Subject

Subject for next Semester (Semester 3)

Results

...my SEM 2 results is not that great.Actually I feel frustrated but when I think again,may I'm lacking in a lot of things.I know I need to study harder this coming semester...

Injection Procedure

I can't remember whether I learned how to do injection like this last time!!!! hahaha

MODELS OF CARE DELIVERY SYSTEM

1.0 Introduction

Model of care delivery system is a method of delivering nursing care to achieve the optimum patient outcome. The structure of care delivery system is to enable the nurse to provide nursing care which include assessing care needs, formulating care plan, implementing and evaluate patient’s response to the intervention.

Manthey(1990)identified the element of nursing care delivery system as a clinical decision making, work allocation, communication and management. Since World War II, Models of Care Delivery System had undergone a lot of changes. Each of the nursing care delivery care system has an advantages and disadvantages. However, none of those systems is considered perfect. Critiqued heard and debates focused on perfectness of each model providing care considering patients, consumers’ and practitioners’ needs which include effectiveness, quality and cost effectiveness.

The goal of successful patient’s care delivery system includes high quality and the achievement of patients’ outcome and satisfaction level. The ability to reach the objective depends on the type of delivery system and how the care is delivered.

2.0 Type of Nursing Care Models.

There are old and new systems and models of care delivery applied but the priorities is in an environment where there is an increased of health care cost and health care errors. Huber,(2006) in her book stated 6 type of model of care delivery system which are, Private Duty Nursing, Group Nursing, Team Nursing, Modular Nursing, Primary Nursing, Case management, Mix model(Hybrid).However the most common model used are Functional Nursing, Team Nursing, Modular and Primary Nursing.

2.1 Functional Nursing.

Functional Nursing began in 1940’s due to the shortage of nurses. During World War ll, depletion of nurses is due to the moving of nurses to the armed forces. Also called task nurse whereby the staff nurses and care givers are used to the optimum advantage. The staff nurses will be working together with other health care provider performing task assigned .In Functional Nursing, different level of personnel worked side by side, each performing the assigned task. (Chitty, 2005).

The Staff Nurse will assess the patient and will assign other staff as medication nurse, dressing nurse, vital sign nurse. Nurse Aids are assigned to give bed bath to patient. The Functional Nursing of Delivery System is characterized by an assembly line approach to care, in which each staff member is assigned a set of tasks (Ringl, 1994).

The advantage of Functional Nursing is that it could accomplish a lot of tasks which they are capable and assigned to do efficiently in a small amount of time.

However the Functional Nursing has the disadvantages whereby there will be uneven continuity of care and absence of holistic view, poor follow up and poor communication with patient. Chitty. K. K (2005) said, they was no one person they could call, “my nurse”.

2.2 Team Nursing

Team Nursing is the most common model of care delivery system being practiced. It was developed in 1950’s to reduce the fragmented care that accompanied Functional Nursing despite the shortage of professional nursing staff. Team Nursing provides total nursing care to a group of patient. The goal is for the team uses a skill mix nursing staff to work together democratically, not as individuals, to provide total care to an assigned group of patients (Bertram, 1994; Sherman, 1990). Team nursing as said by (Kron 1978) is based on philosophy in which groups of professional and non-professional personnel work together to identify, plan, implement and evaluate comprehensive client-centered care towards the common goal providing qualitative comprehensive nursing care.

Team Leader is accountable for all of the care activities and the team member possessing the skill needed by the individual patient. The most skillful team members will provide care for the most seriously ill patient and the least experience members will provide care for the patient who needs least care.

The Staff Nurse coordinates and leads the team in assigning, delegating, and supervising care. Job satisfaction should be high when the team member’s capabilities are maximized. Team member will support the group productivity and growth for the team. However, Team Nursing requires team spirit and commitment because the team leader will be changing, thus the continuity of patient care may differ.

Although Functional and Team Nursing were implemented in an effort to increase efficiency and cost effectiveness, they have been criticized as being strictly task oriented, increasing fragmentation of care, and reducing the amount of direct nursing care provided by the Staff Nurse (Bertram, 1994; Sherman, 1990).

2.3 Modular Nursing

Modular Nursing is modification of Team Nursing (Barbara Cherry, Susan R. Jacob. 2002) which requires less staff. The size of module or team is according to the physical layout of the ward, patient’s equity and skill mix nursing. The concept is for the smaller group of staff will be assigned to small group of patient and therefore the communication is more efficient.

Team leads by Staff Nurse and the team member will provide patient’s care as directed by her. The team leader’s activity will be developing, updating nursing care plans and solving problem encountered by the team members, communicate with physician regarding patient’s progress and other health care personnel. (Yoder Wise,2003) said that when staff consistently assigned to the same module, continuity of care and communication will improved and therefore the team leader will have time to participate in planning and coordinating care.

In Modular Nursing, team leader is accountable just like Team Nursing and the successful of this model is depending on the team leaders’ leadership.

2.4 Primary Nursing.

Primary Nursing is direct patient’s care which covers 24 hours, continuous accountability for planning and implementing patient’s care from admission till they discharge. The Staff Nurse will establish relationship with patient and family, making decision and coordinate the patient’s activities with other health personnel and seen as more knowledgeable and responsible. It increases the nurse satisfaction by learning in depth the care required. The primary nurse coordinates the plan of care throughout the patient’s hospitalization, and associate nurses carry will out the plan during the absence of the primary nurse. (Bertram, 1994; Shukla, 1983b).

Assignment will be allocated by the nurse leader according to the expertise and specialties of the staff and type of cases. The Staff Nurse coordinates and leads the team in assigning, delegating, and supervising care (Bertram, 1994). It has been debated saying that Primary Nursing is not cost effective because Staff Nurses spend time doing things that other, less expensive employees can do. However, during the shortage of staff, Primary Nursing cannot be implemented.

The advantages of the Primary Nursing are increased patient and family satisfaction when the nurse and patient knew each other well. Primary Nursing also promotes job satisfaction to nurses when they had autonomy to the decision making towards the patient’s care.

However, it is expensive to hire all staff nurses when Primary Nursing applied. The continues care for patient, heavy responsibility and conflict with the associate nurse might cause the nurse to suffer from stress.

3.0 Clinical Practice scenario

I am a Clinical Instructor for private Nursing College in Ipoh. When this assignment was started, my clinical posting was at Tapah District Hospital and therefore my observation was based on this hospital. Tapah Hospital is an old, small hospital with capacity of 100 beds. The hospital doesn’t provide advanced services and facilities to patient. The facilities are limited to minor cases among the population which covers small areas around the town. The wards and units are scattered at different location and at different building. The Male medical and Female Medical ward separated but shelters are attached to both wards to shelter from rain and hot sun.

The x ray, laboratory and pharmacy department located next to emergency department are up to 30 meters away from the ward. However, ambulance service is always available if any crisis arises. Patient will be accompanied by nursing staff if ever x-ray needed. If there is shortage of staff noted, additional staff will be called in. Nursing staff stayed at the hospital quarters or houses nearby and therefore staff is available at all time. They had an A&E and Outpatient clinic.

They are 3 Nursing Sisters. Each of them are assigned to Maternity, Pediatric and Medical ward. The Nursing Sisters will be on duty at 8.00a.m-5.00pm and taking turn to do On call. However, Emergency Department taken over by the Medical Assistant.

Patients’ populations are small. Occasionally the Male Medical Ward is having 8-12 patients and during the peak days they will be 16-20 patients. Patients are from different ethnic and mainly are from the local people and the Orang Asli (Indigenous People) nearby especially patient in the Maternity ward. Due to the distances, the discharge procedure delayed and longer stay in the ward noted compared to the other ethnic. The hospital provides Transit Ward for the convenience of the Orang Asli to stay especially to the pregnant mother awaiting for delivery.

Tapah Hospital is not equip with ventilator, central monitoring or invasive monitoring neither high tech equipment and therefore there does not require many highly skills staff. The allocated nurses are enough to maintain the well flow of care. The Staff Nurses are from the mix skill which could enhance high standard of patient’s outcome. Computer system is not in use in the ward. Tracing blood results from the laboratory and x-rays done manually by sending Nurse Aids to the particular department.

4.0 Model of Care Delivery System In Tapah Hospital.

I have observed Tapah Hospital practicing Functional Nursing which is also called task nurse. In the ward, there will be 2-3 Staff Nurses and 1 Community Nurse with an additional of 2 Nurse Aids will be assigned during the shift. It is also depend on the staff availability.1 Staff Nurse will be the leader or incharge nurse as assigned by the Nursing Sister. The nurse leader will follow ward rounds and communicate with physician or any other health care personnel, do changes in patients’ treatment and ensure all care are rendered .The other Staff Nurse will serve medication, attending new admission, ordering drugs and helping around if any of the staff need assistant.

The Community Nurse will be assigned for dressing and other procedures such as updating intake output chart, checking vital sign, checking blood sugar level and putting up IV fluids. Giving bath to patient, serving food and feeding done by the Nurse Aids. The Nurse Aids had limited scope of competencies. They are on job trained and able to do bed bath, bed making, positioning of patient, serving food, collecting trays, admitting and discharged of patient.

Delegation of assignment is according to the staff level. The activity of daily living will be done by Nurse Aid and procedure which requires high level of skills will be done by the Staff Nurses.

5.0 Discussion

Practically, Functional Nursing being practiced well in Tapah Hospital. However Primary Nursing is the most appropriate model with regards to environment, patients’ population and staff availability.

5.1 Environment

If Primary Nursing been practiced, greater competence in skill are optimized will enhance positive effect on quality patients’ outcome. The hospital could provide advanced equipment and invasive procedure could be performed. Critically ill patient will be taken cared well in view of the skill mix competencies of staff background and ensure continuity of patient care. Patient will be satisfied and complain will be less heard.

Transferring patient for further management can be avoided whereby it is occurred currently in this hospital. In the case of transferring intubated haemodynamically unstable patient to other centers for ventilation support, the patient might be at risk of accidental extubation in the ambulance and staff who accompanying the patient will be in stress.

Primary Nursing attract high quality nursing staff offering high quality of care which patient and family experiences increased satisfaction (Yoder-Wise, 2003). Staff satisfaction will be achieved when given an opportunity to nurse ill cases with advanced equipment, enable staff to maintained nursing skill to the optimum and able to use their education to provide holistic care. Furthermore, the staff will lost their skill in long period of time if the nursing skill is ignored. The “thank you” from patient is a big gift to the nurses. Kenneth J. Sellick, S. R. (2003, July) said a study was conducted in a large acute medical-surgical hospital incorporated a control group and quantitative measures of the variables under investigation showing significantly higher levels of patient and staff satisfaction were shown which support the philosophy of Primary Nursing.

In Primary Nursing features, staff will develop good communication, relationship and

responsibility towards patients through (Marriner-Tomey, 2000) continuity of care for 24 hours per day throughout the hospitalization. When staff: patient rapport buildup, health education can be emphasis in the sense of wellness which could changed patients’ and family towards healthy lifestyle.

5.2 Patient Population

Patient population at Hospital Tapah is small. Occasionally the Male Medical is having 8-10 patients and the peak days they will be 16-20 patient. Female Medical received 6-18 patients. Patients are from different ethnic and the Orang Asli (Indigenous People) nearby. I am focusing on the admission for the Orang Asli. Malays, Chinese and Indian doesn’t have so much problem for hospital admission, however for Orang Asli, admission to the hospital is a stressful experience. The advantages of primary nursing focus on clients need greater nurse autonomy and greater continuity care during the hospitalization (Huber, D. 1996). Language and culture barrier is very inconvenience to the Orang Asli.

If ever the Orang Asli were transferred to Ipoh or Teluk Intan Hospital for further management, the relative will be in dilemma due to the difficulties in life style, transportation and accommodation. Most of the Orang Asli stays far from the town and they cannot afford to spend a lot of money for transport and lodging. (Jeffrey R. Vincent, 2005) In their book said, “In 1999, half of the Orang Asli were poor, and one is approximately seven lived in extreme poverty”.

Due to the distances, the discharge procedure for Orang Asli always delayed and they will stay longer in the ward waiting for transport facilities compared to the other ethnic. However the hospital provides Transit Ward for the convenience of the Orang Asli to stay especially for the pregnant mothers awaiting for delivery.

5.3 Staff Availability

Primary Nursing requires Staff Nurses. Staff Nurses at Tapah Hospital comes from different specialties’. The Staff Nurses can provide all the care to the patient and therefore unlicensed or unprofessional staff will be decreased which reduced cost. Macdonald, M. (2006) in her descriptive literature in an attempt to decide whether primary nursing is worth trying, explored to determine whether the process of implementing primary nursing is worthwhile and finally agree there are staff and patient satisfaction, quality of care and the cost effective.

Staff Nurses at Hospital Tapah stays at the hospital quarters provided or at the housing area nearby and therefore if the need arises the staff is available to meet the requirement.

6.0 Critical analysis and critique

Nursing models constructed of theories and concept used by the nurses to assess, make plan, implementing and evaluating care. Caring is not unique in nursing. It is human behavior including cognitive, affective, psychomotor and administrative skills. Models of Care Delivery system gone through a lot of changes due to criticized in order to formulated another new system which results in better patient outcome and cost effective. However, there is a lack in the models often because of the lack on similarity of staffing, patient population on comparison unit cultural aspect and job satisfaction. The models could be better than the other in terms of cost, staffing and patient outcome.

Functional and Team Nursing are cost effective in view of reduced number of Staff Nurses but patient outcome is not as excellent as Primary Nursing. Compared to the pass, the patient now is acutely ill, but the Staff Nurses: patient ratio is declined. As mention by JoAnn Graham Zerwekh, Jo Carol Claborn (2003) increased acuity of patient results in increased of responsibilities and at the same time increases the nurses workload.

Primary nursing is expansive but reasonable. Patient is satisfied, complain not heard. Standard of care will remained excellent and the hospital will be well known. If the staff is competence and productive the cost might be equal and Primary Nursing will do better. Job satisfaction will motivate Staff Nurses to go for further study to the tertiary level and the will impact on positive patient outcome and increased nursing standard. The organization will be able to retained competence staff which will reduce cost on recruiting new staff.

Increased Nurse: patient ratio will have positive impact to patient good outcome whereby less error occurred such as medication error. Resources, J. C. (2004)did mention that lower staffing level are also associated with higher fall rates and medication error.Staff will be leaving to a better place when job satisfaction is poor due to stress at the work place, shortage of staff, low salary. According to Huber, D (2006), the shortage of nurses is due to 2 reasons for leaving their home country (1) for economic security, (2) professional opportunity.

Shortage of staff will increased overtime usage which is more expensive and restriction on admission whereby transferring of ill patient to another hospital for further management. The Unit manager will have problem in planning the staff on duty roster and end up with closing of wards. Huber,D (2006) said, staff shortage had a serious impact on nursing staffing and staff including increased overtime usage, higher stress, restricted expansion, changes in recruiting and hiring practices, decreased quality of care, and increased difficulty in scheduling coordination.

Considering the culture of indigenous people, they have got the right to get quality care from the health care organization and therefore I strongly emphasized that Primary Nursing should be taken into consideration to be practiced at the area like Tapah Hospital.

7.0 Conclusion

In this study, I have explored the care organized by nurses. I have discussed the advantages and disadvantages of the care delivery system in relation of how the models been managed and the impact of it. Currently patient seen to be demanding due to increased awareness of the quality care as the health care management are seen by the public as more concerned about controlling costs rather than protecting the rights of patient. Patient’s Right to the access to health care that is sufficient to provide access to appropriate high quality health care, receive treatment, emergency services whenever needed, consider to respectful and non - discriminatory care to be treated equally, irrespective of race, sex, age or disability as per the medical condition.

However, the nurses’ role is crucial in managing the care of delivery system to meet the need of health care outcome in the future. Model of Care Delivery System have changed by the cost control factor to meet the consumer expectation. The consumer concerned with the cost but at the same time they demand for competency and quality outcome.

Begin with the Functional Nursing, changes was done which the design formulated becoming Team Nursing to overcome the shortage of nurses. The Modular Nursing which requires less staff appeared when the Team Nursing model had been modified when nurses’ shortage become critical. Primary Nursing was designed for continues care which is more costly but ensure excellence quality outcome and satisfaction to consumer and staff. However the cost control appears to be the barrier. Primary Nursing requires more staff but study have shown that the cost comparison were inconclusive between the Team and Primary Nursing (Gardner, 1991; Lang &Clinton, 1984; Lee, 1993).

REFERENCES:

1) Huber, D. (2006). Leadership and nursing care management:Models of Care Delivery.(318-323)USA: Saunders Elsevier.Limited Preview(Online)

2) Rowland, B. L. (1997). Nursing administration handbook By Beatrice L. Rowland. Howard S. Rowland. United States of America: An Aspen Publication.Limited Preview(Online)

3) Chitty, K. K. (2005). Types Of Nursing Care Delivery System Hystorically Used In Acute Care Setting. In K. K. Chitty, Professional nursing: concepts & challenges (4th ed,pp. 361-362). USA: Elsevier Saunders.Limited Preview(Online)

4) Greta L. Krapohl, E. L. (1996). The impact of unlicensed assistive personnel on nursing care delivery. findarticles.com .(Online) http://findarticles.com

5) Basavanthappa, B. T. (2002).Hospital and its Routine. In B. T. Basavanthappa, Fundamentals of Nursing (pp. 134-135). India: Jaypee.Limited Preview.(Online)

6) Marriner-Tomey, A. (2000). Management. In A. Marriner-Tomey, Guide to nursing management and leadership (p. 383). USA: Mosby.Limited Preview(Online)

7) Macdonald, M. (2006). Primary nursing: is it worth it? Journal of Advanced Nursing , Journal compilation © 2009 Blackwell Publishing Ltd.(Online)

http://www3.interscience.wiley.com/journal.

8) Kenneth J. Sellick, Shirley Russell, Jacqueline L. Beckmann, (July 2003). Primary nursing: an evaluation of its effects on patient perception of care and staff satisfaction. International Journal Of Nursing Studies , 545-551.(Online)

http://www.journalofnursingstudies.com/article

9) Yoder-Wise (2003). Care delivery strategies. In . Yoder-Wise, Leading and managing in nursing By Patricia S. Yoder-Wise (pp. 262-263). USA: Mosby Elsevier.Limited Preview.(Online)

10) Huber, D. ( 2006). Model Of Care Delivery. In D. Huber, Leadership and nursing care management By Diane Huber (p. 323). USA: Saunder Elsevier.Limited Preview(Online)

11) Jeffrey R. Vincent, R. M. (2005). Natural Wealth:Depletion or Conservation? In R. M. Jeffrey R. Vincent, Managing natural wealth: environment and development in Malaysia (p. 383). USA: Recources For The Future.Limited Preview(Online)

12(Kowalski K,2009). Report: Nurses Are Key Components for Continuity of Care. Mosby's Nursing Consult .

http://www.nursingconsult.com.newdc.oum.edu.my

13) Huber, D. (2006). Nursing Shortage. In D. Huber, Leadership and nursing care management (p. 627). USA: Saunders Elsevier.Limited Preview(Online)

14) Resources, J. C. (2004). Problems In ICU Associated With Nursing Shortages. In J. C. Resources, Improving Care in the ICU (p. 101). USA: Joint Commission Resources.Limited Preview(Online)

15) JoAnn Graham Zerwekh, Jo Carol Claborn. (2003). The Health Care Organisation And Patterns Of Nursing Care Delivery. In J. C. JoAnn Graham Zerwekh, Nursing today: transition and trends (pp. 349-351(Chapter15)). Canada: Saunders Elsevier.Limited Preview(Online)

16)Huber, D. (2006). Models Of Care Delivery. In D. Huber, Leadership and nursing care management (p. 323). USA: Saunders Elsevier.Limited Preview(Online)

17)Barbara Cherry, Susan R. Jacob. (2002). Leadership And Management In Nursing. In S. R. Barbara Cherry, Contemporary nursing: issues, trends, & management (p. 452). USA: Mosby Elsevier.Limited Preview(Online)

18)Yoder-Wise (2003). Modular Nursing. In . Yoder-Wise, Leading and managing in nursing By Patricia S. Yoder-Wise (pp. 542). USA: Mosby Elsevier.Limited Preview.(Online)

ETHICAL DECISION MAKING

1.0 Introduction

Ethical Decision making is a process of decision making accomplished of resolving problematic situation which is more debated on ethical. It is actually an ethical conflict principle involving the duties of the nurse meeting the client’s need and wishes, families concerned which will impact on decision making, while at the same time (Becker, 1991a and 1991b) said have to follow the hospital policy, the doctor’s order and taking into consideration at the legal implication of any intervention made.

It’s hard to define ethics. According to the Canadian Oxford dictionary (2001), ethics is the science of morals in human conduct: moral philosophy. Ethic is not the same as what people accepted but standard of people will deviate from the ethical standard behavior. To decide the right or wrong are moral which provide reflect on human standard and behavior where else ethics refers to how human should behave and ought to do which involves analysis of action. Chitty, (2003) said that, ethics reflected the moral statement “one should not lie” and the lying should be defined and explore when the lying might be acceptable in some circumstances.

Ethical standards include standards relating to the rights, such as the right to freedom from injury, the right to privacy and continue effort of studying our moral beliefs and moral conduct in view of reasonable and well founded reasons.

Raijah A Rahim:Dr Khatijah Lim:Prof.Madya Hjh Rohani Arshad. (2009) said that, ethics is concerned with motives and attitudes and the relationship of these attitudes to the good of the individual which may be distinguished from the law as a whole.

Can ethics be taught? I would say, Yes, because person’s growth through moral development that challenged them to look at issues that will develop moral and define right and wrong that promote the ideal of justice or human right or human welfare.

2.0Description

Registered Nurse are the best position to advocate for the patient’s right for their patient and it is frequently involved ethical issues and ethical decision making. Ethical dilemma arises daily when nurses had been confronted with the choice in which ethical reason both for and against the choice are equally desirable (Pierce, 1997).I would consider discussing on ethical issue of Informed Consent which is frequently occurred that confronting nurses currently.

2.1 Issue-Informed Consent

Informed consent is an ethical requirement that involved client’s right to be informed and to make an autonomous decision making to protect their own body towards the therapy that might affect them. From Wikipedia, “Informed consent” is said to be a legal condition whereby a person can be said to have given consent based upon a clear appreciation and understanding of the facts, implications and future consequences of an action. Informed consent obtained to promotes cooperation, safety and health of the patient which the nurse as the best position to advocate for the right of the patient to be treated fairly and equally, dignity and respects.

The patient must have the power of choice and competent in other words mental capacity to the decision making of informed consent voluntarily. It should be seen as an invitation to participate in their health care decision and should be carried out in the layman term for easy understanding. Patient should have an opportunity to ask questions pertaining to the procedure or treatment for a better understanding prior deciding to proceed or to refuse a particular course of medical treatment or any kind of intervention. AMA, (2007) suggest, informed consent must be understood by patient which consist of effective communication process which encourage patient to ask question.

In order to give informed consent, the individual concerned must have adequate information and understanding and be in possession of all relevant facts at the time consent is given. Impairments to reasoning and judgment which would make it impossible for someone to give informed consent include such factors as severe mental retardation, severe mental illness, intoxication, severe sleep deprivation, Alzheimer's disease or being in unconscious state or in a coma. At minimum, participants should have information on purpose and scope of the study the type the question that will potentially be asked, how the results will be used, and how the anonymity will be protected(Richards & Schwarts, 2002)

2.2 Scenario

I would like to discuss a scenario on administration of subcutaneous(s/c) Clexane in the patient with Acute Myocardial Infarction in this study pertaining to the informed consent. The scenario is, “Mr. Ahmad, male 42 years old, Muslim man admitted to CCU for complain of chest pain, stabbing in nature at 5.00am but went to the hospital for treatment at 6.30am after morning prayers the next day. Mr. Ahmad is married with children wish to get well very soon because he is the head of the family. His wife is not working.

In the Emergency Room, he was given Oxygen via nasal cannula,12 lead ECG was done. Noted to have ST-elevation in lead ll, lll and AVF. However, Mr.Ahmad’s. Blood sent for laboratory test. Trop I is positive. Cardiac enzymes are highly elevated. Diagnosed as Acute Inferior Myocardial Infarction. He was thrombolysed. Mr. Ahmad was given IV Morphine which relieved his chest pain.

Acute Myocardial Infarction (AMI) is the term used for clinical diagnosis caused by irreversible myocardial necrosis results from an abrupt decreased or total cessation of coronary blood flow to a specific area of myocardium (Linda D.Urden,Kathleen M.Stacy,Mary E.Lough, 2005). AMI is life threatening. The survival is better if revascularized is earlier within the first 2 hours. Immediate intervention is by fibrinolytic therapy or percutaneous coronary intervention (PCI).However, if patient does not received fibrinolytic therapy (will break down clots) or PCI, anticoagulant is required. The used of anticoagulant agent is to prevent blood clotting and prevent new clots forming. Anticoagulant does not dissolved blood clot. Anti platelet prevent platelet aggregation.

Clexane/Lovenox (Enoxaparine) is an antithrombotic agent known as Low Molecular Weight Heparin (LMWH) is used to inhibit clots formation in the arterial and venous blood vessels to prevent potential acute and chronic complication of blood vessel thrombosis.

3.0.0 Discussion: - consider the 5 steps:-

The following, I would like to discuss the issue according to the Ethical Decision Making Process which is considered a tool for resolving ethical dilemma.

3.1.1 Assessment (collection, analysis and interpretation of data)

Mr. Ahmad is a young Muslim man, married with children. Mr. Ahmad complain of chest pain and was diagnosed as having Acute Inferior MI which is life threatening. He was thrombolysed. The Doctor explained to Mr. Ahmad that he prescribed s/c Clexane due to the excellent long term clinical benefit. However, the doctor explained to Mr. Ahmad, s/c Clexane is a drug of porcine origin. Mr. Ahmad was required to sign consent if he agrees with the Clexane injection.

Mr. Ahmad was in doubt to decide whether to accept the treatment. Mr. Ahmad does not take diet offered to him and complained unable to sleep well though Mr. Ahmad looked drowsy due to IV Morphine. While in the CCU, Mr. Ahmad prays on the bed itself because he was put on Complete Rest in Bed and closely monitored. Islam strictly forbids consuming pork. The origin of the medication is giving an extreme personal and emotional conflict to Mr. Ahmad due to the religious beliefs to receive the medication. Mr. Ahmad was asked to sign consent if he agrees with the treatment.

3.1.2 The dilemma

At my point of view, although the he was thrombolysed and Clexane cause bleeding, but the origin of the medication is giving an extreme personal and emotional conflict to Mr. Ahmad due to the religious belief. Mr. Ahmad was asked to give consent prior the administration of Clexane because he is a Muslim man.

Explanations and informing Mr. Ahmad about the origin of the medicine is to avoid religious distress and possible litigation and promotes respect for his religious beliefs and may promote therapeutic alliance. Mr. Ahmad should be given a respect to get sufficient information of his condition, benefit of Clexane as antithrombotic agent and the implications of Clexane administration whereby can cause bleeding, uncommon Thrombocytopenia in a way that he can understand and enable him to exercise his right to make informed decisions which is relevant to him.

A study was done in 50 Muslim’s patient involving 18 general practioners (GP’s) shows that 42% of the patient stated won’t take any medicine if the origin is unsure.58 % stating will stop taking medicine if the origin is haram.(Sanofi-Synthelabo,2004)

When receiving medical treatment the patient should bears the responsibilities of bringing their religious belief to the clinician’s attention to respect and facilitate the controversial choices of competent individuals, subject to resource limitations, our own and others well-being autonomy. Mr. Ahmad is noted to be drowsy due to the Injection Morphine for pain relief and might impaired his judgment on making decision and therefore the clinician and doctors should assist patient to make rational choices either irrational or against a person's interests. (Ward. M, 2006).

3.1.3 Consideration choice of action

Mr. Ahmad was given time to think and make a good decision to accept the treatment for a better health in the future. According to (Bourne, R. 2007) long term studies have shown that there are clear long term benefits for patients taking the drug (Clexane) on patients with acute ST-segment elevation myocardial infarction (STEMI).

However the alternatives treatment Fondaparinux also offers the benefits and risk which is from the synthetic source. The new antithrombotic molecules which induced an inhibition of activated factor X (Fondaparinux, Arixtra) shows effectiveness and safety in prevention of acute myocardial infarction which show that new anti-Xa inhibitors also have interesting properties in antithrombotic therapy. Fondaparinux had the possibilities to offer new therapeutic which could simplify the management of patient who required anticoagulant.(Garcia Hejl C, Garcia C, Thefenne-Astier H, Servonnet A, Samson T, Foissaud V., 2008)

3.1.4 Analysis of the advantage and disadvantages for each course of action

The benefits and risks of a proposed treatment.

Clexane (Enoxaparine)is used to stop abnormal blood clots forming within the blood vessels. It can be dangerous because the clot may detach and travel in the bloodstream, where it becomes an embolus. The embolus may eventually get lodged in a blood vessel and blocked the blood supply to a vital organ such as the heart, brain or lungs. This is known as a thromboembolism. If the clots formed in a coronary artery, it reduced the blood flow to the heart and causes chest pain (angina) which results in a heart attack as what happened to Mr. Ahmad. Sanofi- aventis announced that the studies confirmed that patient with ACS will benefit from Clexane administration (Sanofi aventis, 2003).

However, Clexane cause, bleeding which is preventable.

Mr. Ahmad was given a choice to choose Fondaparinux The nature Origins of the drug and purpose of a proposed treatment. to respect his religious belief to make an ethical decision making. According to (Garcia Hejl C, Garcia C, Thefenne-Astier H, Servonnet A, Samson T, Foissaud V., 2008) recent clinical trials show that new anti-Xa inhibitors also have interesting properties in antithrombotic therapy. Fondaparinux offer new therapeutic possibilities that could simplify the management of patients under anticoagulant treatment.

However, Fondaparinux was reported can induce severe bleeding and other complication which requires close monitoring. Mr. Ahmad decision making was crucial.The efficacy of Fondaparinux is comparable, the choice between these classes relies on the risk of adverse effects, which depends on some patient’s characteristics. LMWH and Fondaparinux are contra-indicated by the patients with a renal clearance under 30 ml/min. Nevertheless, as every anticoagulant, Fondaparinux can induce major bleeding. Hubert Nielly, Aurore Bousquet , Patrick Le Garlantezec, Eric Perrier and Xavier Bohand. (2009).

Fondaparinux is administered by subcutaneous injection and is rapidly absorbed and distributed. The plasma half-life is approximately 17 hours, allowing for once daily administration. The drug is not metabolized and is eliminated unchanged by the kidneys. Other agents may be safer in patients with moderate or severe renal insufficiency. There is no known antidote or agent that reverses the anticoagulant effect of Fondaparinux. No data to support the use of plasma or prothrombin complex concentrate. Therefore, rFVIIa may be considered in the management of bleeding complications in patients receiving Fondaparinux.In a case of moderate thrombocytopenia (platelet count 50,000 to 100,000/mm3) if the platelet count falls below 100,000/mm3, the drug should be discontinued. Anthony J. Comerota and Teresa Carman (Anthony J. Comerota, Teresa Carman, 2008).

Either both medicines prescribed, to ensure positive outcome is achieved, Mr. Ahmad was informed that blood will be taken for laboratory investigation and haemodynamic status will be monitored closely while he was on treatment. Mr. Ahmad was reminded that the origins of the drug and purpose of a proposed treatment to respect his religious belief to make an ethical decision making.

3.1.5 Make a decision.

As Muslim’s man, the decision making is very crucial, either to receive the Inj Clexane from the porcine origin or Inj. Fondaparinux which the synthetic source but will cause bleeding severely. However, the both medicine is required to prevent complication due to the heart failure in future as he is still young.

Mr. Ahmad shouldn’t be influences but should be reminded, that the Quran is seen as an eternal and immutable truth, the principles of the law are seen as immutable. In some circumstances, the application and interpretation of the law changes with each age. Islamic law (syari'ah), is dynamic and flexible, exemplified by saying that "necessity renders the prohibited permissible”. Based on the prophet Mohammad's saying, "For every illness, there is a cure, except death”. (Kamyar M. Hedayat and Roya Pirzadeh, 2001) However, Mr. Ahmad has the right to refuse the treatment in view of his belief as Islam strictly forbids consuming pork.

White, C.,(2006) said, according to our Muslim’s chaplain, when there is no alternative of non porcine treatment available and there is a risk to life, it is allowable for Muslims to receive a drug of porcine origin. However, some Muslims may choose not to receive treatment or prophylaxis with heparin because of its porcine origin and patients do have the right to make the decision for themselves.

3.2.0 Plan of action

All patients have the right to get the highest standard of healthcare. According to (WMA, 2008) the patient has a right to get an appropriate information in order to make decisions and therefore:-

i) The proposed of medication explained to Mr. Ahmad.

ii) The benefit and complication of the medicine explained.

iii) Other alternative explained to Mr. Ahmad.

iv) Mr. Ahmad was given an opportunity to ask questions to elicit a better understanding of the treatment.

v) Mr. Ahmad was given the authority to make an informed decision to proceed or to refuse the treatment.

Vi) Allow religious leader for an example an Imam or Ustaz to console and the patient to make an ethical decision.

3.3.0 Implementation/consider choice of action

In order to administer s/c Clexane, the nurse should obtained consent if the patient agrees for the treatment. The indication of the medication explained. Benefit and complication should be endorsed when explained by the physician with understandable language and the conversation should be witnessed by another healthcare professional, and the substance of the conversation should be signed by both parties, the patient, physician and the witness who is could be the nurse responsible for the patient. The route, duration and dosage, sign and symptom of medication informed. Documentation of informed consent should be clear. The treatment should be stop immediately if the patient changed the decision. Refusal of treatment will be documented clearly.

3.4.0 Evaluation

i) Were the action practical? The respect for patients’ autonomy, in making decisions about their own treatment is a great beneficence in order to prevent the complication in the future even though the treatment might be unpleasant, uncomfortable or even painful but it might be the best interests of the patient.It is fair if the patient refused the treatment after the indication, complication, method and duration of treatment been explained.

The right to refuse treatment is the principle of autonomy of patient and becoming the challenged value of the health care provider. The decision making to refuse treatment ordered by physician which is known from porcine origin is ethical because Mr. Ahmad is a pious Muslim man and he belief that Clexane, the porcine origin medicine is haram even though the Muslim’s leader said it is permissive in some circumstances. The Quran states that, "you are forbidden [the consumption] of carrion, blood, swine flesh. . . . for these are unclean." (Quran 5:3, 6:145).

The alternative treatment suggested was Fondaparinux which is the synthetic medicine. Fondaparinux caused bleeding however patient will be monitored closely. The nurse veracity gave a justice to the patient who has the right to be treated equally regardless of race, sex and ethnic and religious belief.

ii) What were the consequences? The alternative treatment benefits Mr. Ahmad because it is safe, relatively cheaper and the recipients had significantly lower mortality rates. Mehta, (2008) said,the incidence of death or reinfarction at 30 days was significantly lower with Fondaparinux than with usual care (9.7% vs. 11.2%), with significant benefits also at 9 days and at final follow-up (3–6 months).

4.0.0 Conclusion

Religious patients may experience distress in accepting an animal-derived medicine product or porcine origin medicine because it may breach their personal views of the religion and therefore patients have their right to refuse treatment.

Nurses shouldn’t make an assumption about their patients' and nurses should be sensitive to a patient's individual religious beliefs, values, and cultural background as part of respecting a patient's autonomy because we live in a multicultural society.

If the patient’s religious belief ignored and neglected to explanation on porcine origin medicine, the health care provider might cause serious consequences, including patient’s distress and litigation. Religious beliefs need to be balanced against clinical need. Religious leaders and physician should work collaboratively when a patient's religious belief interferes with the treatment to find acceptable compromises in cases where suitable treatments do not exist, and the only medicine available is from porcine origin or otherwise cause death.

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