NR 513 Week 4 Ethics Case Analysis, PACU Transfer Example

Ethics Case Analysis: A Surgeon Asks the On-Call PACU Nurse to Send a Patient Straight to the Floor Before He Meets Discharge Criteria, and the Duties Sorted by Who Holds Them

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College of Nursing, Chamberlain University

NR 513: Professional Role Enhancement

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Month Day, Year

Ethics Case Analysis: A Surgeon Asks the On-Call PACU Nurse to Send a Patient Straight to the Floor Before He Meets Discharge Criteria, and the Duties Sorted by Who Holds Them

The Facts

The case is a composite; no real patient, surgeon or hospital is described. At 0140, a 58-year-old man arrived in the postanesthesia care unit (PACU) after an emergency laparoscopic appendectomy under general anesthesia. The on-call PACU nurse was alone in the unit; the second registered nurse under the on-call plan was the house supervisor, on another floor. At 0220 his modified recovery score was 8 of 10: he was drowsy but rousable, and he needed 2 L/min of oxygen to keep his saturation above 92%. The unit's policy, approved by the anesthesia department, requires a score of 9 or more and saturation of at least 92% on room air, or an anesthesia provider's written approval, before transfer to a surgical floor. At 0225 a second emergency patient, a woman with an ectopic pregnancy, was being prepared for surgery. The surgeon called the PACU and asked the nurse to send the first patient to the floor now so she could take the second patient, saying he looked fine and the floor could watch him. The anesthesiologist was in the operating room starting the second case and did not answer the first page.

The Duties, Each With Its Holder and Its Route

Duty to the first patient's safety. Owed to the patient. The route if unmet is harm, followed by a complaint, a claim or a report to the board. This duty has a body behind it: the Ohio Board of Nursing can review whether a nurse's practice met the standard of a reasonably prudent nurse. Under the ANA code, the patient comes first among the people a nurse answers to (American Nurses Association, 2025).

Duty to the second patient's timely care. Also owed to a patient, one the nurse has not yet met. A delay in surgery for a possible ruptured ectopic pregnancy can cause serious harm. The route if unmet is the same, but the nurse's part in it is indirect: she does not control the operating room, and the surgeon could proceed with the anesthesiologist's agreement while the PACU nurse is still busy.

Duty to follow the transfer policy. Owed to the employer and, through it, to the anesthesia department that wrote the criteria. The route if unmet is peer review and possible discipline. This duty has an institutional body behind it.

Duty to cooperate with the surgeon. Owed to a colleague and to the team. The route if unmet is conflict, a complaint to the nurse manager and a difficult working relationship. This duty has no regulator behind it; it rests on the nurse's own sense of teamwork and on the hospital's culture.

Duty to meet the specialty's staffing standard. Owed to both patients. ASPAN's standard requires two registered nurses in the unit during Phase I care, including during on-call situations (American Society of PeriAnesthesia Nurses, 2025). The nurse is already not meeting it, not by choice. Taking the second patient while the first is still in Phase I would make that gap worse.

The Case for Sending Him

The case for transfer is serious and deserves to be stated at full strength. The surgeon is right that the second patient may be in danger, and a surgeon's judgment about a patient he has just operated on counts for something. The first patient is stable, his score is only one point short, and the surgical floor has nurses who can monitor him. A PACU nurse who holds a stable patient while a woman bleeds internally could be seen as putting a policy above a life. In a small hospital at night, rigid criteria can produce exactly the bottleneck this case describes.

The Case for Keeping Him

The case against transfer rests on what the score is measuring. A drowsy patient who needs oxygen after general anesthesia and opioids is in the group at greatest risk in the first hours after surgery. In an analysis of anesthesia liability claims arising in the PACU, Kellner et al. (2018) found breathing-related harm to be the leading category, and late recognition was part of the story in more than half of the claims where the patient died. A surgical floor at 0230 typically has one nurse for five or six patients and no continuous monitoring. The criteria exist so that this patient is not moved to a place where his breathing will be checked every few hours instead of continuously. The surgeon is not the person who wrote the criteria and cannot waive them; only an anesthesia provider can, under the policy.

The two patients are also not in direct competition in the way the call suggests. The second patient needs an operating room and an anesthesiologist, both of which are available. She will need the PACU in an hour or more, not now.

The Decision, and the Debt It Leaves

The nurse told the surgeon she could not send the patient to the floor until he met the criteria or the anesthesiologist approved the transfer in writing, and that she would reassess him in fifteen minutes. She asked the house supervisor to come to the PACU and to call in the second on-call PACU nurse, so that two nurses would be present when the second patient arrived. She paged the anesthesiologist again with a clear message about the transfer request and the patient's score. At 0245, off oxygen, the patient's saturation held at 93% and his score reached 9; he went to the floor at 0250 with a bedside handoff and a request for continuous pulse oximetry for four hours.

The debt is real and she names it. The surgeon was angry, and the working relationship will need repair; she plans to speak with him the next day, not to apologize for the decision but to explain the criteria and ask what would help him on a future night. The second patient's surgery was not delayed, but it might have been, and a nurse who holds a patient must accept that possibility. And the nurse was not able to meet the staffing standard at any point that night, which she will report through the unit's safety reporting system so the schedule is reviewed.

Law, Ethics and What Was Actually in Her Power

Law and policy answered part of the question: the nurse had no authority to override the anesthesia department's criteria, and the surgeon had none either. Ethics answered the rest, which was what to do with the time and people available. The nurse could not create a second PACU nurse or a second anesthesiologist. She could decline to move an unstable patient, call for help, and make the gap visible. Treating the case as though she had unlimited resources would have produced a tidier answer and a less honest one.

References

American Nurses Association. (2025). Code of ethics for nurses. https://codeofethics.ana.org/

American Society of PeriAnesthesia Nurses. (2025). 2025-2026 perianesthesia nursing standards, practice recommendations and interpretive statements. https://www.aspan.org/Publications-Resources/ASPAN-Publications/ASPAN-Standards

Kellner, D. B., Urman, R. D., Greenberg, P., & Brovman, E. Y. (2018). Analysis of adverse outcomes in the post-anesthesia care unit based on anesthesia liability data. Journal of Clinical Anesthesia, 50, 48-56. https://doi.org/10.1016/j.jclinane.2018.06.038