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chapter 3 | Nursing Practice and the Law 33 CikguOnline
A condition is considered terminal when, to a checked the heart rate, pupils, and respirations and
reasonable degree of medical certainty, there is lit- stated, “I just cannot do it to her.” (Guido, 2001,
tle likelihood of recovery or the condition is p. 158). She ordered the nurses to stop the resusci-
expected to cause death. A terminal condition may tation, and the physician pronounced the death of
also refer to a persistent vegetative state character- the client. The nurses stated that if they had not
ized by a permanent and irreversible condition of been given a direct order they would have contin-
unconsciousness in which there is (1) absence of ued their attempts at resuscitation. “The court
voluntary action or cognitive behavior of any kind ruled that the physician’s judgment was faulty and
and (2) an inability to communicate or interact that the family had the right to sue the physician
purposefully with the environment (Hickey, 2002). for wrongful death” (Guido, 2001, p. 158). The
Another form of advance directive is the health- nurses were cleared in this case because they were
care surrogate. Chosen by the client, the health-care following a physician’s order.
surrogate is usually a family member or close friend.
The role of the health-care surrogate is to make the Nursing Implications
client’s wishes known to medical and nursing per- The Patient Self-Determination Act does not speci-
sonnel. Imperative in the designation of a health- fy who should discuss treatment decisions or advance
care surrogate is a clear understanding of the client’s directives with clients. Because directives are often
wishes should the need arise to know them. implemented on nursing units, however, nurses need
In some situations, clients are unable to express to be knowledgeable about living wills and health-
themselves adequately or competently, although care surrogates and be prepared to answer questions
they are not terminally ill. For example, clients with that clients may have about directives and the forms
advanced Alzheimer’s disease or other forms of used by the health-care institution.
dementia cannot communicate their wishes; clients As client advocates, the responsibility for creat-
under anesthesia are temporarily unable to com- ing an awareness of individual rights often falls on
municate; and the condition of comatose clients nurses. It is the responsibility of the health-care
does not allow for expression of health-care wishes. institution to educate personnel about the policies
In these situations, the health-care surrogate can of the institution so that nurses and others involved
make treatment decisions on the behalf of the in client care can inform health-care consumers of
client. However, when a client regains the ability their choices. Nurses who are unsure of the policies
to make his or her own decisions and is capable in their health-care institution should contact the
of expressing them effectively, he or she resumes appropriate department.
control of all decision making pertaining to med-
ical treatment (Reigle, 1992). Nurses and physi- Legal Implications of Mandatory
cians may be held accountable when they go Overtime
against a client’s wishes regarding DNR orders and
advance directives. Although mostly a workplace and safety issue,
In the case Wendland v. Sparks (1998), the physi- there are legal implications to mandatory overtime.
cian and nurses were sued for “not initiating CPR.” Due to nursing shortages, there has been an
In this case, the client had been in the hospital for increased demand by hospitals forcing nurses to
more than 2 months for lung disease and multiple work overtime (ANA, 2000). Overtime causes
myeloma. Although improving at the time, during physical and mental fatigue, increased stress, and
the hospitalization she had experienced three car- decreased concentration. Subsequently, these con-
diac arrests. Even after this, the client had not ditions lead to medical errors such as failure to
requested a DNR order. Her family had not dis- assess appropriately, report, document, and admin-
cussed this either. After one of the arrests, the ister medications safely. This practice of overtime
client’s husband had told the physician that he ignores other responsibilities nurses have outside of
wanted his wife placed on artificial life support if it their professional lives, which affects their mood,
was necessary (Guido, 2001). The client had a motivation, and productivity (Vernarec, 2000).
fourth cardiac arrest. One nurse went to obtain the Forced overtime causes already fatigued nurses
crash cart, and another went to get the physician to deliver nursing care that may be less than opti-
who happened to be in the area. The physician mum, which in turn may lead to negligence and