The present patient care situation involves an East Asian family whose elderly grandmother, J., has been diagnosed with second-stage lung cancer. The woman came to the United States through a family reunion program and has not yet learned English properly to converse in a medical setting. Therefore, at the hospital, J. has to use her relatives as interpreters to receive information about her condition. Upon learning about J.’s cancer diagnosis, her family decided not to tell her immediately. As they explained to the nurse, J. is a frail old lady who will be crushed if she becomes aware that her condition may as well be lethal. For this reason, they intend to lie to her that she has pneumonia and pretend as if her cancer treatment is for curing this disease. The nurse is torn between communicating with J. using an interpreting aid or playing along with her family and letting them decide what the woman knows about her health status and what she does not.
Lung cancer is the leading cause of cancer deaths worldwide. Only 16% of lung cancer cases are identified at an early stage, which is true for J (American Lung Association, 2020). At the moment, J.’s tumor is localized in her lungs, which gives her a 56% chance of survival in the next five years (American Lung Association, 2020). However, if cancer spreads, she will only have a 5% probability of surviving the disease (American Lung Association, 2020).
J. used to live in rural China all her life until her health deteriorated two years ago. Her children, first-generation immigrants in the United States, decided to apply for a family reunion visa for J. that would allow her to come live with them. In the US, J. is fully dependent on her children, socially and financially. She cannot read, understand, or speak English, which is why her family takes charge of all health decisions. J.’s family claim that her health literacy is not enough to understand her diagnosis correctly. Due to her poor English knowledge, J. did not express any verbal preferences or write an advance healthcare directive to exercise self-agency.
When solving the dilemma, some external influences should be taken into account. For instance, by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), sensitive patient health information is protected (Olejarczyk & Young, 2020). Every patient has the right to obtain all relevant information and only disclose it to third parties with his or her knowledge and consent. In addition, the American Cancer Society developed a bill of rights that is supposed to empower patients to take an active role in improving their health (Olejarczyk & Young, 2020).
The nurse needs to separate the facts from the assumptions when approaching a complicated ethical case such as that of J. For instance, it should not be assumed that J. is completely on board with her family’s decisions regarding her health. In addition, the nurse should not assume that not knowing about her diagnosis will help the woman cope. Because sometimes, it is easier to assume, J. and her family should be asked additional questions. The nurse may want to know whether the patient is mentally able and if her knowledge of English is truly this poor. What one should keep in mind is that J. is likely to be in sound mind and adequate to reason, which is why she should be the primary decision-maker about her health.
From an ethical standpoint, the curse of action that J.’s family has chosen so far violates the principle of autonomy. The patient has the right to take control of her body and make decisions accordingly (Levine-Ariff & Groh, 1990). The woman’s children may indeed be acting from the place of love, which would be in line with the principle of beneficence. The family is convinced that being unaware of the cancer diagnosis will spare J. a great deal of suffering and emotional pain. However, the family members may not know what exactly is good for her physically and mentally since she is practically excluded from the process and not given a voice. If the nurse plays along, she may act against the principle of fidelity (Levine-Ariff & Groh, 1990). When J. was admitted to the hospital, the caregiver took up the responsibility of building a trusting relationship with her. There can be no trust if the nurse is complicit in J.’s family lies.
There are three different alternatives from which the nurse can choose. Firstly, he or she can let the family act as they see fit. By choosing this course of action, the nurse will avoid conflict but break the patient’s trust. Alternatively, the caregiver may consider convincing the family to tell J. about her cancer diagnosis. In this case, J. will learn the information from her closest people and in the language that she understands. However, trying to change the mind of the people who are set in their ways may be near to impossible for an outsider. In addition, even if the family appears convinced, the nurse will have no way of telling whether they acted on their promise and told J.
The third option may be the best and most ethically sound one. Language discordance is a growing problem in American healthcare that may no longer be solved by relying on accidental interpreters, body language, and stringing together fragments of multiple languages (Abdelrahim et al., 2017). J. may greatly benefit from using a professional Chinese-English interpreter’s services. An interpreter may be a better mediator than a family member for a variety of reasons. A professional is impartial to the situation and will not try to manipulate the outcome. Additionally, they have a good grasp of the medical lexicon that they can properly translate and explain to the patient. Therefore, the nurse should check whether such a service is available at her hospital, and if not, resort to phone interpretation.
The present case has demonstrated that one of the nurse’s roles is being a patient’s advocate. Nsiah et al. (2019) suggest that patient advocacy may not be a preference but a requirement because failure to protect patients leads to negative consequences. According to the study’s findings, advocacy is a multifaceted concept that includes a variety of actions that nurses may take to improve the quality of care. In the present case, the nurse is essentially the patient’s voice: she speaks up for J. and stands in for her needs. Another aspect is protecting patients’ rights, such as the right to information, and using it to exercise self-agency and make decisions about one’s health.
References
Abdelrahim, H., Elnashar, M., Khidir, A., Killawi, A., Hammoud, M., Al-Khal, A. L., & Fetters, M. D. (2017). Patient perspectives on language discordance during healthcare visits: findings from the extremely high-density multicultural State of Qatar. Journal of Health Communication, 22(4), 355-363. Web.
American Lung Association. (2020). Lung cancer fact sheet. Web.
Levine-Ariff, J. & Groh, D.H. (1990). Creating an ethical environment. Nurse managers’ bookshelf a quarterly series: 2:1. Baltimore, Maryland: Williams & Wilkins.
Nsiah, C., Siakwa, M., & Ninnoni, J. (2019). Registered nurses’ description of patient advocacy in the clinical setting. Nursing Open, 6(3), 1124–1132. Web.
Olejarczyk, J.P. & Young, M. (2020). Patient Rights. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.