Case Study #1
The case study feature of the newsletter is intended to promote critical thinking in ethics, stimulate discussion and possibly suggest resolution.
A 35 yr old Muslim woman from Kuwait, Mrs. M, was admitted to the hospital for c/o headache, nausea, vomiting. Her past medical history included Arnold-Chiari malformation: a congenital brain defect with elongation of the cerebellum and medulla that impairs cerebrospinal fluid (CSF) drainage. She also had a history of pseudotumor cerebri, a clinical name for benign intracranial hypertension of unknown origin. Her past history of neurological disease resulted in the placement a vetriculo-peritoneal shunt (VPS) used to shunt excess CSF into her peritoneum because her body was unable to reabsorb the fluid. The increase in CSF leads to an increase in intracranial pressure which may result in headaches, nausea and vomiting. Mrs. M was also 8 weeks pregnant on initial admission. She was married with four small children.
Mrs. M underwent extensive neurological testing to ascertain the cause of her headaches, nausea and vomiting. The neurosurgeons questioned the need for a VPS revision. Was she not able to absorb her CSF? Were her symptoms related to her pregnancy? While answers to these questions were pending, Mrs. M experienced severe headache pain (8 on a scale of 10), and required intravenous (IV) Morphine to ease her pain. She also experienced frequent vomiting and was made NPO, and given Zofran IV. In addition, she expressed severe denial of her pregnancy and seemed to be unaware of the ramifications of extensive testing and medication management for her unborn child. Her other four children were sent back to Kuwait because she could not care for them in her condition. Her husband was staying in the area and working long hours for money to support her and the children. She was discharged and readmitted five times for the same complaints and the neurological origin of her symptoms remained in question.
Some areas of special consideration included: impaired communication due to a language barrier (she did speak English to some extent, "broken English", but her family did not). As a Muslim woman, cultural and religious considerations came into play.
Clinical/Ethical Questions?
- Is it the duty of the nurse in this situation to decide if the patient is able to make sound decisions?
- Is it the nurse's duty to explore the issue of the denial of pregnancy by the patient?
- Is the nurse responsible for getting the husband involved in the situation?
- How does the health care team honor and respect the patient and family cultural norms even if they disrupt patient care?
- What is the nurse's role in addressing Mrs. M's NPO status?
- Is there a point at which pain relief for the patient via morphine will affect the fetus? How should the nurse be involved in this medical management issues?
- How would you, the nurse cope with this situation?