Pediatric health care is being transformed as managed care models of service delivery and payment become widespread. Hospitals are downsizing in response to the changing economic climate and the shift from tertiary care to primary care. Health care professionals, especially nurses, who once enjoyed employment security are now uncertain about their futures. Everyone, especially families of children with special needs, are threatened by the proposed cuts in services, diminished access to specialists, and constraints in personal choice.
Imbedded in these realities are conflicts about which values should guide our health care system. For many, the values of access, cost, and quality are fundamental to the design of any health care system. Despite widespread commitment to access, cost, and quality, values such as individual autonomy and choice, professional autonomy, patient advocacy, and caring are equally important to others. Recent changes in our health care system have changed our conception of some of these values and threatened the importance of others. For example, changes in health care delivery and financing have elevated the importance of cost efficiency even at the expense of quality, broadening the gap between the values we espouse and the reality we experience in everyday life.
Value conflicts such as these and the clinical realities of a transformation of the health care system have created intense ethical dilemmas for pediatric nurses. Pediatric nurses are struggling to balance their ethical obligations to patients, families, other professionals, institutions where they practice, and to society. As cost containment mechanisms evolve, many nurses will experience conflicts between their obligations to benefit the patient and to avoid or at least minimize harm to the patient.
In today's health care environment it is becoming increasingly difficult to reconcile what the patient needs to provide quality care and what insurers will pay for. For instance, Maria, a 10-year-old, is struck by an automobile while riding her bicycle. The emergency medical system (EMS) is called and she is taken to the closest emergency department, which happened to be the Children's Hospital, for stabilization and evaluation. Her work-up reveals a concussion, an open compound fracture of the left femur, a simple fracture of the left arm, and multiple abrasions. Surgery is needed to reduce and pin the fractured femur. As part of the admitting protocol, her insurance company is notified of her admission and authorization for surgery is requested. The insurance company representative denies her admission and instructs the caregivers to transfer her to another hospital that is part of their plan. The closest hospital that participates in Maria's plan is an adult hospital without pediatric specialists that is located 25 miles from her current location. Maria is in great pain and is intermittently hysterical because of the trauma, and because she has never been admitted to a hospital before. Her family is distraught and becomes very emotional when the caregivers inform them of the decisions of the insurance company. Caregivers experience a great deal of conflict as they attempt to weigh the risk of more psychological distress, emboli, infection, and perhaps suboptimal care for the child and her family. Pediatric nurses may wonder how to effectively advocate for Maria and whether they should vigorously advocate for her to remain in the Children's Hospital (analysis of this case will be provided in a future column).
Alternatively, pediatric nurses are confronted with ethical conflicts that arise from their practice environment. Many pediatric nurses are working in environments where registered nurses are being replaced with unlicensed assistive personnel (UAP). Concerns about delegating nursing tasks to others may arise when nurses are concerned that patient well-being may be jeopardized or that their own professional license may be at stake. Moreover, other nurses are experiencing intense conflicts between their professional values and the values of the organization where they practice. For example, as hospitals have been focused solely on the bottom line, the climate of many institutions have become increasingly adversarial and unsupportive to individual practitioners. Administrators may offer ultimatums, forcing nurses to practice under suboptimal conditions that compromise their integrity and quality of patient care. When faced with the threat of unemployment, some nurses are retreating from their advocacy responsibilities for patients to preserve their own well-being and survival.
All health care professionals are experiencing the ethical demands of resource allocation at the micro and macro levels. Treatment decisions are regularly being questioned by payors or the public. Pediatric nurses, for instance, experience daily challenges about the efficacy of providing innovative or expensive therapies to neonatal and pediatric patients with uncertain futures. Concurrently, pediatric nurses are also challenged by the changing political climate that threatens health care services for vulnerable children and their families, and reduces essential services for children with special health care needs.
Ethical conflicts are a dimension of every pediatric nurse's practice. There are no easy solutions to these challenging realities. To address these issues we must begin to have dialogues with each other, our patients and families, other professionals, administrators, and in public forums. I invite you to share case examples that exemplify the types of ethical conflicts that arise in your practice with me and with readers of this column. Please send a one-page summary of the case that identifies the ethical conflicts and suggests strategies used to address the issues. Include your name, address, telephone numbers, FAX, and e-mail address. The identities of participants and the institution involved in the case should be protected to ensure confidentiality. Mail cases to Cindy Hylton Rushton, DNSc, RN, FMN; Jannetti Publications; East Holly Aver Box 56; Pitman, NJ 08071-0056. I look forward to hearing from you.
Cindy Hylton Rushton, DNSc, RN, FAAN, is a Clinical Nurse Specialist in Ethics at The Johns Hopkins Children's Center, Baltimore, MD.
Dialogues in Ethics & The Law focuses on exploring the interface between ethics and the law in clinical practice. If you have suggested topics or cases for consideration In the column, please contact Cindy Rushton, DNSc, RN, FMN: 2312 Henslowe Drive: Rockville, MD 20854: (301) 340-6923; (301) 340-9682 FAX.