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Case Study of Palliative Look after Bowel Cancer

Mrs Cheng has a 2 years history of bowel cancer recently being complicated by liver metastases. Doctors possessed given her a prognosis around one month still left to live. She is admitted to the medical ward for palliative treatment.


Mrs Cheng is the only real survivor of the Boxing Day Tsunami in her family. She has thus no practical support system to talk about.


From a palliative care perspective, it could seem appropriate to assist the individual in get together her special needs during the final days of her life.


The medical center prohibits smoking for legal reasons. Thus Mrs Cheng is allowed smoking only at a garden outside of a healthcare facility.

2. Have the facts


Bowel tumors is presented with a growth of the malignant tumor in the intestines or rectum (Realtime Health, 2010). It is the third most commonly diagnosed cancer tumor in Australia (Tumor Council Australia, 2010).

The final stage of the colon tumor often denotes that the cancer has spread to other organs, including the liver. Currently, there is absolutely no known effective treatment available for stage 4 bowel cancer (Tumor Council Australia, 2010).

In Mrs Cheng's case, her bowel tumor has been further complicated by liver metastases. This is unfortunate but typical in patients with end-stage bowel cancer.

Palliative care

As identified by World Health Company (WHO) (2010), Palliative treatment is an way that improves the quality of life of terminally-ill patients and their families by spotting the needs of an terminally-ill patient, and concentrating on making them comfortable (Palliative Good care Victoria, 2007).

It is important for nurses to comprehend that patient treatment must continue until the end of life and this everything within the method of the medical team be done to ensure that the patient's fatality will be peaceful and dignified (Tumor. Online, 2010).

Palliative Health care Australia recognizes the importance of palliative care, and affirms that it should be considered a center competency for those health care specialists (Palliative Good care Australia, 2008).

Patient's understanding

It is important to ascertain Mrs Cheng's level of understanding for the 'no-smoking insurance policy', the manpower situation and unhappiness of the personnel. Without proper clarification, being a patient, Mrs Cheng may be ignorant of the issues which acquired arisen. It is thus the responsibility of the team to ensure that she totally knows the inconveniences enforced.

Patient advocacy

Patient advocacy, as stated in the Australian Nursing and Midwifery Council (ANMC) Code of Ethics for Nurses in Australia, is the obligation of the nurses to question medical care which they may respect as probably unethical or illegitimate (ANMC, 2008).

Ironically, because of the presence of manpower shortage, nurses advocating in the interest of Mrs Cheng may experience an honest dilemma as they could find difficulty distributing equal amount of attention and medical care to all of those other patients. Likewise, the contrary would be true if advocacy is to be in the interest of the other patients.

Patient's support

Being the sole survivor of the Boxing Day tsunami in her family, Mrs Cheng has inordinately poor public support. It is not known if Mrs Cheng has any extended family members.

The presence of a kin is most favorable in palliative care and attention. A family member may be able to render a higher level of psychological support to Mrs Cheng, and also provide her some positive and healthy distraction from her smoking behavior.

Thus, aid from social workers should be enlisted in tracing possible prolonged members of the family of Mrs Cheng.

Staff disagreement

Some of the personnel had showed dissatisfaction by threatening resignation. To mitigate the matter, the nursing product manager needs to interview the influenced staff, to get a clearer knowledge of the problem and any precipitating factors that may have led the staff to the point of intimidating resignation.


As Mrs Cheng smokes about 25 cigarettes daily, and each smoking trip would take up 12 minutes of the associated staff's working time. So, approximately 300 minutes of manpower would be studied up daily, to see to the particular need of Mrs Cheng.

Staffing is a factor which frequently inhibits the grade of care, and restricts the time available for nursing care delivery to each patient (Irurita, 1999). The issue of both manpower wastage and shortage must be address.

Disruption of care

Mrs Cheng's smoking habit requires extended intervals of attention from the medical professionals. It is thus inescapable that attention is being deprived from all of those other patients in the ward. This needs to be looked into, as neglect may derive from such disruption of treatment.

Passive smoking

By accompanying Mrs Cheng to the garden for cigarette smoking, it is unavoidable for the accompanying nurse to be exposed to harmful unaggressive smoking. As Mrs Cheng smokes closely, the visibility of the nursing staff to the hazardous fumes, are relatively immerse. Thus, actions should be studied to safeguard the well-being of the staff.

3. Consider the four principles


Autonomy is known as the exercise of one's free will, that ought to be regarded as acceptable, so long as it generally does not affect the privileges of others adversely (Staunton & Chiarella, 2008, p. 31). Being mentally skilled, Mrs Cheng should have got the free will to smoke cigars for around she desires.


Beneficence is often referred to as the theory of 'above all, do good' (Staunton & Chiarella, 2008, p. 32). It affirms that the healthcare professional should always respond, with the best interest of the patient at heart (Dominick, 1999). Thus, advocating Mrs Cheng to give up smoking may be an action of 'beneficence', as smoking can be an unhealthy habit and induces unwanted health final results.


Non-maleficence is the theory of 'above all, do no damage' (Staunton & Chiarella, 2008, p. 32). Thus from the 'non-maleficence' point of view, one should not forbid Mrs Cheng from indulging in cigarette smoking as it might affect her adversely, in relation to her emotional health and stability.


Justice identifies the responsibility of the professional medical professionals to take care of all patients with equality and fairness (eNotes. com, 2006). A good example of justice, specifically in countries where racism is obvious in many aspects of life, is when nurses display equal and impartial care and treatment towards all patients, regardless of age, making love, and ethnicity.

Value assertion 3 of the Australian Nursing and Midwifery Council (ANMC) Code of Ethics for Nurses in Australia claims that nurses should value and value the diversity of folks (ANMC, 2008). While do affirmation 4 of the ANMC Code of Professional Conduct for Nurses in Australia claims to respect the dignity, culture, ethnicity, values and beliefs of people receiving good care and treatment (ANMC, 2008).

As a palliative patient in the ward, it is perchance that Mrs Cheng's special needs are more so looked after than all of those other patients in the machine. One could claim that, regardless of Mrs Cheng's plight, it is equitable that equal attention and treatment should be rendered to all or any the patients in the machine.

4. Identify moral conflicts

Beneficence versus Non-maleficence

Beneficence versus Non-maleficence is one of the very most apparent moral dilemmas which can be important to Mrs Cheng's smoking habit. Beneficence, here, may refer to protecting Mrs Cheng from the ill effects of smoking by advocating her to lead a smoke-free life; while non-maleficence, may refer to respecting Mrs Cheng's wants by approving her requests to smoke cigars.

The healthcare team needs to weigh the benefits and deficits of adopting either principle. Being truly a medical ward, it is dubious if all the nurses on the unit understand the crux of palliative nursing. Hence, it is of eminent importance that the complete team gain an improved knowledge of palliative care. As such, a higher degree of empathy and a far more humanitarian methodology may be invoked in the nurses looking after Mrs Cheng.

In spite to be one of the most preventable factors behind ill health and loss of life (HealthInsite, 2010), it is slightly irrelevant to go over about the problems of health awareness with a dying patient. It is also uncompassionate to truly have a terminally-ill patient cut down on or to stop smoking during the final days of her life, as drawback symptoms may result from abstinence from smoking, creating more distress to Mrs Cheng, and in turn, further compromises her standard of living.

Autonomy versus Beneficence

Despite being a terminally-ill patient, Mrs Cheng is psychologically able and experienced. Thus her autonomy as a person should be reputed. Mrs Cheng indulges in, and attracts enjoyment from smoking cigarettes. An ethical turmoil develops when Mrs Cheng's autonomy disharmonizes with the healthcare professional's process of beneficence.

An effort to protect Mrs Cheng's autonomy means supporting her in achieving her needs of getting her cigarette smokes; while on the other hand, one with the process of beneficence at heart would discredit such an act.

The writer feels that the process of beneficence should not overwrite that of the patient's autonomy. Value statement 2 of the Singapore Nursing Plank code of ethics and professional do, states to respect and promote the patient's autonomy and privileges for self-determination (SNB, 2006). Thus restricting Mrs Cheng from smoking should be deemed as unethical and unprofessional.

Nevertheless, any worried nurse may inform Mrs Cheng on the undesireable effects of smoking and advice her on the choice of Nicotine Alternative Therapy (NRT), in so doing ensures that she actually is fully aware of the undesirable health benefits of smoking and the options available.

However, additionally it is important to ensure that this is not done in a domineering manner. Clause 2. 1 of the Australian Medical and Midwifery Council (ANMC) nationwide competency criteria for the rn, areas to ensure that personal principles and attitudes aren't enforced on others (ANMC, 2006).

Should Mrs Cheng choose to keep smoking, her autonomy should be well known and conserved, for as long as she is psychologically competent of making her own decisions.

5. Consider the Law

Smoking is prohibited for legal reasons in a healthcare facility. Nonetheless, being emotionally able, Mrs Cheng should wthhold the autonomy of making her own decisions. In this instance, undertaking the function of cigarette smoking, so long she does not do it within a healthcare facility.

It is not said if Mrs Cheng owns the physical capabilities to go herself about in a wheelchair. Nonetheless, should she require any assistance, it is the work of the nurse to assist her in the aspect of her flexibility. Clause 1. 2 of the ANMC National Competency Benchmarks for the Registered Nurse states to fulfill the duty of attention towards patients (ANMC, 2006). In Mrs Cheng's circumstance, a obligation of good care would involve accompanying her to your garden for cigarette smoking.

There is not a clear moral or legal monthly bill that protects the interest of the nurses. However, in Australia, the value of nurses safeguarding themselves was discussed in a guideline titled 'The Responsibilities of Nurses and Midwives in the Event of a Declared National Disaster'.

Owing to the duty of care, it could be the liability of the nurses to escort Mrs Cheng for cigarette smoking. Nevertheless, nurses shouldn't be oblivious to the fact they are exposure to passive smoking in the process, and take precautionary measures, such as donning a face mask to prevent unnecessary and extreme inhalation of harmful fumes (ANMC, 2008).

6. Making the honest decision

The writer is convinced that Mrs Cheng should retain her right to smoke cigarettes. As the palliative patient, Mrs Cheng's needs should not be compromised.

It could very well be lucid that the nurses in the medical unit feels frustrated over caring for Mrs Cheng. Apart from manpower shortage, they also lack particular knowledge and therefore could find difficulty in empathizing with Mrs Cheng's needs. Thus, it is perchance that majority of the nurses would be willing to nurturing more for the medical patients, for whom they could render nursing treatment more confidently.

The administrator should enquire with the palliative product of the hospital regarding the opportunity of transferring Mrs Cheng to a palliative ward, where she may acquire more individualized medical good care from trained palliative nurses. By doing so, would concurringly, solve the problem of the manpower scarcity, as well as the dissatisfaction among the affected nurses.

In the event that a copy is not possible, the manager may explore the possibility of enlisting the help of a palliative volunteer, to tend to this special need of Mrs Cheng. This would alleviate the responsibility on the medical team. There are several palliative volunteer programmes in Australia, one which is Victoria's Palliative Care and attention Program (Victorian Federal government Department of Human Services, 2007).

7. Report the decision

Documentation is actually an integral element in nursing attention, as it provides as an important tool for communication between customers of the health care team. Nurses need also remember that the patient's improvement records could be commanded as legal documents in case of a legal prosecution, thus it is important that entries are concise and factual (Hansebo, Kihlegren, and Ljunggren, 1999).

Clause 10. 2 of the ANMC National Competency Requirements for the Registered Nurse states the importance of nurses to documents all varieties of communication, nursing interventions and individual/group responses, precisely and as soon as possible (ANMC, 2006).

The manager should assume the responsibility of documenting the problems of the nurses, so as to better facilitate an research of the possible main causes of the challenge. Upon coming to the honest decision, points arranged upon by the team needs to be clearly registered, to ensure that everyone on the unit is aware of the decision.

Nurses should inform Mrs Cheng on the unsafe effects of smoking, and have it noted in the notes. Mrs Cheng's demands to proceed to your garden to smoke also needs to be recorded, moreover for each and every journey made.

It is also important for the nurse to convey that Mrs Cheng has been along with a nurse or professional volunteer throughout her quest to the garden; this is specially true if Mrs Cheng is bodily frail and requires assistance with mobility.

8. Evaluation the decision

Clauses 4. 1, 7. 6, and 8. 1 of the ANMC Country wide Competency Criteria for the RN state the importance of nursing treatment evaluation.

The manager needs to review and assess staff satisfaction frequently, to reduce any amassment of discord or unhappiness amongst the participants of the healthcare team. This might also provide chance for ventilation and early on intervention, and in turn prevent issues from escalating to an immitigable express.

Nurses on the ward should review the safeness and comfort of Mrs Cheng with the palliative volunteer, if any. While it is beneficial to have a volunteer to see to the needs of Mrs Cheng, her safe practices and wellbeing must not be compromised.

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