Posted: October 20th, 2022

A 14-year old boy is hospitalized for relapse of leukemia

Week # 7 Discussion (ANA Code of Ethics)
Case # 1 Robbie
• A 14-year old boy is hospitalized for relapse of leukemia after a failed bone
marrow transplant. The family has been told his condition is terminal, there is
nothing more to be done except keep him comfortable.
• His mother is distant, uncommunicative and rarely visits. When she does, she
doesn’t touch Robbie or speak to him. She sits in a recliner by the window
reading novels and requesting cokes multiple times per visit.
• The staff calls a family meeting but the mother is conspicuously absent.
• Robbie’s father is frantic, demanding further treatments, regardless of low
likelihood of efficacy. During the family meeting, he directs the team NOT to
tell Robbie he might die, as he would lose hope. He states:
“In our culture, we keep this news from patients to avoid upsetting them.”
• You are the nurse. When you are alone caring for Robbie, he asks you
“Am I dying?”
Answer the following questions in your statement:
How should you respond?
o What are three options you could select?
o Cite advantages and disadvantages of each.
o How does the Code guide you in the virtue of truth-telling?
o Who is the authorized decision-maker in this case?
o What other considerations play a part in your response

Case #1:
As a nurse, we often struggle with the balance between hope and telling the patient the complete truth. We communicate through our body language, tone of voice and the words we use. I would sit on a chair at the same level as Robbie removing any barriers and give him my full attention. I would explore Robbie’s perspective and concern by asking questions such as “tell me more about what you think is going on right now” or “what fears do you have right now?” Asking these questions can be particularly helpful in this situation. I would feel more comfortable asking questions to elicit Robbie’s understanding to reduce his distress and anxiety. By allowing Robbie to discuss his fears can help support a sense of control in frightening and disempowering situation to help him prepare for information that will follow.
An advantage of this will show that I am engaged and actively listening as Robbie explore his concerns and fears. Actively listening ensures that I understand how Robbie is feeling such as if Robbie stated that he feels worried, I would explore that topic and ask, “can you tell me more about how that feels?” Another advantage is to allow Robbie to ask as many questions as possible to alleviate the tension building up. A disadvantage of this is not always having all the answers to the questions that Robbie will ask. Another disadvantage is unclear communication of Robbie’s inauspicious prognosis will be vague due to the father’s request to the team to not tell Robbie that he will die to lose hope.
As healthcare professionals, we are expected to always tell the truth simply because it is the right thing to do. Our code and duty that is required is to tell the truth. Given the duty of openness and honesty that is expected from a healthcare professional, it is important to maintain that relationship with the patient. The meaning of truth and acceptance of it varies between cultures. Therefore, it is necessary to treat patient’s sensitivity and providing information with great communication skills. The authorized decision maker in this care would be either Robbie’s father or mother. In this situation, his mother has been distant and uninvolved with Robbie’s diagnosis. However, Robbie’s father is more involved demanding further treatments. Robbie’s father directed the team to not tell Robbie the truth because he would lose hope is something as healthcare workers, we would have to respect the parent’s wish. Other considerations for this situation would be to involve other potential sources of support in the room such as other doctors, nurses and family members while providing Robbie with the appropriate information. Having multiple healthcare workers along with family is essentially ideal to have so that everyone can provide Robbie with the appropriate answers.

Case 1
In this unfortunate situation the RN is faced with a few options as to how she will handle this situation. After the father has instructed the team to not let Robbie know of his fate, they firstly might feel liable to the father as not to tell him. Secondly, they may feel compelled to tell the truth to the patient himself, as this is who the RN and team is caring for firsthand.
Looking at a smaller scale situation from personal experience, I work in a procedural area with children ages 2+. Before the procedure each of these kids needs to have an IV placed for anesthesia to be administered. Almost half the kids will ask us while they’re being admitted if they’re going to be “getting a shot.” Sometimes the parents have already warned the kids what will be happening, and other times parents deliberately lie and tell the child that they will not be getting any shots or injections at this visit. It now becomes the nurse’s responsibility as to what they will do in this case. Most of the time the RN usually redirects this question in a different way, almost as a distraction. It is not to lie to the child, but more so we can get this small part of their day over with to prepare them for the rest of the procedure as we know this little “white lie” will not harm the child drastically. Weighing if what we do will cause more harm than good is very important in guiding our practice in my opinion.
Similarly, I think I would redirect Robbie’s question and not directly answer it. I may ask something along the lines of, “what scares you the most right now” or “how are you currently feeling.” At the end of the day Robbie is still a minor and I would not want to go over the parent’s head by secretly saying things that the father has asked us not to. The father and mother are the authorized decision makers and what they say unfortunately must go. Ethically and morally, we may not agree with their choices or how their dynamic as a family might be, but this is not our place to judge or make decisions for the health of the child.
By asking Robbie these questions, you can get a feel for how he is feeling and go over that with him, without saying his final fate as his father advised against. If we decided to go the other way against the father’s advice and tell Robbie what was going on, he could end up in a panic and not handle the information well (especially as a 14-year-old).
As the RN, if I still felt uneasy about this situation and how it was going, I could speak to my manager and the healthcare team and possibly have a second meeting with the ethics team, social work etc. Trying again for a family meeting could be organized, and everyone’s wishes could be talked about openly rather than going behind anyone’s back secretly as one may want to. This would keep everyone on the same page, while allowing the primary care takers (the parents) to still be the decision makers in this case.

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