Helen's story... An ethical dilemma


As a healthcare professional, I am bound to act according to a Code of Conduct, and to follow national guidelines and evidence-based research to ensure the best care. There are, however, always exceptions to the rules when patients display unusual symptoms that don’t seem to fit textbook conditions, or when a patient is experiencing a virtually unknown condition.


This can make management difficult, especially when the patient is your husband and you, as a wife, carer and nurse, are torn between observing staff acting correctly according to guidelines, yet missing the actual diagnosis and management because the condition is simply not well understood. To what extent do you sit back and let the staff act in the way that they have been trained? In this case, he was suffering from autonomic dysreflexia, a hypertensive emergency in the spinal cord injured patient, relatively unheard of by medical staff outside specialist spinal injury centres.


He was admitted with a severe, pounding headache, a blood pressure of 200/130 mmHg and a pulse of 50. His pupils were dilated and he was sweating profusely in the face and shoulders. Having been rebuked by the first paramedic who attended at home, for “calling the ambulance just for a headache”, he met an efficient team in the emergency department who commenced ECG recording and blood tests. Different diagnoses were considered: heart attack? Hypertensive crisis due to a renal, endocrine or neurologic cause? Panic attack? Drug use?


My suggestions that this could be an episode of autonomic dysreflexia, usually caused by bladder or bowel distension (though any noxious stimulus such as a pressure sore or broken bone can be a trigger) were ignored. Left untreated, autonomic dysreflexia can lead to convulsions, stroke and death. Time was wasted as more traditional diagnoses were sought. Once recognized, another dilemma arose as sublingual GTN (glyceryl trinitrate) is used in the management of autonomic dysreflexia.


As a carer, I knew this. However, medical staff were reluctant to use GTN in this as-yet unlicensed way. Thankfully, this episode self-resolved, but as both a carer and nurse, to what extent should I intervene in future when, as a nurse, I can understand the rationale behind the actions of medical staff but, as a carer, I know they might not be for the best?



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