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1 2 WRONG SURGICAL SITE Virtue Ethics: Wrong Site Surgery Jodi Turco NURS 521 – Ethics in Healthcare November 2, 2019 Florence Nightengale said, “It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do no harm†(1863). The reasons I chose to respond to this story are because I remember when there was an occurrence in a hospital near where I live in which a doctor operated on the wrong leg of a patient and because I was shocked that it was actually a true story. Integrity is living up to one’s own moral standards and character. The fundamental ethical principles in nursing are autonomy, nonmaleficence, beneficence, and justice. Medical professionals are seen as the some of the most trusted professionals today and are trusted with the lives of our patients every day.

The physician discussed in the story made an error, which is part of being human. Where he lost all of his integrity is when he chose to continue on with the operation after a mistake was made and then continued to lie to the parents of his patient about the mistake until more than a year later. In the video, there is a safety expert that states, “Health care has far too little accountability for results … . All the pressures are on the side of production; that’s how you get paid.†He added that increased pressure to quickly turn over operating rooms has trumped patient safety, increasing the chance of error. It is my opinion that there should be criminal charges considered based on the fact that the physician lied to the family.

Their son suffered damages that were extremely severe due to the actions of the physician that could have possibly been alleviated if they weren’t kept a secret for so long after the fact. In my clinical setting, integrity as it is missed in this story is by holding a “time-out†prior to any procedure to ensure that the patient, procedure, site, etc. are correct. Integrity is also maintained by advocating for patients. By owning up to near misses if they happen and ensuring that my practice does not put my patient in harm’s way no matter what. Reference King, C. (2017).

Clinical ethics: Patient and provider safety. Aorn Journal, 106 (6), . doi:10.1016/j.aorn.2017.10.003 Statement of Focus Answer the following questions honestly. No one will read your responses. Doing so will contribute to an effective area of focus. 1.

What area of ESE or Education do you feel YOU can change or improve? Please think of this in light of your proposed action research focus this term. We can change the task refusal behaviors of a student with special needs by reducing them and increasing the client’s compliance with non-preferred demands and activities. 2. Why is this change particularly meaningful to YOU as an educator?

That change is particularly meaningful to us as behavior analysts and future educators because client’s task refusal reduces possibilities of learning, independence, acquisition of skills, and has a negative social impact. 3. What do other educators or professionals tell you when YOU discuss this topic with them? Other behavior analysts tell us that the task refusal is a maladaptive behavior commonly showed by students with special needs. They indicate that this behavior limits the opportunities of students to learn and become independent performing his Activities of Daily Living (ADLs) and reach academic’s progress to be placed at school in the least restrictive environment.

They indicate that as behavior analysts we can change those behaviors, and therefore provide the students with more opportunities to learn and achieve his academic goals. 4. How is the desired outcome a part of YOUR educational philosophy? As behavior analysts and future educators, we advocate for the inclusion of students with special needs in society. Changing task refusal behaviors, we provide them the opportunity to have a place in school and society.

5. Describe the situation with your student/group of students that you want to change by implicitly focusing on: (What is the problem you would like to improve) Who? What? When? Where?

How? Who? We want to change a specific maladaptive behavior showed by a student with special needs. What? We want to change specifically the task refusal behaviors showed by a student with special needs.

When? The change is projected to be accomplished within 6 months. Where? We expect that task refusal behaviors will decrease in all settings in which the student interacts: home, school, and community. How?

We will implement antecedent and consequence strategies and interventions to reduce the task refusal behavior of the student. Also, we will teach replacement skills (e.g. on task-sitting skill, following instructions) and the student will acquire desired behaviors and reduce the task refusal behaviors. 1 ADVANCED DIRECTIVE VS. POLST Advanced Directive vs. POLST Jodi Turco, RN December 2, 2019 Florida laws around advance directives are found in chapter 765 of Florida Statutes and split into three types: living wills, health care surrogate designation and anatomical donations.

Each can be completed separately, but that would be redundant. The definition according to Florida Statutes is, “Advance directive†means a witnessed written document or oral statement in which instructions are given by a principal or in which the principal’s desires are expressed concerning any aspect of the principal’s health care or health information, and includes, but is not limited to, the designation of a health care surrogate, a living will, or an anatomical gift made pursuant to part V of this chapter†(2018). I obtained a copy of an advance directive form from the registration department of the facility that I work in and filled it out. It was straight forward and vague in that it says, “I direct that life-prolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying†in the living will section and goes on to designate a surrogate.

The second page is the Designation of Health Care Surrogate which states, “I fully understand that this designation will permit my designee to make health care decisions and to provide, withhold, or withdraw consent on my behalfâ€. It further designates a second surrogate as an alternate. The final page is the Uniform Donor Form which indicates whether or not a person wants to donate their organs or tissues for donation to others who need it or for research purposes. All of the forms require witnesses to be put into effect, but the Living Will and Health Care Surrogate forms require witnesses that are not blood related or the spouse of the person. To comply with Florida and Federal Laws, there are accompanying pages that explain the compliance requirement to provide a copy of a blank advance directive to each patient but ensure them that their care is not dependent upon the completion of the forms.

Also attached are explanations and/or limitations of each. Of note is that there is a separate form needed if a patient wishes to not be resuscitated from a cardiac arrest. That form is a Do Not Resuscitate Order (DNRO) and must be completed by a physician. There were some odd feelings stirred up in me while I filled out the forms. The Living Will is tough to do because it makes you think about the end of your life, which is extremely uncomfortable to think about.

It also asks you to think of the people that you’d trust to uphold your wishes in the event that you’re incapacitated. I couldn’t help but laugh at the fact that I struggled to choose two people in my life that I’d trust with those choices, but I think that maybe that is because no one in my family has a medical background to understand the processes of diseases or death to ask the questions that you or I would. It also made me thankful that my father had a living will in place when he passed away. I remember being comforted by the fact that we knew removing life-support was what he would have wanted. The organ donation form is a no-brainer for me, as I have been a donor since I was old enough to make the decision for myself.

I have had the discussion with my family that I would like to have my body donated to those in need or to science to provide education to the next generation of medical professionals. Meyers et al. state, “The Physician Orders for Life Sustaining Treatment (POLST) form provides choices about end-of-life care and gives these choices the power of physician orders†(2004). Florida does not have a statewide POLST program, but if a person is facing a serious illness they can inquire with their doctor or treating medical facility about completing one. A POLST form differs from a DNRO in that it expands upon life-sustaining measures such as feeding tubes and hydration. It is meant to be used in conjunction with, not as a substitute for a Living Will and is also a part of a patient’s medical record that can be transferred from facility to facility to ensure continuity of care.

I work in an emergency department where lifesaving interventions are an everyday occurrence. The term “a good death†was coined by the Institute of Medicine with the meaning “one that is free from avoidable distress and suffering, for patients, family, and caregivers; in general accord with the patients’ and families’ wishes; and reasonably consistent with clinical, cultural, and ethical standards.†The importance of understanding end-of-life documents is critical to my practice. The POLST form is one that my state does not provide, but I believe would be an important adjunct to the living will now that I see how vague it really is. The POLST is most appropriate for patients that have serious illnesses as it helps loved ones to understand the details of a patient’s wishes.

It makes communication amongst the varying disciplines more seamless. An advance directive is composed of two parts (or three in Florida): an advance directive, the designation of a health care surrogate, and an option to donate organs. A living will discusses the preferences of a patient to whether or not they want to receive pain medication, antibiotics, food or water at the end of life. It differs from the POLST form because it is filled out in a hypothetical scope. It is also not legally binding like an advance directive is.

End-of-life decisions are not comfortable to make by any means, but this assignment brings to light the importance of these documents. Having conversations with our patients about these forms and being able to communicate the reasons for them is a vital part of a nursing career. They can also put patients at ease knowing that their loved ones will not have to make tough decisions in the event that they become incapacitated. They also help start a dialogue with patients and families about end-of-life wishes. Reference (n.d.).

Chapter Florida Statutes - The Florida Senate. Retrieved December 4, 2019a, from Kellogg, E. (2017). Understanding Advance Care Documents: What the Nurse Advocate Needs to Know. Journal of Emergency Nursing , 43 (5), 400–405. Retrieved December 4, 2019, from 10.1016/j.jen.2016.12.001 Meyers, J.

L., Moore, C., McGrory, A., Sparr, J., & Ahern, M. (2004). PHYSICIAN ORDERS for Life-Sustaining Treatment Form: Honoring End-of-Life Directives for Nursing Home Residents. J Gerontol Nurs , 30 (9), 37–46. Retrieved December 4, 2019, from 10.3928/

Paper for above instructions

Wrong Surgical Site: A Virtue Ethics Perspective

Introduction

The surgical domain is predicated upon trust; patients entrust their lives to skilled professionals with the expectation of receiving the utmost care. However, surgical errors, such as operating on the incorrect site, violate this sacred trust and evoke profound ethical concerns. As Florence Nightingale posited, "It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do no harm" (Nightingale, 1863). In this paper, I will explore the ethical dilemma surrounding wrong-site surgeries through the lens of virtue ethics, emphasizing integrity, accountability, and the moral obligation of healthcare professionals to prioritize patient safety.

Understanding Wrong-Site Surgery

Wrong-site surgery is a significant error within the healthcare system. According to the Joint Commission, such incidents occur when the procedure performed does not align with the designated site (The Joint Commission, 2021). This can manifest in various forms, including the surgery being performed on the wrong limb or in the incorrect area of the body. The consequences are severe, leading to physical, emotional, and financial repercussions for patients, families, and medical professionals alike (Nuckols et al., 2019).
A poignant example includes a case where a surgeon operated on a patient's healthy leg instead of the injured one, compounded by a deliberate attempt to deceive the family regarding the mistake. Such actions raise intense moral and ethical questions regarding the integrity of healthcare professionals.

Virtue Ethics in Healthcare

Virtue ethics, rooted in the works of Aristotle, emphasizes character and the cultivation of moral virtues over the mere adherence to rules or consequences (Hursthouse, 1999). It posits that moral character inherently influences the decisions individuals make. In the context of healthcare, physicians are entrusted with not just technical skills, but also with moral responsibilities towards their patients.
1. Integrity: A core virtue within healthcare is integrity—a commitment to act in accordance with one’s moral principles. The physician's actions in continuing with the surgery after a mistake directly contravene this virtue. By choosing to mislead the patient’s family, the physician displayed a lack of honesty and accountability, tarnishing trust (Rosenberg, 2015).
2. Accountability: Accountability is another pivotal virtue. The healthcare system must foster an environment where medical professionals feel empowered to openly discuss errors without the fear of retribution (Gaba, 2000). To address wrong-site surgeries effectively, healthcare institutions should implement rigorous protocols and encourage a culture that prioritizes patient safety.
3. Beneficence and Non-Maleficence: These ethical principles mandate that healthcare providers promote the well-being of patients while avoiding harm (Beauchamp & Childress, 2013). When healthcare providers neglect these principles, as seen in the discussed case, they perform a disservice not only to patients but also to the healthcare profession as a whole.

The Role of Institutional Policies

To prevent tragedies like wrong-site surgeries, healthcare systems must adopt stringent protocols. The implementation of “time-out” procedures—where all surgical teams verify the surgical site, procedure, and patient identity before initiating any procedure—can significantly reduce errors (King, 2017). Institutions should also conduct regular training and drills concerning these protocols, reinforcing a culture of safety and vigilance.
Moreover, transparency in addressing medical errors is crucial. Studies show that when healthcare providers acknowledge and disclose errors, the likelihood of lawsuits diminishes, fostering a more honest and collaborative environment within healthcare teams (Wysocki & Kelly, 2021).

Reflection on the Discussed Case

In the case presented, the physician’s deceptive actions seem to emerge from a systemic issue linked to production pressures and a culture of fear in admitting mistakes (King, 2017). Patients suffer not only from the errors made but from the compounded trauma of being misled. It is essential that healthcare professionals, guided by virtue ethics, value integrity, accountability, and a commitment to do no harm.
As professionals in healthcare, issues concerning surgical integrity should trigger profound reflections on one's moral character and ethical obligations. This case exemplifies the importance of fostering a healthcare culture where moral considerations prevail over operational efficiency. Upholding virtue ethics in surgery obligates providers not only to possess technical skills but also to embody moral excellence.

Conclusion

Wrong-site surgery is a tragic reflection of failures within the healthcare system, particularly concerning the virtues of integrity and accountability. Utilizing virtue ethics as a lens through which to view these incidents urges healthcare professionals to cultivate moral character and prioritize patient-centered care. By fostering institutional policies that emphasize safety, transparency, and the acknowledgment of errors, we can work collaboratively toward a future where patient trust is reinstated, and such fundamental ethical breaches are minimized.

References

1. Beauchamp, T. L., & Childress, J. F. (2013). Principles of Biomedical Ethics. Oxford University Press.
2. Gaba, D. M. (2000). Anaesthesiology as a Model for Patient Safety in Healthcare. Quality & Safety in Health Care, 9(2), 109-116.
3. Hursthouse, R. (1999). Virtue Ethics. In Stanford Encyclopedia of Philosophy. Retrieved from [Stanford Encyclopedia](https://plato.stanford.edu/entries/ethics-virtue/).
4. King, C. (2017). Clinical Ethics: Patient and Provider Safety. AORN Journal, 106(6).
5. Nightingale, F. (1863). Notes on Nursing: What It Is, and What It Is Not. Harrison and Sons.
6. Nuckols, T. K., et al. (2019). Medical Errors: A New Diagnosis. Healthcare, 7(2), 100001.
7. Rosenberg, C. E. (2015). The Careless Cure: Ethical Challenges of New Technologies. The Hastings Center Report, 45(5), 7-14.
8. The Joint Commission. (2021). Preventing Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery. Retrieved from [The Joint Commission](https://www.jointcommission.org/).
9. Wysocki, N., & Kelly, J. (2021). Transparency and Disclosure in Medical Errors. NEJM Catalyst. Healthcare Innovation.
10. Meyer, J. L., et al. (2004). Physician Orders for Life-Sustaining Treatment Form: Honoring End-of-Life Directives for Nursing Home Residents. Journal of Gerontological Nursing, 30(9), 37-46.