacturers will do any and all of the following sponsorship activities:
Purchase booth space in the exhibit hall.
Provide unrestricted grants for general conference overhead in return for a listing as sponsor on the program.
Fund specific speakers, including speaking fee, travel, slides, and handouts.
Purchase books as gifts for attendees.
Fund the travel expenses of some high volume prescribers.
You have the names and telephone numbers of several drug reps in your area. You aren’t sure what to ask for or what is appropriate under the new federal compliance program guidance for pharmaceutical manufacturers.
Situation 4
A patient of yours wants to quit smoking. His health plan will pay for Wellbutrin (buproprion) for depression but not Zyban (buproprion) for smoking cessation. You wonder whether it is “insurance fraud” to save a patient money by treating smoking cessation with a prescription for Wellbutrin, given the medication and dosing is the same as Zyban.
▪ Analyzing the Ethical Choices Inherent in These Situations
Situation 1: Providing Care on the Street
When faced with Situation 1, a nurse practitioner who ignores the patient having a seizure is doing nothing illegal. There is no legal requirement that a healthcare provider pay attention to patients, even when a patient is sitting in front of the provider in a clinic. However, most healthcare providers feel an ethical, as well as business, responsibility to provide care for patients who come to the office. As for the individual who falls down in the street, has a seizure in public, or has had an automobile accident, the
individual clinician may make his or her own decision whether to become involved. The decision will be based on the clinician’s analysis of whether he or she is ethically obligated to respond and whether other considerations outweigh any ethical dictates. Any two nurse practitioners may come to opposite conclusions.
individual clinician may make his or her own decision whether to become involved. The decision will be based on the clinician’s analysis of whether he or she is ethically obligated to respond and whether other considerations outweigh any ethical dictates. Any two nurse practitioners may come to opposite conclusions.
Four forces encourage clinicians to provide care:
Fear of a lawsuit for malpractice, if he or she neglects to treat an illness;
Fear of a charge of patient abandonment, if one does not give care;
The need for compensation; and
The clinician’s own values, which include the clinician’s sense of ethical responsibility.
Malpractice
For a successful lawsuit for malpractice, four elements have to be satisfied. First, there must be a duty of care owed the patient by the clinician. Second, the clinician has to have breached the standard of care. Third, there must be an injury to the patient. Fourth, the patient’s injury must be causally related to the clinician’s breach of the standard of care.
A clinician who provides care or advice for a person on the street establishes a duty of care. A clinician who walks by without offering advice or service does not establish a duty of care. Thus, the clinician who chooses not to become engaged is shielded from a lawsuit for malpractice, because there is no duty of care.
Patient Abandonment
In the case of the woman seizing in the grocery store, a clinician cannot be charged with patient abandonment if the clinician never becomes engaged in the woman’s care. Patient abandonment is defined slightly differently in different states, and often is addressed on the websites for the Board of Nursing. For example, the Colorado Board of Nursing states that for patient abandonment to occur, the registered nurse has to have accepted the assignment and severed the relationship without giving reasonable notice to the appropriate person (such as supervisor or patient) so that arrangements can be made for care by others. It is not patient abandonment, therefore, to refuse to accept an assignment or a patient-nurse relationship. Therefore, a nurse who walks by a person in distress on the street could not be accused of patient abandonment.
Reimbursement
In a roadside assistance situation, reimbursement is not an issue, as there is no system under which a clinician can submit a bill for such care. The reimbursable settings of care are office, hospital, nursing home, patient’s home, and domiciliary facility, and there are no procedure codes for the setting “sidewalk” and “grocery store.”
Ethics
The clinician faced with a decision to ignore or become involved with an individual in distress will weigh his assessment of right and wrong, and attempt to come to a
decision, in which his behavior conforms to a standard of right behavior. Some considerations might be:
decision, in which his behavior conforms to a standard of right behavior. Some considerations might be:
Are there other people already helping the individual?
Are my skills any more helpful than what is already being done for the individual? The NP can help shield the patient’s head from hard or sharp surfaces, but so can the nonclinician bystander. If the nurse practitioner has no education or experience in emergency medicine, the nurse practitioner may not be any more qualified to help than another bystander.
What, exactly, can I do for the patient? For example, the treatment for seizures is IV Valium. The NP on the street has no Valium to offer the patient. On the other hand, if the situation is that an individual has fallen to the ground, apparently unconscious, and a nurse practitioner knows cardiopulmonary resuscitation, then there is something the nurse practitioner can offer.
Do I have the legal authority to diagnose and treat in this situation? In most states, a NP needs a collaborative agreement with a physician to diagnose and treat, and those agreements do not usually extend to on-the-street encounters.
Will I feel that I did not meet my own expectations of myself if I pass by without offering help?
If I were the patient, and a nurse practitioner walked by and saw me, would I want the nurse practitioner to offer to help?
Nurse practitioners make situation-by-situation decisions on whether to become involved with clinical care on off-hours. There is no legal mandate to offer services. A clinician may choose to become involved or not, depending upon the situation and the clinician’s analysis of what is the humane and reasonable thing to do.
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