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Ethical Case Study Examples In Nursing

Shirley Keck, age 61, was admitted to Kansas medical center. Because of understaffing of nurses in the hospital, Shirley’s nurse did not assess her often enough and did not monitor her oxygen level. Shirley’s deteriorating condition was not noticed by the nurse because the nurse was overworked. Shirley suffered a respiratory arrest with a resulting brain injury.

Shirley went to the hospital with what she thought was a bad cold, and was admitted with a diagnosis of pneumonia. Following admission, she became increasingly feverish and short of breath, but her family’s calls for help went unanswered. In fact, her daughter was unable to find anyone when she went to the nurses’ station looking for help. The patient eventually stopped breathing, and someone finally responded to the family’s desperate and frantic calls for help. Shirley was successfully resuscitated, but sustained brain damage due to oxygen deprivation. She was left unable to walk, talk, or care for herself.

At the time of this incident, there were 41 other patients on this unit. Although the hospital’s own staffing standards called for 5 registered nurses and 2 licensed practical nurses to staff this unit, only 3 registered nurses were on duty. The plaintiff’s attorneys contended that lack of monitoring by nurses—caused by short staffing—led directly to the permanent brain damage Keck suffered. Furthermore, the attorney claimed that the hospital’s staffing plan, calculated according to hours of care per patient per day, failed to account for patient acuity, resulting in one nurse caring for as many as 20 patients at a time. The hospital claimed that the unit was safely staffed at all times. However, when the records for the unit in question were subpoenaed, they indicated that the hospital failed to meet its own staffing standards for 51 out of 59 days before this incident. Moreover, during depositions, a staffing supervisor said that administration warned about the costs of scheduling extra nurses, and a staff nurse submitted copies of documents in which the staff expressed their concern about the impact short staffing was having on patient care safety. According to the American Trial Lawyers Association, this was the first case to target corporate level staffing decisions rather than individual provider negligence.

The defendant hospital blamed the doctors caring for the Shirley Keck, and denied any allegations of understaffing in order to increase profits. It would have been very interesting to see what a jury would have done with this case; however, the hospital agreed to a $2.7 million out-of-court settlement while still denying allegations of short staffing. To put this in perspective, in 2010 the median range for out of court settlement was approximately $125,000 versus $235,000 for jury verdicts–and the hospital settled for $2.7 million in 1999. Moreover, the family refused to agree to any conditions that the settlement remain confidential so that others people might not suffer injury as a result of poor staffing. Thus, Keck’s story became nationally news, and was presented on CBS – 60 minutes, NBC nightly news, and CNN, and published in Reader’s Digest, Chicago Tribune, Wichita Eagle, and other media.

About the same time a Kansas Court was considering this case, The Wall Street Journal (September 29, 1999) published an article about another corporation that chose to risk human lives to save money. On the front page in a bylined article the paper reports the stunning punitive damages—$4.9 billion—levied against GMC. Even though it was reduced to a “mere” $1.2 billion on appeal, GMC lost the case because of the “cold calculus” of life versus money. Patricia Anderson, her four children and family friend Jo Tigner were awarded $107 million to compensate them for their pain, suffering and disfigurement. As the fire consumed the Malibu, the adults were able to escape, but the four children were trapped in the back of the car. Young Alisha Parker was the most gravely injured. Her burns were so severe that she lost the fingers of one hand and has undergone more than 70 surgeries.

Jurors awarded $4.8 billion in punitive damages after finding that GM acted out of fraud or malice. The verdict was quick and unanimous, particularly after jurors heard evidence that GM chose not to spend $8.59 per car to relocate the Malibu fuel tank because it cost less to settle lawsuits from injuries and deaths in fuel fires. One piece of evidence was a 1973 internal “value analysis” memo which calculated that deaths from such accidents cost the company $2.40 per automobile. So the executives decided not to recall and repair the cars to save roughly $6.00/vehicle. Attorneys for the plaintiffs did not ask for a specific amount, but pointed out that GM paid one of its expert witnesses $3.5 million over four years and spent about $4 billion annually on advertising.


Case commentary

Why talk about Anderson v GMC or even Keck v Wesley Medical Center? Because staffing is still an issue. It will become more of an issue as reimbursement continues to be curtailed. Moreover, as patient ratios are increasingly mandated, and studies of the impact of nurse staffing on patient outcomes are providing a growing body of knowledge, it is not only possible but likely that now that we can know what is safe hospital leadership will be held liable if they do not maintain safe staffing levels. Indeed, in the Keck case, it is important to note that Keck never filed a suit or even a claim against the nurse assigned to her care. Making a profit at the expense of human life and well-being is and always will be an issue that is directly impacted by staffing decisions. Indeed, the attorneys in the Keck case could easily have asked how much it would have cost the hospital to staff the unit according to its own standards!

Maintaining safe care is the first ethical and legal duty of any hospital, and of all health professionals. Setting and meeting its own staffing standards is a hospital’s regulatory and moral duty. Moreover, as researchers produce the data needed to ensure safe patient care (and as these data are introduced as evidence in malpractice cases), there will be more pushback from courts as judges and juries react to a cold calculus of profits over human life. Indeed, in many instances, it may be the healthcare executives who make staffing decisions who are dragged into court instead of harassed and overwhelmed staff nurses. What do you think?

Selected references

Keck v Wesley Medical Center, no. 99 –C20307 (D. KS 1999)

Medical Malpractice Settlements, onlinelawyersource.com/medical_malpractice/settlements.html. Accessed November 5, 2011.

Anderson v. General Motors Corp., BC116926 (Super. Ct., Los Angeles).

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According to the Associated Press, a Brookdale Senior Residence facility* worker who identified herself as a nurse, refused to administer cardiopulmonary resuscitation (CPR) to Lorraine Bayless, an 87-year-old woman who collapsed in the facility’s dining hall because “It was against company policy.” Although the nurse called 911, and the dispatcher urged her to start CPR or to find someone who was willing to do so, the nurse refused. The press reports that there was no Do Not Resuscitate (DNR) directive in place. Shortly after this report, Brookdale Senior Living issued a statement saying the employee’s failure to heed to a 911 dispatcher’s directions was a mistaken interpretation of the policy. Fortunately for this company, Bayless family members said she did not want life-prolonging treatment.

Believe it or not, this case study is not about whether or not an 87-year-old person should receive CPR: it is, after all is said and done, a matter of personal choice for the patient. A 2012 study showed that only about 2% of adults who collapse on the street and receive CPR recover fully. Another from 2009 showed that anywhere from 4% to 16% of patients who received bystander CPR were eventually discharged from the hospital. And only about 18% of seniors who receive CPR at the hospital survive to be discharged, according to a study from Ehlenbach and colleagues. So, enough on this subject.

The points at issue are:

1. Did the nurse have a duty of care to this person — even if she had only passed her by on the street?
2. Does company policy trump ethical or legal obligations?
3. Does age or place of residence (a senior living facility) exclude one from the rights accorded to other citizens?
4. Does this “policy of noninterference” (other than to call 911) in a medical emergency extend to other kinds of emergencies? The woman collapsed in the dining hall, so it is not inconceivable that she could have slipped with her knife and cut an artery. Would the nurse simply watch her exsanguinate while 911 is on its way? If she slipped and fell and hit her head, would she be ignored until the emergency squad arrived?

As Carolyn Rosenblatt, a nurse attorney writing in Forbes commented, “I was not surprised to learn that there was ‘company policy’ about a nurse in an independent seniors’ residence not giving nursing care…However, the horrible image of a nurse standing by refusing to permit anyone else there to get emergency instructions from the 911 dispatcher is most disturbing, no matter what kind of a home this was.”

In response to the points at issue:


Points 1 and 2: In the face of a company policy that refuses intervention in an emergency situation, the nurse still has a duty of care to a resident even though this facility does not provide skilled nursing care. Although the patient was living in an assisted living facility and not a nursing home, the American Nurses Association Code of Ethics for Nurses is clear: “The nurse’s primary commitment is to the patient, whether an individual, family, group or population.” This is clear, but just in case there is a possibility of misinterpreting it, the statement means that a facility’s policies do not supersede a nurse’s obligation to a patient, resident, or, for that matter, a passerby.

Point 3: Let’s put this another way: Is there such a thing as equal rights for the elderly? If one joins a senior living facility, is one’s right to life abrogated by its policies? I think not. One of the most important characteristics about policies is that they should be clear. Apparently Brookdale’s policy to call 911 in an emergency is clear; however, Brookdale’s policies on the emergency care of its residents until 911 gets there apparently is not clear. Why would the company have its employees call 911 if they are not to follow the instructions given to them by the 911 dispatcher?

Point 4: Certainly the elderly woman in question has a right to refuse treatment – and can do so by executing an advance directive. The fact that she did not do so is both salient and unsurprising. Most of us do not — and all of us should do so. A person or someone who holds his or her healthcare power of attorney may refuse treatment for that person. A nurse, administrator, institution, or company may not — through their policies or any other means. Can you imagine an organization with a policy that forbids employees from helping to save the life of its clients (or of other employees) in an emergency?

A duty to care

To put the matter succinctly, the nurse, if she was a nurse as she told the 911 operator (we know it was a she because copies of the 911 call were shared with the public), had a duty of care to this resident regardless of policies or her own uncertainties. This is a professional and ethical obligation. I am not a lawyer so I cannot say that she had a legal obligation to so. However, Good Samaritan laws offer legal protection to people who give reasonable assistance to those who are injured, ill, in peril, or otherwise incapacitated, especially to doctors and nurses. Good Samaritan laws provide a defense against torts arising from the attempted rescue.

I don’t think such laws don’t constitute a legal duty to rescue. But just as certainly, we don’t expect to see nurses on the phone with a 911 dispatcher refusing to even hand the phone to a passerby so the dispatcher can instruct someone else to administer CPR. And do what? Even though CPR is at best marginally effective in such circumstances, what is the alternative? Just watch them die?

*According to its website (www.brookdale.com) Brookdale is a national company that operates approximately 1,150 communities, with 80,000 associates serving about 100,000 residents every day.

Selected references
Ehlenbach WJ, Barnatao AE, Curtis JR, et al. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. N Engl J Med. 2009;361:22-31. www.ucdenver.edu/academics/colleges/medicalschool/departments/medicine/intmed/imrp/CURRICULUM/Documents/Ehlenbach%20WJ–In-hosp%20CPR%20epidemiology%202009.pdf

Hagihara A, Hasegawa M, Abe T, et al. Prehospital epinephrine use and survival in patient with out-of-hospital cardiac arrest. JAMA. 2012;307(11). 1161-8. http://www.acc.org/latest-in-cardiology/articles/2014/07/18/17/33/prehospital-epinephrine-use

Rosenblatt C. Nurse refuses to give CPR, senior dies: Ethical problem or legal issue? Forbes. March 8, 2013. www.forbes.com/sites/carolynrosenblatt/2013/03/08/nurse-refuses-to-give-cpr-senior-dies-ethical-problem-or-legal-issue/

Sasson C, Rogers MAM, Dahl J, Kellerman AL. Predictors of survival from out-of-hospital cardiac arrest: A systematic review. Circulation. 2010;3:63-81 (published online November 10, 2009). www.firstaidcorps.org/wp-content/Predictors-of-Survival-From-Out-of-Hospital-Cardiac-Arrest-A-Systematic-Review-Meta-Analysis.pdf

Leah Curtin is Executive Editor, Professional Outreach for American Nurse Today

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