How would you handle your personal inter­actions with Mr. and Mrs. S, and what would you do to help educate your staff in working with families in a situation such as this one?

Case Study: To Feed or Not to Feed
Baby S is a neonate admitted to the NICU at the county hospital where you work as the nurse manager. Mrs. S had an amniotic fluid embolus during her delivery, and Baby S experienced anoxia. Consequently, Baby S had an Apgar score of 0 at birth. The baby was “successfully” resuscitated but remained unconscious. All of the baby’s organs experi­enced hypoxic insult. Baby S was placed on a ventilator and parenteral nutrition was later initiated. Mrs. S is physically very weak and experiencing extreme grief, along with her husband, over the condition of their infant. They have two other young children, aged 2 and 5 years old. Baby S has been weaned from the ventilator but has remained unre­sponsive. Mr. and Mrs. S have requested that the hospital staff discontinue their infant’s nutrition and hydration. The NICU medical, nursing, and social work staff have not pre­viously experienced a situation quite like the one that is occurring with the S family.
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Case Study Critical Thinking Questions
Based on information that you know from the case study, use Jonsen’s Four Topics Method (pages 53 and 54 in 5th edition and 61 in 6th edition of your text) to answer the questions in each of the four boxes. Consider and discuss the applicable principles that accompany each box. Explain to me how the principles (autonomy, beneficence, nonmaleficence, and justice) apply to the appropriate quadrant. The principles that apply to each quadrant are identified for you in the model. The discussion of the principles is worth 2 points per quadrant, leaving this part out leaves points on the table!
You are meeting with the neonatologists, the NICU charge nurse, the infant’s pri­mary nurse, the hospital chaplain, and the social worker in the NICU. What do you contribute to the group’s discussion with regard to how you think the staff should proceed in providing the best care for Baby S and her family.
How do the Baby Doe Rules (page 145 in text) affect this case?
As would be expected, Mr. and Mrs. S are also experiencing a great deal of emo­tional and moral suffering and grief. How would you handle your personal inter­actions with Mr. and Mrs. S, and what would you do to help educate your staff in working with families in a situation such as this one? What do you know about the grief that parents experience when their infant is extremely impaired or dies? How would you try to help Mr. and Mrs. S?
ANSWER
Jonsen’s Four Topics Method
Medical Indications
Baby S is a neonate who experienced anoxia during birth, resulting in hypoxic insult to all of her organs. She was successfully resuscitated, but she has remained unresponsive. Her medical team has determined that she has a very poor prognosis.
Applicable principles: Beneficence and nonmaleficence
Beneficence is the principle of doing good for the patient. In this case, the medical team must weigh the potential benefits of providing Baby S with nutrition and hydration against the potential harms. The potential benefits include prolonging her life and giving her a chance to recover. The potential harms include causing her unnecessary suffering and prolonging her death.
Nonmaleficence is the principle of avoiding harm to the patient. In this case, the medical team must weigh the potential harms of withholding nutrition and hydration against the potential benefits. The potential harms include causing Baby S to die of starvation or dehydration. The potential benefits include relieving her suffering and allowing her to die peacefully.
Patient Preferences
Mr. and Mrs. S have requested that the hospital staff discontinue their infant’s nutrition and hydration.
Applicable principles: Autonomy and beneficence
Autonomy is the principle of respecting the patient’s right to make their own decisions about their care. In this case, Mr. and Mrs. S have the right to decide whether or not to provide nutrition and hydration to their daughter.
Beneficence is the principle of doing good for the patient. In this case, the medical team must weigh the potential benefits of respecting Mr. and Mrs. S’s wishes against the potential harms of doing so. The potential benefits include relieving Baby S’s suffering and allowing her to die peacefully. The potential harms include causing Mr. and Mrs. S to experience guilt and regret.
Quality of Life
Baby S has a very poor prognosis. Her medical team has determined that she is unlikely to ever recover and that she is likely to experience significant suffering if she is kept alive.
Applicable principles: Beneficence and nonmaleficence
Beneficence is the principle of doing good for the patient. In this case, the medical team must weigh the potential benefits of providing Baby S with nutrition and hydration against the potential harms. The potential benefits include prolonging her life and giving her a chance to recover. The potential harms include causing her unnecessary suffering.
Nonmaleficence is the principle of avoiding harm to the patient. In this case, the medical team must weigh the potential harms of withholding nutrition and hydration against the potential benefits. The potential harms include causing Baby S to die of starvation or dehydration. The potential benefits include relieving her suffering.
Contextual Features
Mr. and Mrs. S are experiencing a great deal of emotional and moral suffering and grief. They also have two other young children to care for.
Applicable principles: Justice and beneficence
Justice is the principle of ensuring that all patients are treated fairly and equitably. In this case, the medical team must weigh Baby S’s needs against the needs of other patients. The potential harms of providing Baby S with nutrition and hydration include diverting resources away from other patients who may have a better prognosis.
Beneficence is the principle of doing good for the patient. In this case, the medical team must weigh the potential benefits of providing Baby S with nutrition and hydration against the potential harms. The potential benefits include prolonging her life and giving her a chance to recover. The potential harms include causing her unnecessary suffering and diverting resources away from other patients.
Conclusion
The medical team must weigh all of the above factors in deciding how to proceed in providing the best care for Baby S and her family. There is no easy answer, and there is no right or wrong answer. The team must ultimately make a decision that they believe is in the best interests of Baby S and her family.
Contribution to the Group Discussion
As the nurse manager, I would contribute to the group discussion by:
Summarizing the medical facts of the case
Presenting the ethical principles that are at stake
Facilitating a discussion of the different options that the team has
Ensuring that all members of the team have a voice in the decision-making process
Supporting the team in making a decision that they believe is in the best interests of Baby S and her family
Baby Doe Rules
The Baby Doe Rules are a set of federal guidelines that prohibit hospitals from discriminating against infants with disabilities. The rules were enacted to prevent hospitals from withholding life-sustaining treatment from infants with disabilities.
In this case, the Baby Doe Rules would not prohibit the medical team from withholding nutrition and hydration from Baby S, as long as they made the decision in consultation with Baby S’