Ethical Issues of a Pediatric Nurse

Parental Conflicts

Parents divorce, but extended families endure -- especially with a sick child to rally around. If only one parent has legal custody of a child, that parent dictates the other parent's access. Parents often use a child as a pawn in their own personal war, creating situations that just plain suck. They aren't fair, and the adults refuse to listen to reason -- to their child's detriment.

You can't force parents to be fair or civil, but you can protect your patient's well-being. If you believe that one parent presents a risk -- e.g., to abscond with the child -- help set up a security plan. Post a guard at the door, if necessary. Insist that disagreements take place outside the child's hospital room. In an ambulatory setting, set careful flags in the medical record to control who may access what information.

A sick kid doesn't need the stress of bickering parents to make things worse. You can't heal family discord, but you can help enforce an environment of safety and healing while the child's in your care.

End-of-Life Care

In most hospitals, the ethics committee appears almost exclusively to deal with disputes about end-of-life care. A child who's been severely injured or suffers from a fatal chronic condition isn't likely to survive, but family members sometimes demand that the hospital do everything to prolong their child's life.

Clinicians usually know when care is futile and have no duty to render futile care. But end-of-life care's as much about the family as the child. Sometimes the family needs time to say goodbye.

As a nurse, you know what's going to happen. Your task is to help the family to accept it. Engage chaplains and staff counselors to provide additional emotional support for grieving family members. Avoid getting sucked into the drama and don't provide false hope: Your task is to ensure the best interest of your patient, and that usually means rendering comfort care until the family is ready to discontinue life support.

Abuse and Neglect

Obvious cases of abuse and neglect usually get sorted out in the emergency room. Less obvious cases are trickier to identify and affect nurses in inpatient as well as ambulatory settings. When you see a kid who's sullen, withdrawn, presents with a complicated trauma history or demonstrates fear of a parent or adult, consider it a warning sign and trust your gut. Most states require RNs who suspect abuse or neglect to file reports with the state's child protective services agency.

Judith Herman, a physician and victim's advocate, noted in her influential 1992 book "Trauma and Recovery" that the "psychological distress symptoms of traumatized people simultaneously call attention to the existence of an unspeakable secret and deflect attention from it."

If you're debating whether a child might be at risk, talk to the kid's doctor or consult with a social worker. An investigation that comes up empty is better than ignoring -- and thus perpetuating -- an "unspeakable secret."

Resistant Guardians

Adults don't need to pass a competency test to procreate, a fact that doesn't always work out well for their sick progeny. Some parents, for religious or cultural reasons, limit the kinds of treatments they'll approve for their children. For example, some fundamentalist sects refuse vaccination, and Jehovah's Witnesses refuse blood transfusions.

As a licensed clinical professional, you know what's best practice for your patient -- but the rights of the parent usually trump medical literature. In cases where a parent's request directly threatens the life or health of a child in your care, don't hesitate to refer the matter to your health organization's ethics committee or to a medical social worker for further evaluation. In some cases, a court may grant temporary guardianship rights on the child's behalf while the fitness of the parents gets extra scrutiny.

Self-Care

Sick children tug at our heartstrings, and being in the middle of ethical disputes about a sick kid can prove emotionally draining. A peds nurse can take a lot, but she reaches a breaking point just like anyone else. Find ways to take care of your own mental health, especially when you've dealt with complicated, emotionally complex problems on the job. Something as simple as a day at the spa or a lazy weekend with your significant other can help -- but don't ever hesitate to seek professional counseling if the emotional burdens you handle on the job intrude on your home life.

An emotionally compromised nurse is herself a clinical and ethical risk to the kids in her care.