Running Head: RIGHT TO REFUSE CARE

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The Right and Right Circumstance to Refuse Care
Hayley Nolan, #820799781

NURS 217

Professor Tamiza Kassam
Humber College

October, 5th, 2015

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RIGHT TO REFUSE CARE

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The Time Magazine Person of the Year is an infamous title which recognizes a person or

group who has been notably influential or prominent during the year (Time Person of The Year,
2015). In 2014, this denomination was given to the courageous efforts of the group of primary care
providers in the Ebola Virus Disease epidemic in West Africa known as the Ebola
Fighters (Person of the Year, 2015). Ebola Virus Disease, simply referred to as Ebola, is a lifethreatening and highly contagious infectious disease transmitted by bodily fluids of symptomatic
persons. Due to the nature of the disease, the health care professionals providing care to infected
patients are at the most risk for contracting the deadly pathogen (WHO, 2015). Unfortunately, Nina
Pham, Registered Nurse in the Intensive Care Unit (ICU) at Texas Health Presbyterian Hospital was
one of the many health care workers infected with Ebola while providing care. Now, the virus-free,
26 year old states that she was a casualty of a hospital system's failure to prepare for a known and
impending medical crisis (McLaughlin & Yan, 2014). In the lawsuit filed against Texas Health
Resources (THR), parent company of Texas Health Presbyterian Hospital, Ms. Pham claims that she
did not receive the training and personal protective equipment needed to care safely. In a separate
interview with Time Magazine, Nina explains that she was hesitant to accept the patient assignment
due to his suspect diagnosis; however, Nina claims that her personal and professional values prevent
her from refusing care to a patient in need (Time Magazine, 2014). There is no doubt that Ms. Phams
altruistic intentions were admirable, per contra, do nurses have a professional obligation to provide
care if they believe that their safety and the safety of the patient is compromised? If so, is it ethical?
It is ethical for a nurse to refuse a patient with a suspect or a confirmed diagnosis of a highly
communicable contagion if he or she deems the situation unsafe as a result of inappropriate personal
protective equipment, education and environment.

RIGHT TO REFUSE CARE

The Centres for Disease Control and Prevention (CDC) recognizes Ebola as a bio safety level

4 pathogen which necessitates the highest level of protective measures by medical professionals who
may be in contact with the pathogen (n.d.). Allegations in the lawsuit against THR made by Pham
include negligence as a result of failure to provide appropriate personal protective equipment. Nurses
on the ICU at the Texas Health Presbyterian, including Nina, wore their own scrubs and conventional
personal protective equipment while providing care to the infected patient. Unfortunately, this
equipment left the neck and hair vulnerable to contamination (Nina Pham vs. Texas Health
Resources, 2015). All workers in Ontario, including nurses, are protected by the Ontario Health and
Safety Act (OHSA) which allows an employee to refuse work if deemed unsafe. However, this is
limited to nurses because there is a certain level of risk accepted as natural to the profession (ONA,
2012). Supporting the position to refuse unsafe work, the Ontario Nurses Association (ONA) states
that dealing with infection is likely inherent in the workers work in a health care facility, but
doing so without proper protective equipment, where such exists is not inherent (2012). Further,
the College of Nurses of Ontario (CNO) Practice Standard Refusing Assignments and
Discontinuing Nursing Services uses a scenario similar to Ninas as an example of nurses practicing
ethical decision making. The document recommends weighing who is at greater risk of harm if
timely nursing care is or is not initiated (2009). Therefore, due to inadequate PPE and the relatively
stable condition of the patient upon admission, the risk of harm to the nurse was much greater than
the risk of harm to the patient. Thus, providing the appropriate grounds to refuse a patient
assignment.

In addition to providing access to the proper personal protective equipment, nurses must have

access to the most recent infection control guidelines and demonstrate knowledge regarding the use
of specialized equipment. Unfortunately, the Texas Health Presbyterian Hospital failed to provide

RIGHT TO REFUSE CARE

nurses with the appropriate training and resources to provide care safely. Nina Pham claims that the
Texas based company did not provide education to nurses on how to care for a patient with a suspect
or positive diagnosis of a highly contagious pathogen such as Ebola (Nina Pham vs. Texas Health
Resources, inc., 2015). According to the CNO, a nurse demonstrates professional accountability by
refraining from performing activities for which she/he is not competent. (2009). This is intended to
protect the patient and the nurse. Thus, due to Ninas lack of knowledge she could refuse care based
on her lack of competence. However, the CNO states that nurses must demonstrate a commitment to
maintain and improve competence (2009). In defence of Ms. Pham, she did communicate her
concerns to administration but she was provided with information from an unreliable resource (Nina
Pham vs. Texas Health Resources, 2015). Therefore, a nurse has the means to refuse care to a patient
if the nurse deems their competence to be inadequate in which a reliable resolution is not readily
available.

Shortly after Ms. Phams condition deteriorated at the Texas Health Presbyterian Hospital,

she was transferred to the National Health Institute (NIH) that provided Nina with the state-of-the-art
care that saved her life (Nina Pham vs. Texas Health Resources, inc., 2015). Unlike Texas Health
Presbyterian Hospital, the NIH was prepared to care for a patient in Ninas critical condition.
Unfortunately, the infected patient at Texas Health Presbyterian Hospital never received the same
standard of care that could have potentially been the difference between life and death. When Ninas
unit manager initially approached her about the patient assignment it was acknowledged that the
patient did not fit the intensive care units criteria (Nina Pham vs. Texas Health Resources, inc.,
2015). According to the CNO, a nurse demonstrates accountability by providing, facilitating,
advocating and promoting the best possible care for clients (2009). This includes advocating for a
better environment to provide care if the nurse deems the current location unsafe and/or inadequate.

RIGHT TO REFUSE CARE

However, this can be challenged in an emergency situation. In support of the defence, the hospital
was aware of the infected patients condition and at the time was stable enough to have transferred to
another facility more capable of providing care (Nina Pham vs. Texas Health Resources, inc., 2015).
Therefore, a nurse may refuse an assignment in a non-emergent situation if he or she believes the
environment is unsafe and/or inadequate.

In an interview with USA Today, Nina was asked if she considers herself to be a hero in

which she humbly replied that she was just doing her job (2014). It is indisputable that nurses make
judgements in the best interest of their patients daily, however, nurses must also make judgements
that reflect their own best interest when necessary. This includes refusing care when the nurses
professional judgment deems appropriate. It is unethical to ask a nurse to care for a patient if they do
not have access to proper personal protective equipment, education and environment to do so.
Although risk is a natural aspect in nursing care, there are certain risks that are not inherent to the
profession (ONA, 2012). Further, nurses have an obligation to identify when their knowledge or
environment prevents the delivery of the best possible care to the patient. The argument presented to
the reader in this paper provides substantial support from the CNO, ONA and OHSA to refuse care in
the situation faced by Ms. Pham at Texas Health Resources. In conclusion, the Texas Health
Presbyterian Hospital was simply not prepared to care for a patient with a highly contagious virus
such as Ebola. Therefore, it is ethical for a nurse to refuse a patient with a suspect or a confirmed
diagnosis of a highly communicable contagion if he or she deems the situation unsafe as a result of
inappropriate personal protective equipment, education and environment.

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References

Canadian Nurses Association. (CNA). (2012). Professional Obligations and Labour Relations

Implications of Refusing an Assignment. Retrieved from http://local70.ona.org/

documentslocal/7/File/Refusing_AssignmentsV6_1.pdf

Centre for Disease Control and Prevention. (CDC). (n.d.). Section IV: Laboratory Biosafety Level

Criteria. Retrieved from http://www.cdc.gov/biosafety/publications/bmbl5/

BMBL5_sect_IV.pdf

College of Nurses of Ontario. (CNO). (2009). Practice Standards: Infection Prevention and

Control. Retrieved from http://www.cno.org/Global/docs/prac/41002_infection.pdf

College of Nurses of Ontario. (CNO). (2009). Practice Standards: Refusing Assignments and

Discontinuing Nursing Services. Retrieved from http://www.cno.org/Global/docs/prac/

41070_refusing.pdf

James, J., & Wheeler, J. (2015). Ebola Nurse Sues Hospital For Negligence. USA Today. Retrieved

from http://www.usatoday.com/story/news/nation/2015/03/02/ebola-nurse-nina-pham-

lawsuit/24284433/

McLaughlin, E., & Yan, H. (2015). Texas nurse who contracted Ebola sues hospital company. Cable

News Network. Retrieved from http://www.cnn.com/2015/03/02/us/nina-pham-hospital-

lawsuit/

Nina Pham v. Texas Health Resources, inc. District Court of Dallas County, Texas. (2015). Retrieved

from https://www.scribd.com/fullscreen/257453276?access_key=key

GKfGNS96c0A47UzJikkq&allow_share=true&escape=false&view_mode=scroll

Time Magazine. (2014). The Nurses: The Ebola Fighters in their Own Words. Retrieved from http://

time.com/time-person-of-the-year-ebola-nurses/

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References

Time person of the year. (2015, September 23). Retrieved October, 2, 2015 from https://

en.wikipedia.org/wiki/Time_Person_of_the_Year

World Health Organizartion. (2015). Ebola Virus Disease. Retrieved from http://www.who.int/

mediacentre/factsheets/fs103/en/