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Tear-Stained Justice

Lara Thompson, MSN, RN, CEN

The basic principles of nursing ethics: accountability, justice, nonmaleficence, autonomy, beneficence, fidelity, and veracity seem so basic on paper, simple, really. We can easily memorize their definitions and apply ethics to educational scenarios with equal ease. But in practice, what is just can be unclear. Justice can get a bit muddled.

In my nursing experience, I have found justice, one of the foundational ethical principles of nursing, to be one of the more challenging to navigate cognitively. Is treatment and allocation of resources equal in all situations and at all times? And should it be? According to the principle of justice, yes. But what is equal can be confusing at times. How can the line between right and wrong be unclear?

How can justice be unclear? Equal provision of treatment is foundational. This situation is a simple ethical principle. What could cloud the clarity of justice?

Suffering, humanity, life…

Enter the trauma bay with me.

When one traumatic injury occurs, a multitude follows. This was a “normal” busy day in a level 1 trauma center. Staff were tending to traumatic injuries and critically ill patients. As “normal” days often do, this day evolved to a level of activity that required staffing reinforcement to continue providing excellence in care for all in need. Reinforcement was called in, me being one of those called to assist with needed care.

I was assigned to an incoming motor vehicle collision or MVC. My patient was an elderly woman who was the car's driver; her school-aged grandson was sitting in the back seat. They were involved in a high-speed collision, resulting in serious injuries for the driver as well as passengers in the other vehicle. The older woman assigned to my care arrived at the trauma bay in full arrest: unresponsive, without respiratory effort, and pulseless. While resources were thrown at all those in need, this patient was clearly beyond rescue, and I was certain revival efforts would cease.

To my surprise, the surgeon called for a thoracotomy tray to open this woman’s chest and attempt to restart her heart in the trauma bay. The survival rate for this type of injury and intervention is less than one percent. And this percentage is even less likely in older adults. I found myself horrified that this gruesome intervention was being applied to this patient in this busy trauma department with basically no hope of survival.

Her grandson lay in the bay beside her, awake, unaware of the events behind the curtain immediately to his left. He may have had no one else in the world. There was no time to know this type of detail. Yet, I was sure he would not want us to do this to his grandmother.

My heart sank. I felt sick. Tears clouded my vision.

My mind was indignant. How could we do this disservice to my patient, the system, and the staff? Shouldn’t we call a spade a spade and throw resources into one we could save? This was not an equal distribution of benefits, as there was no benefit to have. Had we fallen to the use of the unsavable to practice advanced trauma skills? Didn’t everyone in the room realize this was futile, wrong, and unjust?

I carried this injustice with me for months. I was even using this example with new nurses as one who did not follow the principle of justice. Until one day, I was challenged.

After sharing this example of injustice, a young nurse stood and asked, “But is this not an example of justice rather than injustice? Should her age and severity of injury keep her from receiving all available treatment?”

I stood stunned.

Justice requires impartiality to patients' age, ethnicity, religion, gender, ability to pay…

Does it extend to the extent of injury? Potential for survival?

Do those questions matter? Or is justice just that – justice for all, regardless…

If resources are available, can they be justly withheld?

I believe my young challenger was right. It was the just action to provide ALL available care, even if the odds didn’t seem favorable. Her grandson, immediately behind the curtain to her right, may have had others in his life. Maybe not. We didn’t have time to know. But wouldn’t he want everything done to save the one he was with today? Would our efforts help dry his tears?

She survived the trauma bay and was taken to the operating room.

Beyond that, she did not survive.

However, her care provision was just.

Nursing ethics seem straightforward on paper, but they can get as cloudy as a tear-stained vision in action. We, as nurses, must continually and critically evaluate our biases to ensure they do not further cloud our view. We are called to provide care to all, regardless of any factors or outcome. This is justice.

About the Author:

Lara Thompson is the Transition to Practice Nurse Residency program coordinator at UF Health Shands Hospital. Most of her career has been in emergency nursing, holding bedside care and nursing leadership positions. Her professional works include presentations and publications on sickle cell disease, sepsis, verbal de-escalation, and the use of simulation in nursing transition to practice.

Professional works:

  • “Interdisciplinary Intervention to Decrease ED Utilization by Sickle Cell Disease Super-utilizers”; Western Journal of Emergency Medicine
  • “A Patient-Centered Emergency Department Management Strategy for Sickle-Cell Disease Super-Utilizers”; UHC Annual Conference poster presentation
  • “Improving CMS Pass/Fail Rates for Sepsis Patients in the Emergency Department”; UF Health Patient Safety and Quality Week poster presentation
  • “SIMplifying Transition: From Graduate to Got It”; ANPD Annual Conference podium presentation
  • “The Main Event: SBAR vs Verbal De-Escalation”; ANPD Annual Conference poster presentation

Lara is an independent contributor to CEUfast’s Nursing Blog Program. Please note that the views, thoughts, and opinions expressed in this blog post are solely of the independent contributor and do not necessarily represent those of CEUfast. This blog post is not medical advice. Always consult with your personal healthcare provider for any health-related questions or concerns.

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