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N U
R S 2
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8
2
Prudence in Nursing Practice
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Course Title
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CALLAGHAN ____________________________________________________________
Assessment Item Title:
Case Study _____________________________________________________________
_______________________________________________________________________
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12
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Word Count (If applicable):
2000-2500
Due Date/Time:
5th, June, 2009
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Kyungeun, SHIN _______________________________ Date: June 01, 2009 ______________________
2182 Prudence in Nursing Practice- Case Study of Jill McDonald
1. Introduction
Often we can see that the news contain reports of sensational court cases related to health care. Many
cases have been revealed about whether the medical personnel’s actions to patients were right or not. The
case of Jill McDonald left room for a debate over complicated issues such as ethical decision-making,
legal capacity or professional accountability. According to Oermann (1991), nurses who are responsible
must plan their actions in order to respond clients’ needs in professional practice. Nurse McDonald,
however, made decision to practice under her own beliefs instead of following planned procedures (AIRC,
1999, [3],[41]). Subsequently, she brought upon herself to be charged with ‘involuntary manslaughter’ - a
substantive offence in health care (Mcilwraith & Madden, 2006). There is no doubt that the decision to
terminate Jill McDonald in Epworth Hospital was right.
2. Ethical issues
It is necessary to discuss the case of Jill McDonald in relation to ethical issues in order to reach
conclusion as to whether she performed right or wrong actions to her patients. Staunton & Chiarella
(2008) pointed out some consideration of the fundamental ethical principles as follow; 1) Shouldn’t this
be nurse’s approach to the problem? 2) What benefits does a patient receive? 3) What are the risks to
patients and how can nurses prevent and manage them?
2-1.
Autonomy
Autonomy engages ‘independence and freedom the right of self-determination.’ It is associated with
respecting the individual expectation and will (Ellis & Hartkey, 2004, p.317). The affirmative side insists
that McDonald had obtained a valid consent of the refusal to treatment from the patient’s husband. When
a patient was in deteriorated condition, family of the patient could refuse the treatment according to
Guardianship Act (Johnstone, 2004). As a result, Jill McDonald respected her patient’s will to withdraw a
CPAP machine from her (ANMC, 2006).
Autonomy, however, should be connected with dignity and trust. Health carer should act for patients’
well-being and should respect and support patients’ wishes related to handling of their illness. In addition,
autonomy requires good communication between health carer and patient (Wallace, 2001). Jill McDonald
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2182 Prudence in Nursing Practice- Case Study of Jill McDonald
referred in her recording that … Mrs A informed of her condition and I feel she agrees with the decision
made (AIRC, 1999, [20]). McDonald just informed her about her present condition that “you are dying
now” due to heart attack and felt herself that the patient agreed to stop the treatment (AIRC, 1999, [30]).
It cannot be seen that McDonald respected the patient’s wish, which based on trust and dignity and good
communication. Consequently, the patient could not have received and exercised the right to selfdetermination because she was in ‘no way able to communicate at all’ by the statement of Nurse Potter
(AIRC, 1999,[30]). Moreover, there was no evidence; written or verbal consent or information provided
to guide the decision to withdraw treatment to her husband in the record. As a result, McDonald deprived
an individual’s autonomy in the decision-making process.
2-2.
Beneficence and non-maleficence
Beneficence and non-maleficence refer to do good without doing harm and act in the best interests of
patients (Ellis & Hartley, 2004). It is important issue whether getting rid off is informal try the decision to
withdraw of the CPAP machine was beneficence or futility. The positive side persists that continuing use
of the machine might be meaningless and futile effort for the patient, so it was beneficence. It was worth
to respect the patient’s wish for a dignified death rather than keeping her life.
However, it is ethically problematic for what McDonald conducted to be considered as a beneficence due
to the case of Northbridge. Northbridge’s brother who was a patient recovered cognitive ability
substantially though continuous treatment was required and a lifted NFR order. Although he had brain
function deficit, his doctor revoked the NFR order for beneficence after Northbridge’s request.
Consequently, he was turned into a rehabilitation program from death (Wallace, 2001). It depends on
where medical care stands at: either the burden for the patient or benefit for the patient to determine
whether the treatment is futility or not (Kerridge et al, 2001). In addition, there is room for debate that
who should make the decision of futility of the medical care. According to Forrester & Griffiths (2005) in
guidelines for people dying with dignity, the attending doctor should consider a request in such situations
as continuous failure of medical treatment or overly burdensome treatment in the decision making for the
best interests of the patient. McDonald could not decide futility of treatment and should not have
disregarded the patient’s right to decide with health carer whether the treatment is futile or not (Truog, et
al, 1992).
Non-maleficence, which involves causing harm in any type such as pain, death, or disability should be
prevented (Lancaster, 1999). The action of removing CPAP machine represented act of maleficence
rather than act of beneficence. By this action, Jill McDonald has caused harm to the patient resulting in
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2182 Prudence in Nursing Practice- Case Study of Jill McDonald
patient’s death although the patient was in recoverable condition (AIRC, 1999,[3]). Therefore, McDonald
is responsible for the patient’s hastily death by making seemingly maleficent decision of withdrawing
potentially life-saving medical machine from her care (Kerridge et al, 2001).
3. Legal issues
It is important for nurses to practice under obligation in their professional field. A nurse has a personal
and legal obligation to provide a standard of client care expected of a reasonably competent professional
nurse. If a patient received harm by the nurse due to not furnishing appropriate standard of care, he or she
may be sued for negligence.
3-1. Negligence
The following three elements of the action by the plaintiff must be proved as a ‘burden of proof’ in all
negligence cases (Wallace, 2001, p.188). The plaintiff had a right of duty of care by the defendant.
A. The defendant breached the duty of care for acting or omitting action.
B. The plaintiff received harm on his/her body or finance by the acting/omitting action.
Jill McDonald has a duty of care to patient A. In conformity to ANMC in Code of Professional Conduct
(2006), a nurse should be familiar with law relevant to professional nursing practice and must provide
safe and capable nursing care to patients as the responsibility of nurse. However, she failed to meet those
provisions. Firstly, she omitted some important actions; to check the result of ECG and not to provide the
record of the patient to Nr Rush when discussing the refusal treatment. Next, she should never place
herself to make an important decision of NFR order. According to Forrester & Griffiths (2005),
documenting the NFR order should be clear and concise. Additionally, the order should be written in the
patient’s notes explicitly by the doctor. Secondly, she also missed opportunity to discuss the patient’s
wishes with treating team and her families together when confronted with the decision-making of the endof-life (NSW Health Guidelines, 2005; AIRC, 1999, [8]). Finally, she should have taken ‘reasonable care
to avoid act or omission’ to be harm to the patient in duty of care and should have predicted rationally in
regards to seriousness of damage to the patient (Wallace, p.188). Consequently, Jill McDonald conducted
the act of negligence.
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2182 Prudence in Nursing Practice- Case Study of Jill McDonald
In an insistence of affirmative, when a patient’ state rapidly deteriorates to become incompetent, the
medical team or family can decide to refuse treatment (Johnstone, 2004). The refusal of treatment, also,
reflected on the patient’s will through informed consent was guaranteed by the health professional
(Forrester & Griffiths, 2005).
The other side of an example is Bland’s case. He had been in a persistent vegetative state for over three
years after brain damage. The court held that removing it would not be a criminal offence. O’Keefe
argued that the diagnosis of persistent vegetative state should pass ‘a period in excess of four weeks’ and
there was no expectation of healing or improvement. Justification for stopping treatment is in futility that
‘the ventilation was deferring death rather than preserving life’ (as cited in Wallace, 2001, p.484).
In McDonald, it is hard to prove that the patient had been in vegetative condition due to short term, futile
treatment and reversible condition. It is not clear that McDonald provided an opportunity of dying with
dignity to the patient rather than deprived her life. In view of the results so far Jill McDonald did not
follow legal responsibility as a nurse (Tilley & Watson, 2004).
3-2. Battery and Assault
The affirmative side suggests that when a patient has been treated without informed consent, it can be
considered as battery even when the patient has not realised that treatment has been performed like the
case of Mallette v Shulman (Guido,1997;Wallace, 2001;Kerridge et al, 2001). Although the case of
Mallette v Shulman (1990) was adjudicated to be a battery, it contained lots of debates because of
happening in emergency. Emergency consent can be given by the doctor without the signature of the
patient under life-threatening situations (Lee, 2001). Every patient has a right to receive treatments for
saving his or her life. However, nothing can justify an action taken by McDonald when she removed the
CPAP. That action was familiar with an assault rather than a battery.
Blay et al (2005) argued that assault of the plaintiff was committed by directly placing an impeding and
rational interference on his/her body by the intentional act or threat performance of the defendant. From
this, it can be seen that Jill McDonald committed an assault on the patient A. Although she made no
physical contact with the patient, she was fully aware that by switching off the machine which would
have a direct physical impact on the patient. She completely recognised the serious harm on the patient
and that it could lead the patient to death without the permission of refusal of treatment from neither the
patient nor a confirmed NFR order by the doctor. Her intention was to interfere with the patient’s physical
condition and bring on death. This meets the criteria of an assault and in fact is beyond assault because it
was an action occasioning death which can be classified as a manslaughter.
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2182 Prudence in Nursing Practice- Case Study of Jill McDonald
4. Accountability issues
Accountability means that the nurse is professionally and legally responsible to patient for something he
or she has done (Crisp & Taylor, 2005;Stanhope & Lancaster, 2002). ‘Nurse must provide the necessary
care competently and in compliance with accepted standards, using sound judgment, thinking critically,
and delegating wisely’ (Eill & Hartley, 2004, p.492). It develops into more significant part of
accountability in nursing practice (Mike, 1997).
The positive asserts that McDonald could make a decision when the patient was in rapidly deteriorating
condition as the team leader. At that time, the hospital did not have any policies related to NFR order.
Furthermore, she practiced NFR to the patient for her quality of life.
However, if she misleads her colleagues of the team because of her wrong advice to decide that the
patient had a NFR, she cannot be avoid accusation of unsatisfactory professional conduct. The nurses are
placed on ‘unsatisfactory professional conduct or professional misconduct’ when they reveal ‘a lack of
adequate knowledge, experience, skill, judgment or care’ in nursing practice (NRB of N.S.W., 2001,
p.17). The First of all, it matters to insufficient knowledge in McDonald. The patient’s situation was
seriously getting worse and could not express her living will. McDonald should have maintained the use
of the more effective CPAP machine instead of using a Hudson mask onto her (AIRC, 1999, [10]). Next,
she accomplished professional misconduct as insufficient experience and judgment. Though the patient
was in suffering due to deterioration of her condition, McDonald should have continuously monitored the
result of her ECG. As a result McDonald deluded herself that it was right for the patient to be permitted a
NFR order when calling with Dr Nagy (AIRC, 1999, [20]). The case of Kahler was illustrated a good
instance of professional misconduct (NRB of N.S.W., 2001, p.234-235). It also did not contain proper
documentation. Documentation is the major responsibility for nurse to have to keep accurately and
completely and documentation provides the most effective defence in nursing malpractice action (Guido,
1997; Lancaster, 1999). It has to reflect adequate information about the patient based on ‘what a nurse do;
see, hear, say, think in relation to the patient’ (Lancaster, 1999). In McDonald’s case, there were
absolutely in the short supply to prove her conducts to be not guilty ethically or legally in the notes of the
patient. This case also presented tangle of communication problems to interrupt in best nursing practice.
Nurses need effective communication with clients and other health professionals to improve the quality of
care (Oermann, 1991). This case involved lots of communication troubles to produce wrong decision by
McDonald. First of all, McDonald failed to contact Dr Fuller for NFR order (AIRC, 1999, [8],[15]). The
second, Nr Potter did not attempt to show ECG result to Dr Nagy, instead, explaining it to Nr Preusker in
another ward. Moreover, nurses in EW4 inclusive of Nr Potter and Nr Preusker did not give Dr Nagy
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2182 Prudence in Nursing Practice- Case Study of Jill McDonald
print out of the ECG (AIRC, 1999, [8]).Finally, there was a misunderstanding between McDonald and Dr
Nagy when they went to decision-making of the NFR order through phone call (AIRC, 1999,[20]).
While a nurse must independently take actions based on knowledge and authority, the action of nurse
must place in the range of legislation or law followed (Mike, 1997;Paley, 1996). While Nr McDonald
freely acted in accordance with her knowledge base against the professional accountability, she could
not convince the Commission she had acted responsibly and professionally. Nurses are accountable for
their own actions. That is, nurses should accomplish appropriate delegation of duties in liability of
individual aspect (Lancaster, 1999). Other aspect of responsibility is that nurses being a supervisor to
other health carers (Hood & Leddy, 2006). Although Nr Potter directly removed the CPAP from the
patient, McDonald was not exempted from accountability because she was a team leader. She not only
misled her team but also misadvised them to lead the patient to death.
5.
Conclusion
It is apparent that the Epworth Hospital had a reasonable claim of terminating to Nr Jill McDonald who
misconduct ethically, legally and professionally in nursing practice. Although there were a lot of
vindications such as absent in Hospital Guideline of NFR, dying with dignity for patient, failing to
contact the doctor and breakdown of communication, she should have followed ethical principles for right
decision-making in the best interest of the patient and should have conducted professional accountability
and accomplished standard of care in accordance with law for saving the patient and protecting herself.
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2182 Prudence in Nursing Practice- Case Study of Jill McDonald
Reference
Australian Nursing & Midwifery Council. (2006). Code of Professional Conduct for Nurses in
Australia. Dickson: ANMC. Retrieved April 21, 2009 from http://www.anmc.org.au/website
Australian Nursing & Midwifery Council. (2006). National competency standards for the registered
nurse. Dickson: ANMC. Retrieved April 21, 2009 from http://www.anmc.org.au/website
Australia Industrial Relations Commission (AIRC). (1999). Jill McDonald v Epworth Private Hospital 347/99 M Print R3645 [1999] IRCommA 417 (29April1999). Retrieved April 20, 2009 from
http://www.austlii.edu.au/cgibin/dip.pl/au/cases/cth/IRCommA/1999/417.html
Blay, S., Gibson, A., & Richards, B. (2005). Torts Law (4th ed.). Pyrmont, NSW: Lawbook Co.
Crisp, J., & Taylor, C. (2005). Potter and Perry's fundamentals of nursing (2nd ed.): Sydney: Mobey.
Ellis, J. R., & Hartley, C. L. (2004). Nursing in Today's World (8th ed.). Sydney: J.B. Lippincott Co.
Forrester, K., & Griffiths, D. (2005). Essentials of Law ofr Health Professionals (2nd ed.). Sydney:
Elsevier
Guido, G. W. (1997). Legal Issue in Nursing (2nd ed.). Stamford: Appleton & Lange.
Kerridge, I., Lowe, M., & McPhee, J. (2001). Ethics and Law for the Health Professionals. Social Science
Press, Katoomba; NSW.
Hood, L. J., & Leddy, S. K. (2006). Leddy & Pepper's Conceptual Bases of Professional Nursing
(6th ed.): Lippincott William & Wilkins.
Johnstone, M. (2004). Bioethics: A nursing perspective (4th ed.). Sydney: Churchill Livingstone.
Lancaster, J. (1999). Nursing Issues in Leading and Managing Change. Louis: Mosby.
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2182 Prudence in Nursing Practice- Case Study of Jill McDonald
Lee, N. G. (2001). Legal Concepts and Issues in Emergency Care. Philadelphia: W.B.Sauders Company.
Mcilwraith, J., & Madden, B. (2006). Health care & the law (4th ed.). Pymont: Lawbook Co.
Mike, W. (1997). Accountability & Intuition: Justifying Nursing Practice. Nursing Standard, 11(23),
39-41.
Nurses Registration Board of N.S.W. (2001). Professional Conduct: a case book of disciplinary decision
relating to professional conduct matters Dickson: NRB of N.S.W. Retrieved Mayl 21, 2009 from
http://www.nmb.nsw.gov.au/professional-conduct-book/default.aspx
NSW Department of Health. (2005). Guidelines for end-of-life care and decision-making [electronic
version]. Retrieved April 4, 2009 from http://www.health.nsw.gov.au
Oermann, M. H. (1991). Professional Nursing Practice. Philadelphia: J.B.Lippincott Co.
Paley, J. (1996). Intuition and expertise; comments on the Benner debate. Journal of Advanced Nursing,
23(4), 665-671.
Stanhope, M., & Lancaster, J. (2002). Foundations of Community Health Nursing. Sydney: Mosby.
Staunton, P. J., & Chiarella, M. (2008). Nursing & the law (6th ed.). Sydney: Elseviser
Tilley, S., & Watson, R. (2004). Accountability in Nursing and Midwifery (2nd Ed.). Carlton: Blackwell.
Truog, R. D., Brett, A. S., & Frader, J. (1992). The problem with futility. New England Journal of
Medicine, 326(23), 1560-1564.
Wallace, M. (2001). Health care and the law (3rd ed.). Pyrmont: Lawbook co.
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2182 Prudence in Nursing Practice- Case Study of Jill McDonald
Appendix III – Marking Criteria for Assessment 3: Case Study
Name: Kyungeun Shin
Tutorial group: 12
Date: June 3, 2009
Marker’s signature:
Criteria
Discussion
of ethical
issues
related to
Case.
Discussion
of legal
issues
related to
Case (either
legislation
or case law)
Discussion
of
accountabili
ty issues
related to
Case.
Develops
and
sustains an
argument
throughout
Use of
evidence
to support
discussion
Academic
literacy
(3085020)
Not
Evident
0 points
Knowledge &
understanding
of ethics not
apparent/
heavily reliant on
personal
opinion/or
restating details
of the case
Knowledge &
understanding
of law not
apparent/
heavily reliant on
personal opinion
and or restating
details of the
case
Knowledge &
understanding
of accountability
issues not
apparent/
heavily reliant on
personal opinion
and or restating
details of the
case
Fail
Standard
6 points
Some ethical
understanding
apparent, but this was,
superficial, incoherent
and/or contained
incorrect, and/or
irrelevant material.
Issues not related to
case
Some legal
understanding
apparent, but this
was, superficial,
incoherent and/or
contained incorrect,
and/or irrelevant
material. Issues not
related to case.
Some attempt, but
this was inadequate
by virtue of being
superficial,
incomplete, or
unclear. Little
understanding of
concept of
accountability.
Pass
Standard
10 points
Adequate
knowledge &
understanding
of ethics apparent
but limited in both
depth and scope
Credit
Standard
14 points
Good discussion
of ethics ,
relevant &
correct. No errors
of fact or
interpretation
Adequate
knowledge &
understanding
of law apparent, but
limited in both
depth and scope
Good discussion
of law, relevant &
correct. No errors
of fact or
interpretation
Adequate and
reasonable
knowledge and
understanding of
accountability, but
limited in both
depth scope.
Good discussion
of accountability
issues arising
from case,
relevant and
correct. No errors
of fact or
interpretation.
No coherent &
logical
connection
between ideas
identifiable in
work
Some relevant points
raised, but difficult to
see a logical
sustained flow of
ideas throughout the
work
Adequate
coherence of ideas,
but this lacked
depth and tended
to be ‘one-sided’/
Conclusion
preceded
discussion not
followed from it
Good, coherent
thread to
discussion
throughout,
balanced,
relevant and
correct. No errors
of fact or
interpretation.
Conclusion
followed from
discussion, not
preceding it
Good use of a
range of
information
sources,
revealing
effective research
skills and
capacity to use
them
Discussion
supported
mostly by
personal
opinion. Very
poor use of
resource
material
10 per cent
deducted
Major problems
throughout.
Many spelling
mistakes or
grammatical
errors and/or
incoherent
sentence
Inadequate sources
cited, too few, or of
poor quality, little
evidence of scope
and depth of reading.
Heavy reliance on a
few sources or
internet sites
5 per cent deducted
Recurring problems
with spelling
mistakes or
grammatical errors
and/or recurring
problems with
sentence, paragraph
and/or overall
structure
Kyungeun SHIN (3085020)
Sources cited were
adequate, but
somewhat limited in
scope
/100
3 per cent
deducted
Occasional
problems with
spelling or grammar
and/or
occasional poor
sentence or
paragraph
structure.
Dist
Standard
16 points
Excellent
capacity to
explain &
assess issues in
a balanced,
way, reflecting a
deep
understanding
of them
Excellent
capacity to
explain &
assess legal
issues in a
balanced way,
reflecting a deep
understanding
of them
Excellent
capacity to
assess
accountability
processes and
make reasoned
suggestions for
either
alternative
decisions or
broader
practice
contexts
Argument was
fairly balanced
throughout and
showed a clear
capacity to
distinguish
between facts,
values and
assumptions
Excellent,
critical use of
information
sources
showing
capacity to
engage with
the literature
High Dist
Standard
20 points
Shows
evidence of
original
thinking
Points
/20
Shows
evidence of
original
thinking
/20
Shows
evidence of
original
thinking
Shows
evidence of
original
thinking in
the way the
argument
was
conducted
and
conclusions
drawn
Breadth and
quality of
sources, &
use in
discussion,
could not be
faulted at
this level
/20
/20
/20
zero deducted
Mainly error free.
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2182 Prudence in Nursing Practice- Case Study of Jill McDonald
structure, little or
no paragraph
and/or overall
structure
Referencing
10 per cent
deducted
Sources not
acknowledged or
APA referencing
not used.
or
More than 10
per cent direct
quotes
5 per cent deducted
Consistent incorrect
use of APA
referencing
in reference list or intext
3 per cent
deducted
Minor problems with
referencing in
reference list or intext
zero deducted
Mainly error free.
May incur SACO
referral
TOTAL /100
TOTAL /50
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