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Troy University School of Nursing One University Place Phenix City, AL 36869 gavery{at}troy.edu

Everyday Choices: Ethics and Decision-Making in Home Care and Community Nursing. Video/2003/28 min. A film by Ben Achtenberg and Christine Mitchell. Written and directed by Ben Achtenberg. Associate Producer: Karen McMillen. Produced by CM. Distributed by Fanlight Productions, 4196 Washington St., Suite 2, Boston, MA 02131. 800-937-4113. Online: www.fanlight.com. E-mail: info{at}fanlight.com. Rental $60 (one day) or $120 (one week), Purchase $229, DVD $249. Also distributed by Terra Nova Films, 9848 South Winchester Ave., Chicago, IL 60540. 773-881-8491. Online: www.terravnova.org. E-mail: tnf{at}terranova.org. Rental $65, Purchase $229.

The film Everyday Choices easily could be retitled Everyday Dilemmas Experienced by a Visiting Home Health Nurse and the Support Staff that Care for Elderly Clients. A dilemma according to the American Heritage Dictionary is a situation that requires a choice between two equal, usually unpleasant alternatives. Dilemmas abound in the poignant portrayal of challenges that emerge as Allison, a young visiting nurse, tries to help Gerardo remain independent in his familiar surroundings. Gerardo is a 75-year-old Hispanic elder, originally from Cuba, who lives alone in a public housing complex with no evidence of real family support. At the beginning of Allison's visits, she faces the dilemma that Gerardo is showing the signs of an early dementia. Allison is worried that his changing health may affect his driving, his employment as a security guard, and his ability to maintain the regimen of his daily medications. He relies on his own resources to remain independent, but that independence is being compromised by his failing health. Allison and some of the staff from the home health agency intervene and become, in effect, a surrogate family for Gerardo. The spiral of dependency begins with an initial dismal medical diagnosis, eventual nursing home placement, a period of lost contact with no medical care, and finally hospitalization with a terminal illness. Ethical and legal obstacles occur throughout Gerardo's home care and are maneuvered tactfully by the health care providers working in concert with Allison. The video portrays Allison supporting Gerardo as much as she is able to—even when she is laid off during a time of state budget cuts that affect the state's visiting nurses program. Through all the numerous choices that are made to support Gerardo's care, Allison's commitment to Gerardo ultimately exemplifies the caring that best characterizes the nursing profession.

Everyday Choices is an excellent teaching tool, not only for nurses, but for all health care providers who influence the decisions that impact the choices made in elder health care. The authenticity of the clinical situations encountered in Gerardo's story can encourage scholarly discussion of the legalities, ethics, and reality of resources needed to keep elders self-determining and living in a community setting. Because of its 30-min format, the video allows the teacher ample time for viewing and discussion in a typical classroom setting. A topical outline easily can be developed using the storyline as a reference. Teaching content is evident throughout the video. Some of the topics suggested include the importance of multidisciplinary communication with peers, avoidance of emotional attachment to the detriment of self, and the inevitable choices that have to be made. In addition, the study guide accompanying the video supplies a multitude of questions to ponder and discuss in a teaching environment. As an example, students could deliberate the question raised about the extent to which decisions made by the nurses as well as by the physicians contribute to the legal and ethical dilemmas evident in Gerardo's story. Other potential discussion topics include the realities of practice and time constraints, third-party knowledge of potential dangers to others, the parameters of medical responsibility, and the personal emotional journeys of health care workers. The video is virtually a myriad of controversial issues that could be the basis of further deliberation.

Even though the film and handout have great academic value, there is one obvious omission: Neither the video nor the study guide mentions the ethical and legal principles that guide professional multidisciplinary team resolutions. The conclusion of the video seemed abrupt and unexpected; there were no voices of professionals or experts who could have given some insight into the medical maze that many times professionals stumble through. The nurse, Allison, still questioned her actions even at the end of the video, and she concluded with moving comments related to not being able to do the job without becoming emotionally attached to her patient. She stated she still cared about all her patients and summarized her feelings by saying, "That's a big portion of it for me." A member of Alison's team declares, "We cry out for black and white answers but there is no black and white—just shades of gray." Certainly the combination of the emotional involvement in caring and yet the requirements of dealing with ethics and legal dilemmas perpetuates an emotional turmoil in community nursing.

Cultural realism is maintained in Gerardo's heavy Hispanic accent and the use of Spanish guitar music in the background. Although the accent at times leaves the viewer lost in the conversation, other characters' dialogue allows the viewer the opportunity to recapture the storyline. Nevertheless, the lack of family involvement in Gerardo's care seems contradictory when one considers that family connections typically are of paramount importance in the Hispanic culture. Additionally, the use of short scenes, much like the brief visits that Allison is allowed to make, reveals the story effectively. The pictures of Gerardo sitting in his chair at home, petting the dog but not feeding it, getting into his car in his security outfit, and searching for answers to questions by the neurologist may be upsetting to viewers. In effect, the viewer perceives a dissonance similar to the emotions that Allison felt. In her case, Allison expresses empathy for Gerardo's circumstances in life and is determined to help at all costs. The "cliff-hanger" scene at the end of the video—which supplies few details given about Gerardo's condition—only emphasizes that no answers are readily available.

Everyday Choices portrays the everyday thoughts, opinions, and emotions that health care providers experience when dealing with the ethics and legalities of declining health in elders. Every nurse or healthcare provider who practices in the community, or even in the hospital, is involved in similar revolving-door situations that lead to no satisfactory conclusions. The practice of medicine and nursing is indeed immersed in the Everyday Choices of patient care.

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