All of the scenarios in the Role 4 suit should be considered from the perspective of a health professional working in a military hospital receiving casualties from military operations with responsibility for the clinical care of patients and management of the facility. The primary supporting reference for this suit is the World Medical Association International Code of Medical Ethics (WMA Code) at: https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/ supported by the WMA Declaration of Lisbon on the Rights of the Patient at: https://www.wma.net/policies-post/wma-declaration-of-lisbon-on-the-rights-of-the-patient/#:~:text=Every%20person%20is%20entitled%20without,with%20his%2Fher%20best%20interests. You should also consider your national professional ethical codes and relevant military law or guidance.

Step 1 – IDENTIFY THE PROBLEM(S)

• Briefly state the Scenario: A junior nurse has publicly disagreed with the treatment plan proposed by a senior consultant in a multidisciplinary review meeting because she believes that the patient does not want this. The consultant has ordered her to leave the room. What do you do?
• List the Issues that arise from the scenario.
• Identify Critical Information required and Assumptions to be made:

This scenario covers the ethics and law regarding informed consent and respect towards colleagues.

Step 2 – ANALYSE

Patient: WMA Code Para 15 - The physician must respect the patient’s right to be informed in every phase of the care process. The physician must obtain the patient’s voluntary informed consent prior to any medical care provided, ensuring that the patient receives and understands the information needed to make an independent, informed decision

about the proposed care. The physician must respect the patient’s decision to withhold or withdraw consent at any time and for any reason.

Clinical: Any member of the clinical team should be supported to express their opinion regarding the preferences of a patient if the patient is not able to do so themselves. WMA Code Para 19 - The physician should be considerate of and communicate with others, where available, who are close to the patient, in keeping with the patient’s preferences and best interests and with due regard for patient confidentiality.

Legal: all staff are entitled to be protected from harassment at work.

Societal/Military: WMA Code Para 30 - The physician must engage with other physicians, health professionals and other personnel in a respectful and collaborative manner without bias, harassment, or discriminatory conduct. The physician must also ensure that ethical principles are upheld when working in teams.

Step 3 – FUSE

• Summarise conclusions
• Insert citations to key reference sources for your analysis
• Determine the exact Decision(s) to be made

Your primary duty is to ensure that your patient receives the medical care that they need after full discussion in the multidisciplinary meeting. You also have a duty to protect your staff from bullying and harassment.

Step 4 – DECIDE

• What is your Decision?
• Why (can you justify it)?
• Residual uncertainly, need for review?

It is vital that the patient is fully informed and provided consent to the recommendations for treatment from the multidisciplinary team. In view of the disagreement between the consultant and the nurse, it may be appropriate for a third party to discuss the treatment recommendations of the meeting with the patient to ensure informed consent. You also have to address the public behaviour of the consultant – both in the event and also in follow-up afterwards.   

Contributor – Group Captain (Rtd) Teresa Griffiths CBE ARRC. Military Chief Nurse, Royal Centre for Defence Medicine (2010 - 2013) and Commanding Officer Defence Medical Rehabilitation Centre Headley Court/Stanford Hall (2016-2018).