Rita is a registered nurse with advanced expertise in psychiatric ward, and she works as a
member of a multidisciplinary team looking after Treatment Resistant Depression (TRD)
patients. Rita oversees patients discharge from the hospital. Prof S, the leader of her team,
heavily relies on her reports before making discharge decisions. Mr R, one of her patients,
died by suicide when he jumped from the 8th floor of an hotel adjacent to the hospital, after
having been discharged.
Mr R’s family raised several concerns about his treatment to the Coroners Court. These
• Appropriateness of the qualifications of the treating nursing team and their
assessments of Mr R and role in the decision to discharge Mr R from Hospital;
• A lack of an appropriate consent process for the implantation of a Deep Brain
Stimulator1 technology (DBS) and particularly, a failure to advise Mr R that suicide
and reversible changes in mood/personality were risks associated with DBS surgery;
• Lack of communication by the clinicians with Mr R’s family;
• Post-operative DBS complications;
• Management of his physical concerns in Hospital;
• The management of his mental health;
• The death could have been avoided had his medical advice and treatment been
Mr R, a twenty-seven-year-old patient, received the diagnostic of depression when aged
fifteen. When Rita first met Mr R, he self-reported more than 30 ineffective and/or poorly
tolerated medication trials and an ineffective course of electroconvulsive therapy which
have lead him to seek last recourse treatment. During their first meeting, Rita suggested to
Mr R to consider the possibility of enrolling in a new experimental DBS trial for TDR, where
she sits as co-researcher with multiple colleagues, under the leadership Prof S.
One week following Rita first meeting with Mr R, he consulted Prof S to undergo an
experimental usage of DBS targeting TRD. During the consultation, Mr R was accompanied
by his brother. Prof S advised Mr R that DBS was an experimental treatment potentially
targeting TDR symptoms. Prof S says that he advised Mr R that the potential risks of the DBS
surgery include death, permanent disabling stroke, infection of the brain or the IPG, seizure
disorder, and reversible changes in mood/personality. Mr R was also told that DBS therapy
1 DBS surgery involves implanting a thin, insulated lead into the brain (most often in the subthalamic nucleus
or the globus pallidus, which are part of the basal ganglia system.) The lead is then connected via an insulated
extension to a device called an implanted pulse generator (‘IPG’). This is similar to a pacemaker. The extension
runs below the skin from the head down the side of the neck behind the ear to the IPG which is usually
implanted under the skin in the chest. When switched on, the IPG produces electrical impulses that are sent to
the brain. The impulses can be adjusted using a patient programmer.
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may not help his symptoms. However, retrospectively, Mr R’s brother disputes that Mr R
was told about reversible changes in mood and personality.
The informed consent signed by Mr R stipulated: “The doctor may [...] withdraw you from
trial at any time if he/she considers this to be in your best interest.” The surgery was
performed without incident one month later, it was uneventful, and Mr R’s surgical wounds
healed well. Mr R had inserted bilateral stimulators within the subcallosal cingulate cortex.
Thursday, one day after the surgery, Mr R indicated to Rita that he experienced some
headache, and commented “I feel like I am who I am now, but it's not the me that went into
the surgery.” These feelings of self-estrangement were experienced with suicidal thoughts
and that for the past day Mr R had thought about nothing else but ending things. He
reported wanting to make sure it was permanent and that this was the only reason he had
not acted on his thoughts. Accordingly, Rita indicated in her records a number of sources for
the distress, including:
• Mr R was experiencing severe pain as a feature of his brain surgery. This was not well
controlled as his DBS device which had only recently been reactivated and was not
yet functioning at optimal levels.
Rita’s impression was that Mr R presented with a mixture of dysphoric/depressive and
hypomanic symptoms. She suspected the DBS stimulation may be contributing to
The following morning, Mr R was seen by Prof S who increased his DBS voltages. That
afternoon, Rita noted Mr R was “very upset and agitated.” He was upset that his voltages
weren’t “tweaked earlier”. Rita explained that he might not necessarily be adjusted every
day. Mr R admitted that his TDR’s symptoms were not too bad yet but was anxious for
further adjustment. He was unsure if the DBS or the stress was causing his mood problems.
The weekend things were stable. However, the brother of Mr R left a voice message to Rita
at work, informing her “I don’t recognise my brother since the surgery. He
uncharacteristically seems so impulsive and appears always changing his mind”.
When assessing Mr R on Monday his primary complaint to Rita was a -twisting- pain in his
head. Mr R associated the pain with increased stimulation and the morning dose of
medications. He told Rita he had a return of agitated mood over the weekend, experience of
self-estrangement and suicidal thoughts. Rita wrote in her report that the suicidal thoughts
were a result of the pain Mr R was experiencing.
Given the severe adverse affects, removal of the device was prescribed by the treating team
based on the belief that no therapeutic benefit would accrue from further treatment.
Despite absence of any benefit from the trial and the severity of suicidality, Mr R formally
refused, opposed, and resisted the device removal.
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Tuesday, Rita noted that Mr R had a better day but his pain remained troublesome. He had
no agitation or suicidal thoughts. Mr R remained fixated on his postoperative course /
device settings. Rita noted improvement in mood although there were some remaining
• sensitivity to stimulation (agitation, mood changes);
• uncertainty regarding his discharge location (currently expressing clear preference to
live independently in Sydney rather than with his brother).
Eight days after surgery, Rita reviewed Mr R and noted his mood was improved and he had
no suicidal thoughts, which according to her demonstrated stability from a mood
perspective. He described one brief episode of mood deterioration two days prior, however
this was not associated with suicidal thoughts. Rita developed a plan for discharge with Mr
R, and discussed this with his brother who insisted it was premature to discharge his brother
from the Hospital, despite Mr R stating he was happy with his mood. Rita’s report was sent
to Prof S. Mr R was discharged that very same day.
Two days later, Mr R’s brother dropped Mr R off at the front of the Hospital and saw him go
inside the administration area. Mr R did not go to the Hospital but instead checked into the
Summit Apartments, an adjacent hotel to the Hospital. This occurred at approximately
10:20am. Around 11h30, Mr R’s brother received a text message from Mr R. This text
message suggests that:
• Mr R’s main concern was his pain;
• Mr R considered he was put back on TRD’s medication without appropriate
supervision and proper pain control;
• The treating team did not believe him or properly listen to him;
• If the possibility of such pain had been explained to him, he may not have had the
• His death could have been prevented had his medical advice and treatment been
Just after 11.30am, an eyewitness reported seeing Mr R jumped from the balcony of his
room (8th floor).
After reading the TRD scenario, ask yourself what are the ethical and legal complexities in this situation?
When responding, and replying, it would be a good idea to consider different options, weigh their merits up against one another as a part of developing your argument. You should apply ethical concepts, theories or principles as well as relevant legal considerations to justify claims. You need to show us that you have understood the content of module 1 and can see the ethical issues at stake in the case study.
The scenario of Mr. R, in my opinion, is ethically wrong. Deontology has the view that we cannot treat others as 'mere- means, only as ends-in themselves (Bruers, 2016). Mr. R was being treated for TRD (Treatment-resistant depression). Mr. R was under the impression he had been given full disclosure on the information and side effects of the trial course. However, in his text message to his brother he claims that if he was told about the painful side effects, he might not have gone through with the trial. This takes away MR. R's autonomy of his body and choices as he was not made aware of all side effects that might affect his mentality (Varkey, 2020). He also gave his consent for the trial to be conducted under this false impression however all relevant information should have been disclosed by Rita as she has an obligation to inform Mr. R of all relevant information relating to his care. However, as a result, he ended his life due to the pain (Varkey, 2020).
Rita as a nurse has obligations to her patients, as the ICN code of ethics, code one outlines 'The nurse holds in confidence personal information and uses judgment in sharing this information (International Council of Nurses 2012, pp. 1–10)'. In this scenario, I disagree that Rita informed Prof. S of all relevant documentation relating to MR. R. As MR. R believed that his thoughts and questions were not being noted and heard by Rita, correctly. As Rita also has a duty of care to Mr. R, looking through the lens of being Non-maleficence, I believe Rita is not upholding her duty of care and is neglecting MR. R as he believed he was not being heard by from the care team of his treatment, if I was Rita these thoughts and concerns would have been further discussed with Prof. S. Rita has a duty of care to not cause harm to a patient, however by not listening to him I see this as a part of neglect and harm as she was only writing minimal reports in her own words and not following up MR R's thoughts with prof. S (McCormick & Min, 2013). Beneficence is the duty to remove someone from harm. In the eyes of Prof. S and Rita, the harm they were removing from MR R, would be his depression. Although more harm was being done to him through the TRD trial, even though he expressed his feelings to Rita. If Rita adhered to ICN code 2 'The nurse, in providing care, ensures that use of technology and scientific advances are compatible with the safety, dignity and rights of people.' The trial might have ended sooner if he agreed as he expressed, he has pain from suspected complications with his DBS for TRD (International Council Of Nurses 2012, pp. 1–10).
Rita also has an obligation to patient-centred care, through the NMBA (Nursing Midwifery Board of Australia) code of conduct, section 2.2 decision making around treatment for someone can be expressed by family members. Before MR R was discharged from the hospital, his brother expressed how he believed it was 'premature' to allow him out due to his mentality. If Rita had reported this correctly to Prof. S, a proper report could have been conducted before he was discharged (Nursing and Midwifery Board of Australia, 2018). With a meeting looking at his future treatments. Through the treatment process, I believe Prof. S and Rita, would see their actions as unmorally wrong, however in my opinion and with deontology their actions of care for MR R can arguably be seen as morally wrong with them treating him as a 'mere- means' due to Mr. R not having Autonomy over his body as he was not fully informed of all implications with the treatment (McCormick & Min, 2013; Bruers, 2016). However, if he was fully disclosed on everything to do with the treatment and he then still consented, in Deontology he would be seen as an end-in himself. As he chooses to continue with the treatment knowing the possible outcomes (Bruers, 2016).
The central ethical questions posed by this case study are related to the principle of autonomy and virtue ethics of the health professional. I want to place my argument that execution of autonomy in the case study does not hold valid informed consent and health professionals do not act according to virtue ethics.
It is important that the patient who undergoes complex treatment like Deep Brain Stimulation (DBS) ought to provide their voluntary and fully informed consent. There are three criteria for informed consent. Firstly, all required information should be provided to the patient for decision-making. Secondly, patient should be competent to understand the information and make the decision on that basis. Finally, there should not be any manipulation and coercion to the patient to make the decision (Beeker, et al. 2017).
In this case study, my concern is that the treatment-resistant depression that Mr. R is going through could have imperiled his ability to make an autonomous decision (Beeker, et al. 2017). Though Mr. R has given his consent to the procedure, I can clearly see that he has given consent to the proposed treatment because he perceives DBS as the last resort as other treatments are not working for him. According to Schermer (2011), it becomes problematic when the patient has given consent to the treatment out of desperation to his hopeless situation. I deem it unethical to gain consent from a patient who is exhibiting desperation and vulnerability because there is uncertainty that he is acting freely without any mental pressure (Becuchamp 2007). It is extremely difficult to analyze the accuracy of the informed consent when the patient has been suffering from disabling symptom for a long time; have already tried many treatments and has no hope of improvement in his situation (Desmoulin-Canselier 2020). Hence, I emphasize the statement of Schermer (2011) that the competency of the patient to consent to the treatment must be taken into consideration.
For informed consent, I would have first examined the cognitive and emotional factors of the patient to assess their level of comprehension as advised by Thomson & Carter (2020), but absent in the case study. I also strongly argue that it is important to conduct a proper pre and post-assessment and devote a significant amount of time to examine and clarify Mr. R’s expectations (Kubu & Ford 2017). For respect for the patient’s choice, there should be pre-procedure counseling to identify all kinds of fear and difficulties for the patient and optimize the acceptance of the treatment (Desmoulin-Canselier 2020).
Similarly, I also notice that the treatment in the case study is not autonomy-supportive because the health professional does their job of narrowing down the benefit and risk of the treatment but does not take his personal circumstances, concerns, and preferences into account, does not listen to the patient, and remain heedless to the detrimental modification of his personality (Desmoulin-Canselier 2020).
Furthermore, the nurse in the case study does not act as per virtue ethics. I am disappointed to see that the nurse focuses on the rules and tasks rather than redirecting her focus towards actions that can promote the well-being of the patient. The aspect of humanity, compassion, and kindness are lacking due to which she is more focussed on reporting task rather than initiating an action to support the patient (Sellman 2017).
While I reflect on the legal issue of the case study, I clearly see that the nurse does not fulfill her legal obligation of person-centered practice by failing to advocate on behalf of the patient and to support the right to informed consent as per the nursing code of conduct (Nursing and Midwifery Board of Australia 2018). Additionally, she does not conduct a comprehensive holistic assessment of the patient which is one of the standards of nursing practice (Nursing and Midwifery Board of Australia 2016). Lastly, the nurse fails to provide comprehensive, safe, and quality nursing practice that is not responsive to the need of the patient (Nursing and Midwifery Board of Australia 2016).