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Table of Contents
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
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33. Nurses & Allied Health Professionals
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Life is short, and the art of medicine long; the occasion fleeting; experience fallacious, and judgment difficult. The medical practitioner must be prepared to do what is right and help the patient, attendants, and externals work together.
~ Hippocrates
Deadly Authority
The Deadly Consequences of Medical Authoritarianism
It was a typical day in the hospital, with patients coming and going, doctors and nurses rushing to attend to their needs. But little did anyone know that a murder was about to take place.
Dr. Jameson, a well-respected physician, was the primary care provider for Mr. Johnson, a patient who was recovering from a heart attack. Nurse Thompson, a member of Mr. Johnson’s care team, noticed that Dr. Jameson had been giving the patient a medication that was not on his chart. She was concerned and brought it up to the attention of the other members of the care team.
The team members, including pharmacists and other allied health professionals, gathered to discuss their concerns with Dr. Jameson. He became defensive and argued that he had the authority to prescribe the medication and that the team should trust his judgment. However, the team continued to express their concerns about the potential harm that could result from this medication.
As the meeting ended, Dr. Jameson abruptly left, and the team members were left to continue caring for Mr. Johnson. However, the next morning, Mr. Johnson was found dead in his room. It was clear that he had been given an overdose of the medication in question.
The hospital staff was in shock, and an investigation was immediately launched. As the investigation unfolded, it was revealed that Dr. Jameson had been using his authority as the primary care provider to make unilateral decisions about Mr. Johnson’s care, disregarding the input and concerns of the other members of the care team.
It was also discovered that Dr. Jameson had been providing unauthorized medical treatments to other patients and had been overprescribing medication. He had been using his position of power to manipulate and control the care of his patients, disregarding their autonomy and the input of his colleagues.
The investigation led to Dr. Jameson’s arrest and eventual conviction for the murder of Mr. Johnson and the harm caused to other patients under his care. The tragedy served as a reminder of the importance of interprofessional collaboration and the shared responsibility of all healthcare providers to ensure the best possible care for their patients.
As the hospital mourned the loss of Mr. Johnson, the staff came together to reaffirm their commitment to the prime directive of maximizing the patient’s best interests and avoiding harm, and to always communicate effectively and work together as an interprofessional team to provide the best possible care for their patients.
Abstract
This topic explores the responsibilities and obligations of medical practitioners, nurses, and interprofessional health professionals in patient care. The patient-practitioner relationship involves informed consent from the patient, while interprofessional health professionals are guided by the prime directive of maximizing the patient’s best interests and avoiding harm. The interprofessional team must communicate effectively and provide emergency care, resolve disagreements, and avoid discussing patient management disputes with the patient. Physicians have a responsibility to support interprofessional health care delivery and medical institutions must ensure that allied health professionals are medically educated and competent. The medical practitioner has the primary responsibility for ensuring that patient management is performed professionally.
**
Think
[33:1] Physicians generally bear the primary legal, professional, and ethical responsibility for the health care of the patient. Traditionally, the patient-practitioner relationship is where the patient divulges their private history and the practitioner performs the physical examination. However, nurses and allied practitioners do much of the personal contact, medication administration, and patient monitoring.
Assess
Patient: 1) Autonomy
[33:2] The medical practitioner is responsible for diagnosis, prognosis, and the presentation of treatment options to the patient. The patient, in turn, provides informed consent authorizing the practitioner to provide the medical treatment. When the patient provides informed consent, the patient also provides general consent for institutional participation in insurance and billing and interprofessional participation with patient management, including nurses, pharmacists, and a consortium of other interprofessional allied health professionals.
Practitioner: 2) Beneficence & 3) Nonmaleficence
[33:3] Physicians, nurses, and other interprofessional health professionals all share the same professional prime directive of maximizing the patient’s best interests in accordance with the patient’s reasonable goals, values, and priorities. This prime directive exemplifies the shared professional principles of beneficence (do good) and nonmaleficence (do no harm) and is the cornerstone of what constitutes the health professionals to be allied.
[33:4] In this context of the patient’s best interests, everyone in this interprofessional team must do the following.
1. Communicate clearly and professionally with all interprofessional team members about patient management.
2. Understand that the professional principle of nonmaleficence (do no harm) is paramount in patient care. Although nobody but the primary practitioner has the legal, professional, and moral authority to modify or change patient management, if an interprofessional team member has nonmaleficence (do no harm) concerns, then those concerns should be immediately discussed with the practitioner and resolved.
3. Provide emergency care when there is an immediate and severe risk of harm or death for the patient as a matter of beneficence (do good). Interprofessional team members have the authority and obligation to provide the medical standards of care unless a specific patient documented order in the medical record or an available living will communicate otherwise.
4. Resolve disagreements among the interprofessional team to maximize the patient’s best interests as determined by the patient’s reasonable goals, values, and priorities.
5. Avoid discussing with the patient disagreements about patient management. Doing so undermines the patient-practitioner relationship, maligns the practitioner’s reputation, and negatively impacts patient healing.
[33:5] Practitioners have a professional responsibility to support and promote interprofessional health care delivery and the team approach to optimize patient care in a complex health system.
Public Policy: 4) Justice
[33:6] The government and medical institutions have implemented laws and policies for making sure that all nurses and other allied health professionals are medically educated, trained, and competent for performing their roles as interprofessional health care team members.
Conclude
[33:7] The medical practitioner’s professional responsibility is to communicate respectfully with the interprofessional team and take responsibility for addressing and resolving any patient management disagreements, conflicts, and concerns. The medical practitioner has the primary responsibility for ensuring that patient management is performed competently and professionally.
[33:8] In summary the medical practitioner bears the primary responsibility for patient care, but nurses and allied health professionals are vital members of the interprofessional team. They all share the same goal of maximizing the patient’s best interests while minimizing harm. To achieve this, clear communication and cooperation are necessary among all team members. Medical practitioners must address and resolve any disagreements or concerns within the team, ensuring that patient management is conducted competently and professionally. This collaborative approach ultimately benefits patients and contributes to better healthcare outcomes.
**
33. Review Questions
1. Physician practitioners do not have the primary legal, professional, and ethical responsibility for the health care of the patient.
2. The interprofessional team equally shares the responsibility for the determination of patient management.
3. Nurses and allied practitioners do much of the personal contact, medication administration, and patient monitoring.
4. When the patient provides informed consent, the patient also provides general consent for institutional participation in insurance and billing and interprofessional participation with patient management.
5. Physicians have a professional responsibility to support and promote interprofessional health care delivery and the team approach.
6. All team members must communicate clearly and professionally about patient management with all interprofessional team members.
**
Wrong 😕
[33:1] Physician bear the primary legal, professional, and ethical responsibility for the health care of the patient. The patient-practitioner relationship is where the patient divulges their private history, and the practitioner performs the physical examination. However, nurses and allied practitioners do much of the personal contact, medication administration, and patient monitoring.
CORRECT! 🙂
[33:1] Physician bear the primary legal, professional, and ethical responsibility for the health care of the patient. The patient-practitioner relationship is where the patient divulges their private history, and the practitioner performs the physical examination. However, nurses and allied practitioners do much of the personal contact, medication administration, and patient monitoring.
CORRECT! 🙂
[33:1] Physician bear the primary legal, professional, and ethical responsibility for the health care of the patient. The patient-practitioner relationship is where the patient divulges their private history, and the practitioner performs the physical examination. However, nurses and allied practitioners do much of the personal contact, medication administration, and patient monitoring.
Wrong 😕
[33:1] Physician bear the primary legal, professional, and ethical responsibility for the health care of the patient. The patient-practitioner relationship is where the patient divulges their private history, and the practitioner performs the physical examination. However, nurses and allied practitioners do much of the personal contact, medication administration, and patient monitoring.
CORRECT! 🙂
[33:1] Physician bear the primary legal, professional, and ethical responsibility for the health care of the patient. The patient-practitioner relationship is where the patient divulges their private history, and the practitioner performs the physical examination. However, nurses and allied practitioners do much of the personal contact, medication administration, and patient monitoring.
Wrong 😕
[33:1] Physician bear the primary legal, professional, and ethical responsibility for the health care of the patient. The patient-practitioner relationship is where the patient divulges their private history, and the practitioner performs the physical examination. However, nurses and allied practitioners do much of the personal contact, medication administration, and patient monitoring.
CORRECT! 🙂
[33:2] The practitioner is responsible for diagnosis, prognosis, and the presentation of treatment options to the patient. The patient, in turn, provides informed consent authorizing the practitioner to provide the medical treatment. When the patient provides informed consent, the patient also provides general consent for institutional participation in insurance and billing and interprofessional participation with patient management, including nurses, pharmacists, and a consortium of other interprofessional allied health professionals.
Wrong 😕
[33:2] The practitioner is responsible for diagnosis, prognosis, and the presentation of treatment options to the patient. The patient, in turn, provides informed consent authorizing the practitioner to provide the medical treatment. When the patient provides informed consent, the patient also provides general consent for institutional participation in insurance and billing and interprofessional participation with patient management, including nurses, pharmacists, and a consortium of other interprofessional allied health professionals.
CORRECT! 🙂
[33:5] Physicians have a professional responsibility to support and promote interprofessional health care delivery and the team approach to optimize patient care in a complex health system.
Wrong 😕
[33:5] Physicians have a professional responsibility to support and promote interprofessional health care delivery and the team approach to optimize patient care in a complex health system.
CORRECT! 🙂
[33:4] In this context of the patient’s best interests, everyone in this interprofessional team must do the following.
1. Communicate clearly and professionally with all interprofessional team members about patient management.
2. Understand that the professional principle of nonmaleficence (do no harm) is paramount in patient care. Although nobody but the primary care practitioner has the legal, professional, and moral authority to modify or change patient management, if an interprofessional team member has nonmaleficence (do no harm) concerns, then those concerns should be immediately discussed with the practitioner and resolved.
3. Provide emergency care when there is an immediate and severe risk of harm or death for the patient as a matter of beneficence (do good). Interprofessional team members have the authority and obligation to provide the medical standards of care unless a specific patient documented order in the medical record or an available living will communicate otherwise.
4. Resolve disagreements among the interprofessional team to maximize the patient’s best interests as determined by the patient’s reasonable goals, values, and priorities.
5. Avoid discussing with the patient disagreements about patient management. Doing so undermines the patient-practitioner relationship, maligns the practitioner’s reputation, and negatively impacts patient healing.
Wrong 😕
[33:4] In this context of the patient’s best interests, everyone in this interprofessional team must do the following.
1. Communicate clearly and professionally with all interprofessional team members about patient management.
2. Understand that the professional principle of nonmaleficence (do no harm) is paramount in patient care. Although nobody but the primary care practitioner has the legal, professional, and moral authority to modify or change patient management, if an interprofessional team member has nonmaleficence (do no harm) concerns, then those concerns should be immediately discussed with the practitioner and resolved.
3. Provide emergency care when there is an immediate and severe risk of harm or death for the patient as a matter of beneficence (do good). Interprofessional team members have the authority and obligation to provide the medical standards of care unless a specific patient documented order in the medical record or an available living will communicate otherwise.
4. Resolve disagreements among the interprofessional team to maximize the patient’s best interests as determined by the patient’s reasonable goals, values, and priorities.
5. Avoid discussing with the patient disagreements about patient management. Doing so undermines the patient-practitioner relationship, maligns the practitioner’s reputation, and negatively impacts patient healing.
33. Clinical Vignettes
1. Ms. Jacqueline Torres is a 65-year-old retired librarian who presents with a sudden onset of severe abdominal pain, nausea, and vomiting. On examination, there is tenderness in the epigastric region, and she has a low-grade fever. Clinical differential diagnoses include peptic ulcer disease, acute pancreatitis, or cholecystitis. The interprofessional team is composed of a physician, a nurse, and a pharmacist. As a member of the interprofessional team, what is the ethical responsibility when there is a disagreement about patient management, and the physician does not agree with the nurse's concerns?
2. Mr. Boris Brown is a 50-year-old construction worker who presents with chest pain and shortness of breath. On examination, he is tachycardic, has crackles in both lung fields, and his blood pressure is low. Clinical differential diagnoses include acute myocardial infarction, pulmonary embolism, or septic shock. The interprofessional team is composed of a physician, a nurse, and a respiratory therapist. As a member of the interprofessional team, what is the ethical responsibility when the respiratory therapist disagrees with the physician's treatment plan?
3. Mr. Michael Davis is a 50-year-old electrician who has been recently diagnosed with hypertension. He presents to the clinic for a follow-up appointment with the physician and reports that he is experiencing side effects from the medication prescribed, including dizziness and fatigue. The interprofessional team includes the physician, a nurse, and a pharmacist. As a member of the interprofessional team, what is the ethical responsibility when a patient reports adverse effects from medication prescribed by the physician?
4. Mr. Edward Wilson is a 50-year-old plumber who presents with a chief complaint of shortness of breath and chest pain. On examination, he is found to have tachycardia, elevated blood pressure, and reduced oxygen saturation. Clinical differential diagnoses include acute myocardial infarction, pulmonary embolism, or pneumothorax. The interprofessional team is composed of a physician, a nurse, and a respiratory therapist. As a member of the interprofessional team, what is the ethical responsibility when there is a disagreement about patient management, and the respiratory therapist disagrees with the physician's management plan?
5. Mr. Quentin Quintero, a 68-year-old retired teacher, is brought to the emergency room by ambulance after experiencing sudden onset chest pain and shortness of breath. On arrival, his blood pressure is 150/90 mmHg, his pulse is 110 beats per minute, and he has an oxygen saturation level of 88% on room air. The nurse on duty immediately recognizes the severity of Mr. Quintero's condition and begins administering supplemental oxygen, aspirin, and nitroglycerin. The physician arrives shortly thereafter and orders an ECG and a series of blood tests to assess for cardiac damage. The results of the ECG and blood tests confirm the nurse's suspicions of a heart attack, and the patient is rushed to the cardiac catheterization laboratory for emergent intervention. What is the ethical obligation of the nurse in this scenario?
CORRECT! 🙂
Explanation: In the context of the patient's best interests, interprofessional team members should communicate clearly and professionally with all team members about patient management [33:4]. In the scenario, if the nurse has concerns about the patient's management plan, they should immediately discuss those concerns with the physician and resolve them as part of the shared professional principle of nonmaleficence (do no harm) [33:4]. However, if there is a disagreement about patient management, the nurse should document their concerns and escalate them to the medical institution's patient advocacy department for resolution [33:4]. The patient-practitioner relationship should be maintained, and discussing disagreements about patient management with the patient should be avoided [33:4]. Refusing to participate in the management plan until their concerns are addressed may cause harm to the patient and is not in line with the shared professional principle of beneficence (do good) [33:4].
Wrong 😕
Explanation: In the context of the patient's best interests, interprofessional team members should communicate clearly and professionally with all team members about patient management [33:4]. In the scenario, if the nurse has concerns about the patient's management plan, they should immediately discuss those concerns with the physician and resolve them as part of the shared professional principle of nonmaleficence (do no harm) [33:4]. However, if there is a disagreement about patient management, the nurse should document their concerns and escalate them to the medical institution's patient advocacy department for resolution [33:4]. The patient-practitioner relationship should be maintained, and discussing disagreements about patient management with the patient should be avoided [33:4]. Refusing to participate in the management plan until their concerns are addressed may cause harm to the patient and is not in line with the shared professional principle of beneficence (do good) [33:4].
CORRECT! 🙂
Explanation: In the context of the patient's best interests, interprofessional team members should communicate clearly and professionally with all team members about patient management [33:4]. If an interprofessional team member has concerns about the patient's management plan, those concerns should be immediately discussed with the practitioner and resolved [33:4]. However, if there is a disagreement about patient management, the team member should document their concerns and escalate them to the medical institution's patient advocacy department for resolution [33:4]. It is not appropriate for the respiratory therapist to modify the treatment plan as per their professional judgment [33:4]. The shared professional principle of nonmaleficence (do no harm) requires the respiratory therapist to comply with the physician's management plan and continue to monitor the patient for any adverse effects [33:4]. Discussing disagreements about patient management with the patient undermines the patient-practitioner relationship and negatively impacts patient healing [33:4].
Wrong 😕
Explanation: In the context of the patient's best interests, interprofessional team members should communicate clearly and professionally with all team members about patient management [33:4]. If an interprofessional team member has concerns about the patient's management plan, those concerns should be immediately discussed with the practitioner and resolved [33:4]. However, if there is a disagreement about patient management, the team member should document their concerns and escalate them to the medical institution's patient advocacy department for resolution [33:4]. It is not appropriate for the respiratory therapist to modify the treatment plan as per their professional judgment [33:4]. The shared professional principle of nonmaleficence (do no harm) requires the respiratory therapist to comply with the physician's management plan and continue to monitor the patient for any adverse effects [33:4]. Discussing disagreements about patient management with the patient undermines the patient-practitioner relationship and negatively impacts patient healing [33:4].
CORRECT! 🙂
Explanation: In the context of the patient's best interests, interprofessional team members must communicate effectively and provide emergency care, resolve disagreements, and avoid discussing patient management disputes with the patient [33:4]. When a patient reports adverse effects from medication prescribed by the physician, the nurse should document the patient's concerns and report them to the physician, who will determine the appropriate management plan [33:4]. The shared professional principle of nonmaleficence (do no harm) requires all team members to take immediate action to address any concerns regarding patient safety [33:3]. Adjusting the medication dosage or prescribing a new medication without consulting the physician is not in line with the interprofessional team's professional prime directive of maximizing the patient's best interests and avoiding harm [33:3]. Telling the patient to stop taking the medication without consulting the physician can also cause harm to the patient and is not in line with the shared professional principle of beneficence (do good) [33:3]. Therefore, the ethical responsibility of the nurse is to document the patient's concerns and report them to the physician, who has the primary responsibility for ensuring that patient management is performed competently and professionally [33:7].
Wrong 😕
Explanation: In the context of the patient's best interests, interprofessional team members must communicate effectively and provide emergency care, resolve disagreements, and avoid discussing patient management disputes with the patient [33:4]. When a patient reports adverse effects from medication prescribed by the physician, the nurse should document the patient's concerns and report them to the physician, who will determine the appropriate management plan [33:4]. The shared professional principle of nonmaleficence (do no harm) requires all team members to take immediate action to address any concerns regarding patient safety [33:3]. Adjusting the medication dosage or prescribing a new medication without consulting the physician is not in line with the interprofessional team's professional prime directive of maximizing the patient's best interests and avoiding harm [33:3]. Telling the patient to stop taking the medication without consulting the physician can also cause harm to the patient and is not in line with the shared professional principle of beneficence (do good) [33:3]. Therefore, the ethical responsibility of the nurse is to document the patient's concerns and report them to the physician, who has the primary responsibility for ensuring that patient management is performed competently and professionally [33:7].
CORRECT! 🙂
Explanation: In the context of the patient's best interests, interprofessional team members should communicate clearly and professionally with all team members about patient management [33:4]. In the scenario, if the respiratory therapist has concerns about the patient's management plan, they should immediately discuss those concerns with the physician and resolve them as part of the shared professional principle of nonmaleficence (do no harm) [33:4]. However, if there is a disagreement about patient management, the respiratory therapist should comply with the physician's management plan and continue to monitor the patient for any adverse effects [33:4]. Refusing to participate in the management plan until their concerns are addressed may cause harm to the patient and is not in line with the shared professional principle of beneficence (do good) [33:4]. Documenting concerns and escalating to the medical institution's patient advocacy department for resolution may be necessary, but compliance with the management plan is essential for patient safety and optimal outcomes [33:4]. Discussing disagreements about patient management with the patient should be avoided to maintain the patient-practitioner relationship and prevent harm to the patient [33:4].
Wrong 😕
Explanation: In the context of the patient's best interests, interprofessional team members should communicate clearly and professionally with all team members about patient management [33:4]. In the scenario, if the respiratory therapist has concerns about the patient's management plan, they should immediately discuss those concerns with the physician and resolve them as part of the shared professional principle of nonmaleficence (do no harm) [33:4]. However, if there is a disagreement about patient management, the respiratory therapist should comply with the physician's management plan and continue to monitor the patient for any adverse effects [33:4]. Refusing to participate in the management plan until their concerns are addressed may cause harm to the patient and is not in line with the shared professional principle of beneficence (do good) [33:4]. Documenting concerns and escalating to the medical institution's patient advocacy department for resolution may be necessary, but compliance with the management plan is essential for patient safety and optimal outcomes [33:4]. Discussing disagreements about patient management with the patient should be avoided to maintain the patient-practitioner relationship and prevent harm to the patient [33:4].
CORRECT! 🙂
Explanation: The nurse's primary ethical obligation in this scenario is to provide emergency care as quickly as possible to minimize harm to the patient. As noted in paragraph [33:4], "Interprofessional team members have the authority and obligation to provide the medical standards of care unless a specific patient documented order in the medical record or an available living will communicate otherwise." In this case, the nurse recognizes the severity of the patient's condition and immediately begins administering supplemental oxygen, aspirin, and nitroglycerin according to established emergency care protocols. Waiting for the physician to arrive before taking action could result in a delay in care that could increase the risk of harm to the patient. Contacting the patient's family or waiting for the patient to provide informed consent before administering treatment are not immediate priorities in an emergency situation where prompt action is necessary to maximize the patient's best interests.
Wrong 😕
Explanation: The nurse's primary ethical obligation in this scenario is to provide emergency care as quickly as possible to minimize harm to the patient. As noted in paragraph [33:4], "Interprofessional team members have the authority and obligation to provide the medical standards of care unless a specific patient documented order in the medical record or an available living will communicate otherwise." In this case, the nurse recognizes the severity of the patient's condition and immediately begins administering supplemental oxygen, aspirin, and nitroglycerin according to established emergency care protocols. Waiting for the physician to arrive before taking action could result in a delay in care that could increase the risk of harm to the patient. Contacting the patient's family or waiting for the patient to provide informed consent before administering treatment are not immediate priorities in an emergency situation where prompt action is necessary to maximize the patient's best interests.
**
33. Reflection Vignettes
1. Dr. John Smith is a 45-year-old medical practitioner with years of experience in cardiology. During rounds with the interprofessional team, Dr. Smith presents a treatment plan for a patient with severe heart disease that includes a new medication regimen. However, the team members, including the nurse and the pharmacist, express their disagreement with the plan due to potential interactions with other medications and the patient’s medical history. They suggest an alternative approach to treatment. In this situation, it is important for Dr. Smith to listen to the concerns and suggestions of the interprofessional team members and take them into consideration when deciding on a treatment plan for the patient. It is important to have open and respectful communication among the team members to ensure the best possible outcome for the patient. Dr. Smith should also consult with other medical professionals, including a pharmacist, to review the patient’s medical history and current medication regimen to make an informed decision about the best course of treatment. Ultimately, the focus should be on providing the best possible care for the patient.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
**
2. Dr. Jane Smith, a 35-year-old oncologist, has created a patient treatment plan for a cancer patient with a rare form of cancer. One of the nurse practitioners, who is part of the patient's interprofessional team, refuses to comply with the treatment plan, stating that the treatment is too aggressive and could cause more harm than good. Despite Dr. Smith's efforts to explain the rationale for the treatment plan, the nurse practitioner remains resistant and seeks the input of other team members. In this situation, the medical practitioner should address the refusal of the interprofessional team member to comply with the treatment plan. The practitioner should attempt to communicate and collaborate with the team member to resolve any differences and ensure that the patient receives appropriate care. If the issue cannot be resolved through communication and collaboration, the practitioner should follow established policies and procedures for resolving conflicts within the healthcare team. It may also be necessary to involve a supervisor or manager to mediate the situation and ensure that patient care is not compromised.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
***
