For this discussion you will be examining ethical nursing practice. In three to five paragraphs answer the following questions in apa format.
- Define in your own words “ethical nursing practice.”
- Describe the basis or framework you used for your definition.
- Explain the difference between legal and ethical nursing practice.
- Discuss one ethical or bioethical dilemma a nurse may encounter and describe how it could be handled.
Use the following reference:
Catalano, J. T. (2015). Nursing Now! Today’s Issues, Tomorrow’s Trends, 7th Edition.
Respond to the 2 postings below in 300 words
To phrase it very simply and broadly, to me ethical nursing practice follows the following concepts: a nurse is ethically obligated to provide the best care within his or her abilities, one’s freedom ends where another’s begins, and treat others as you wish to be treated. These concepts are difficult to apply to real life situations in the healthcare field because they carry so much ambiguity. I feel these concepts tie in very nicely with the six principles of nursing mentioned in chapter 6 in Nursing Now! (Catalano, 2015). These six principles are simpler to apply to the healthcare field because they are less ambiguous.
Ethical nursing practice abides by all six of the principles of nursing: autonomy, beneficence, nonmaleficence, justice, fidelity and veracity (Catalano, 2015). Autonomy is the principle that each client has the right make decisions on the what and how for their care (Catalano, 2015). Beneficence is the principle that every action is taken with the intention of improving the life of the client (Catalano, 2015). This is done through a holistic approach, including all factors in the clients life (Catalano, 2015). Nonmaleficence is the principle that no harm will be done (Catalano, 2015). This ethically obligates the nurse to prevent harm from coming to the client from their own hands, the nurse’s, or another’s. Justice is the principle that dictates equal care to all people (Catalano, 2015). Fidelity is the principle that entails honoring commitments and promises, to self and others (Catalano, 2015). Veracity is the principle that compels the nurse to always tell the truth (Catalano, 2015). It also provides the right to the client to know everything that has to do with their health and care (Catalano, 2015). These ethical principles provide a good foundation of framework for nurses.
“Nurse” comes from the latin word nutricius which means to nourish (Catalano, 2015). By definition it is a nurse’s job to nourish, encourage growth and health. If a nurse abides by the six principles he or she is better equipped to provide nourishment. While considering actions, a nurse must not only consider the ethical implication, but the legal implications as well. Legal and ethical principles are in place to allow humans to live peacefully together. Many legal regulations come from ethical principles, due to support from a majority of the population they become “law” (Catalano, 2015). For an ethical principle to become a law it must be enforceable by law enforcement officials and have equal application to the entire population (Catalano, 2015). Not all ethical principles meet these conditions, however, they are equally as important in promoting peaceful interactions and the survival of the species. Even though ethical principles are not enforced by our governments they are by licensure boards (Catalano, 2015). Nurses, and other health care providers, who repeatedly disregard ethical practice risk having their license revoked (Catalano, 2015).
One ethical dilemma a nurse could encounter would be a client demanding a treatment they feel is necessary but could in reality cause them harm or death. This would be an ethical dilemma because it would challenge nearly all the ethical principles of nursing: autonomy, beneficence, nonmaleficence, and veracity. Autonomy, because the client is requesting a treatment. Beneficence and nonmaleficence, because if the nurse provides the treatment as requested he or she knows it will cause harm. Veracity, because the nurse knows the treatment would be harmful and he or she is obligated to tell the client the truth. I feel the best solution to this dilemma would be to acknowledge the client’s request and very respectfully educate them on why that treatment could harm them and if possible provide them with information on another treatment. Hopefully on learning the truth the client would choose not to have the harmful treatment or would choose a treatment that would be beneficial.
Catalano, J.T. (2015). Nursing Now! Today’s Issues, Tomorrow’s Trends, 7th Edition. Retrieved from https://ambassadored.vitalsource.com/#/books/undef…
In my opinion “ethical nursing practice” is based on the knowledge learned and taught in school as well as the experiences gained while working as a nurse. Ethical nursing is when a nurse acknowledges and demonstrates essential aspects of good nursing. As a nurse you must obtain the ability to make ethical and sensible decisions based on the well being of your patient and the rights of the individual. This may also be based on the principles and protocols of your facility that provide a baseline of care to the patients.
Ethical nursing practice I believe is focused more on the morals and beliefs of the nurse. With this being said it is also based on how one feels and what an individual believes is right or wrong. Legal nursing practice is based more on the laws and procedures set forth by the State Board of nursing. These are strict rules established to define what is allowed and what is not. These laws are punishable if in the instance they are broken or abused.
One of the ethical dilemmas a nurse may face is disclosing medical information, diagnosis, conditions, or treatments to family members , friends, or even the patient. If they Dr instructs you not to speak on a diagnosis to family and/or the patient it is your responsibility and principle as a nurse to do what is ask of you by the Dr. However the nurses own moral values may come into play because one would consider that it is the patients right and/or family’s right to know the truth. When patients or family members ask the nurse for answers the nurse may instruct them to speak with their Dr about their concerns/cares as it is not something you may directly be informed about.
Catalano, J. (2015) Nursing Now! Today’s Issues, Tomorrow’s Trends. (7th ed.) Philadelphia; F.A. Davis.
Supportive reading excerpt: (please reference in apa when writing in your own words)
6 Ethics in Nursing
Joseph T. Catalano
After completing this chapter, the reader will be able to:
- • Discuss and analyze the difference between law and ethics
- • Define the key terms used in ethics
- • Discuss the important ethical concepts
- • Distinguish between the two most commonly used systems of ethical decision-making
- • Apply the steps in the ethical decision-making process
A LEARNED SKILL
Nurses who practice in today’s health-care system soon realize that making ethical decisions is a common part of daily nursing care. However, experience shows that in the full curricula of many schools of nursing, the teaching of ethical principles and ethical decision-making gets less attention than the topics of nursing skills, core competencies, and electronic charting. As health-care technology continues to advance at a rapid pace, nurses will find it more and more difficult to make sound ethical decisions. Many nurses feel the need to be better prepared to understand and deal with the complex ethical problems that keep evolving as they attempt to provide care for their clients.1
There are many individuals who confuse ethics with social norms, religious beliefs, or the legal system. Some simply believe ethics are the same as morals. Although elements of ethics may be found in all these places, ethics itself is a stand-alone set of concepts and principles that guide humans in general, and professionals in particular, in making decisions about what types of behaviors will help or harm other members of society. Ethics generally presents broad concepts to guide decision-making and does not have specific rules such as are found in moral systems.
Ethical decision-making is a skill that can be learned. The ability to make sensible ethical decisions is based on an understanding of underlying ethical principles, ethical theories or systems, a decision-making model, and the profession’s code of ethics. This skill, like others, involves mastery of the theoretical material and practice of the skill itself. This chapter presents the basic information required to understand ethics, the code of ethics, and ethical decision-making. It also highlights some of the important bioethical issues that challenge nurses in the current health-care system.
As a part of a philosophical system, ethics is generally divided into levels or categories:
- Meta-Ethics: The abstract, overarching philosophical way of understanding ethics. One of the most important questions that philosophy in general addresses is the question of epistemology, or how we know that we know. In ethics, this question is refined to how do we know what is right and wrong. It also seeks to answer the question, “What is truth?” It is concerned with the meaning of ethical language and explaining the fundamental meaning of the words. The discussion below of the ethical terms is actually a meta-ethics approach to understanding ethics. Without meta-ethics, it is almost impossible to take the next step to normative ethics.
- Normative Ethics: The use of the concepts and principles discovered by meta-ethics to guide decision-making about specific actions in determining what is right or wrong when interacting with other people. Normative ethics tends to be more prescriptive than meta-ethics and forms the basis for theories and systems of ethics (below). Both the codes of ethics and the deontological ethical system (below) find their underpinnings in meta-ethics and normative ethics
- Applied Ethics: The application of the theories and systems of ethics developed by normative ethics to real-world situations. Applied ethics is broken into specialized fields such as health-care ethics, legal ethics, bioethics, or business ethics. This is the category of ethics that is used most by nurses and other health-care providers. It is used in resolving ethical dilemmas.
- Descriptive Ethics: A bottom-up approach to ethics that starts with what society is already doing ethically and developing ethical principles based on the observed actions of people rather than starting with ethical principles and applying them to society such as normative ethics does. There are no preset values in descriptive ethics except for the consistent ethical decisions that are already being made by the majority of members of society. It is also sometimes called comparative ethics and forms the basis for situational ethics and the utilitarian system of ethics. Although widely used in politics, economics, and business, it creates additional issues for health-care providers when applied to difficult health-care decisions.
“Values are usually not written down; however, at some time in their professional careers, it may be important for nurses to make lists of their values.”
In Western cultures, the study of ethics is a specialized area of philosophy, the origins of which can be traced to ancient Greece. In fact, certain ethical principles articulated by Hippocrates still serve as the basis for many of the current debates. Like most specialized areas of study, ethics has its own language and uses terminology in precise ways. The following are some key terms that are encountered in studies of health-care ethics.
Values are ideals or concepts that give meaning to an individual’s life. Values are derived most commonly from societal norms, religion, and family orientation and serve as the framework for making decisions and taking action in daily life. People’s values tend to change as their life situations change, as they grow older, and as they encounter situations that cause value conflicts. For example, before the 1950s, pregnancy outside of marriage was unacceptable, and unmarried women who were pregnant were shunned and generally separated from society. Today this situation is more widely accepted, and it is not uncommon to see pregnant high school students attending classes.
Values are usually not written down; however, at some time in their professional careers, it may be important for nurses to make lists of their values. This value clarification process requires that nurses assess, evaluate, and then determine a set of personal values and prioritize them. This will help them make decisions when confronted with situations in which the client’s values differ from the nurse’s values.
Value conflicts that often occur in daily life can force an individual to select a higher-priority value over a lower-priority one. For example, a nurse who values both career and family may be forced to decide between going to work and staying home with a sick child.2
Morals are the fundamental standards of right and wrong that an individual learns and internalizes, usually in the early stages of childhood development. An individual’s moral orientation is often based on religious beliefs, although societal influence plays an important part in this development. The word moral comes from the Latin word mores, which means “customs” or “values.”
Moral behavior is often manifested as behavior in accordance with a group’s norms, customs, or traditions. A moral person is generally someone who responds to another person in need by providing care and who maintains a level of responsibility in all relationships.3 In many situations in which moral convictions differ, it is difficult to find a rational basis for proving one side right over the other. For example, animal rights activists believe that killing animals for sport, their fur, or even food is morally wrong. Most hunters do not even think of the killing of animals as a moral issue at all.
What Do You Think?
What type of value conflicts have you experienced in the past week? How did you resolve them? Were you satisfied with the resolution, or did it make you feel uncomfortable?
Laws can generally be defined as rules of social conduct made by humans to protect society, and these laws are based on concerns about fairness and justice. The goals of laws are to preserve the species and promote peaceful and productive interactions between individuals and groups of individuals by preventing the actions of one citizen from infringing on the rights of another. Two important aspects of laws are that they are enforceable through some type of police force and that they should be applied equally to all persons.
The term ethics has its origins in the Greek word ethos, which is generally translated as “quality” or “character.” It is a branch of traditional Western philosophy known as moral philosophy that studies moral behavior in humans and how humans should act toward each other individually and in groups. Ethics, as a system of beliefs and behaviors, goes beyond the law, which has as its primary underlying principle the preservation of society. Ethics is more focused on the quality of the society and its long-term survival. Similar to the legal system, ethical systems are only needed when there is a group of people living together. A hermit living in a cave on a mountain by himself does not need laws or ethical systems. Primitive societies that were composed of a small number of individuals had to have some basic laws for survival, such as not killing each other, and some basic ethical principles, such as distributive justice—for example, all members of the tribe get the same amount of food. As society increases in size and becomes more complex, there is a need for more laws and a stronger ethical system.
A System of Morals
Ethics are declarations of what is right or wrong and of what ought to be. Ethics are usually presented as systems of value behaviors and beliefs; they serve the purpose of governing conduct to ensure the protection of an individual’s rights. Ethics exist on several levels, ranging from the individual or small group to the society as a whole. The concept of ethics is closely associated with the concept of morals in the development and purposes of both. In one sense, ethics can be considered a system of morals for a particular group. There are usually no systems of enforcement for those who violate ethical principles;4 however, repeated and obvious violation of ethical precepts of a code of ethics by professionals can result in disciplinary action by the profession’s licensing board.
A code of ethics is a written list of a profession’s values and standards of conduct. The code of ethics provides a framework for decision-making for the profession and should be oriented toward the daily decisions made by members of the profession.
An ethical dilemma is a situation that requires an individual to make a choice between two equally unfavorable alternatives. The basic, elemental aspects of an ethical dilemma usually involve conflict of one individual’s rights with those of another, conflict of one individual’s obligations with the rights of another, or combined conflict of one group’s obligations and rights with those of another group.5
Principles in Conflict
By the very nature of an ethical dilemma, there can be no simple correct solution, and the final decision must often be defended against those who disagree with it. For example:
- A client went to surgery for a laparoscopic biopsy of an abdominal mass. After the laparoscope was inserted, the physician noted that the mass had metastasized to the liver, pancreas, and colon, and even before the results of the tissue biopsy returned from the laboratory, the physician diagnosed metastatic cancer with a poor prognosis. When the client was returned to his room, the physician told the nurses about the diagnosis but warned them that under no circumstances were they to tell the client about the cancer.
- When the client awoke, the first question he asked the nurses was, “Do I have cancer?” This posed an ethical dilemma for the nurses. If they were to tell the client the truth, they would violate the principle of fidelity to the physician. If they lie to the client, they would violate the principle of veracity.
KEY CONCEPTS IN ETHICS
In addition to the terminology used in the study and practice of ethics, several important principles often underlie ethical dilemmas. These principles include autonomy, justice, fidelity, beneficence, nonmaleficence, veracity, standard of best interest, and obligations.
Autonomy is the right of self-determination, independence, and freedom. It refers to the client’s right to make health-care decisions for himself or herself, even if the health-care provider does not agree with those decisions.
As with most rights, autonomy is not absolute, and under certain conditions, limitations can be imposed on it. Generally these limitations occur when one individual’s autonomy interferes with another individual’s rights, health, or well-being. For example, a client generally can use his or her right to autonomy by refusing any or all treatments. However, in the case of contagious diseases (e.g., tuberculosis) that affect society, the individual can be forced by the health-care and legal systems to take medications to cure the disease. The individual can also be forced into isolation to prevent the disease from spreading. Consider the following situation:
- June, who is the 28-year-old mother of two children, is brought into the emergency department (ED) after a tonic-clonic–type seizure at a shopping mall. June is known to the ED nurses because she has been treated several times for seizures after she did not take her antiseizure medications. She states that the medications make her feel “dopey” and tired all the time and that she hates the way they make her feel.
- Recently, June has started to drive one of her children and four other children to school in the neighborhood car pool 1 day a week. She also drives 62 miles one way on the interstate twice a week to visit her aging mother in a nursing home in a different city. The nurse who takes care of June this day in the ED knows that the state licensing laws require that an individual with uncontrolled seizures must report the fact to the Department of Motor Vehicles (DMV) and is usually ineligible for a driver’s license. When the nurse mentions that she has to report the seizure, June begs her not to report it. She would have no means of taking her children to school or visiting her mother. She assures the nurse that she will take her medication no matter how it makes her feel.
The ethical issue in this case study is a conflict of rights and obligations. June has a right to autonomy to determine whether she will take her medication and whether she will self-report having seizures to the DMV. The nurse has an obligation to recognize and honor June’s autonomy, but she also has an obligation to maintain public safety, including reporting June’s seizures. This is a classical case of an ethical dilemma. Does June’s right to autonomy supersede the nurse’s obligation to public safety? Do the legal issues involved in the situation affect the ethical decision the nurse makes? How would you decide?
Justice is the obligation to be fair to all people. The concept is often expanded to what is called distributive justice, which states that individuals have the right to be treated equally regardless of race, gender, marital status, medical diagnosis, social standing, economic level, or religious belief. The principle of justice underlies the first statement in the American Nurses Association (ANA) Code of Ethics for Nurses (2014): “The nurse in all professional relationships practices with compassion and respect for the inherent dignity, worth, and uniqueness of each individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.”4
“By the very nature of an ethical dilemma, there can be no simple correct solution, and the final decision must often be defended against those who disagree with it.”
Distributive justice sometimes includes ideas such as equal access to health care for all. As with other rights, limits can be placed on justice when it interferes with the rights of others.6 For example:
- A middle-aged homeless man who was diagnosed with type 1, insulin-dependent diabetes mellitus demanded that Medicaid pay for a pancreas transplant. His health record showed that he refused to follow the prescribed diabetic regimen, drank large quantities of wine, and rarely took his insulin. The transplantation would cost $108,000, which is the total cost of immunizing all the children in a state for 1 year.
Fidelity is the obligation of an individual to be faithful to commitments made to himself or herself and to others. In health care, fidelity includes the professional’s faithfulness or loyalty to agreements and responsibilities accepted as part of the practice of the profession. Fidelity is the main support for the concept of accountability, although conflicts in fidelity might arise from obligations owed to different individuals or groups. For example:
- A nurse who is just finishing a very busy and tiring 12-hour shift may experience a conflict of fidelity when she is asked by a supervisor to work an additional shift because the hospital is short-staffed. The nurse has to weigh her fidelity to herself against fidelity to the employing institution and against fidelity to the profession and clients to do the best job possible, particularly if she feels that her fatigue would interfere with the performance of those obligations.
Beneficence, one of the oldest requirements for health-care providers, views the primary goal of health care as doing good for clients under their care. In general, the term good includes more than providing technically competent care for clients. Good care requires that the health-care provider take a holistic approach to the client, including the client’s beliefs, feelings, and wishes, as well as those of the client’s family and significant others. The difficulty in implementing the principle of beneficence is in determining what exactly is good for another and who can best make the decision about this good.4
Consider the case of the man involved in an automobile accident who ran into a metal fence pole. The pole passed through his abdomen. Even after 6 hours of surgery, the surgeon was unable to repair all the damage. The man was not expected to live for more than 12 hours. When the man came back from surgery, he had a nasogastric tube inserted, so the physician ordered that the client should have nothing by mouth (NPO) to prevent depletion of electrolytes.
Although the man was somewhat confused when he awoke postoperatively, he begged the nurse for a drink of water. He had a fever of 105.7°F. The nurse believed the physician’s orders to be absolute; thus she repeatedly refused the client water. He began to yell loudly that he needed a drink of water, but the nurse still refused his requests. At one point, the nurse caught the man attempting to drink water from the ice packs that were being used to lower his fever. This continued for the full 8-hour shift until the man died. Should the nurse have given the dying man a drink of water? Why or why not? Or is it not that simple?
Again, the ethical dilemma in this situation is a conflict of rights and obligations. The client has a right to self-determination (autonomy) that would certainly include the right to have a drink of water. The nurse has an obligation of beneficence to do good for the client. She also has an obligation to carry out the physician’s orders. However, is withholding water, which is an essential nutrient for life, really doing good for the client? On the other hand, she is fulfilling her obligation to follow the physician’s order, which may be based on the physician’s belief that withholding water is good for the client because giving it will harm him in some way or quicken his death. If the nurse believes that the physician is wrong, does her judgment supersede his?
“Fidelity is the main support for the concept of accountability, although conflicts in fidelity might arise from obligations owed to different individuals or groups.”
What would you do? Is there something else the nurse could have done, such as calling the physician and asking him to change the order? Are physician’s orders always absolute, even when they seem to be causing harm to the client?
Nonmaleficence is the requirement that health-care providers do no harm to their clients, either intentionally or unintentionally. In a sense, it is the opposite side of the concept of beneficence, and it is difficult to speak of one term without referring to the other. In current health-care practice, the principle of nonmaleficence is often violated in the short term to produce a greater good in the long-term treatment of the client. For example, a client may undergo painful and debilitating surgery to remove a cancerous growth to prolong his life.4
By extension, the principle of nonmaleficence also requires that health-care providers protect from harm those who cannot protect themselves. This protection from harm is particularly evident in groups such as children, the mentally incompetent, the unconscious, and those who are too weak or debilitated to protect themselves. In fact, very strict regulations have developed around situations involving child abuse and the health-care provider’s obligation to report suspected child abuse. (This issue is discussed in more detail in Chapter 7.)
Veracity is the principle of truthfulness. It requires the health-care provider to tell the truth and not to intentionally deceive or mislead clients. As with other rights and obligations, limitations to this principle exist. The primary limitation occurs when telling the client the truth would seriously harm (principle of nonmaleficence) the client’s ability to recover or would produce greater illness. Although the principle of veracity is not a law, it is one of the basic foundations for the trusting relationship between nurse and client that underlies any successful therapeutic relationship.
A Right to Know
Health-care providers often feel uncomfortable giving a client bad news, and they hesitate to give clients difficult information regarding their condition. But feeling uncomfortable is not a good enough reason to avoid telling clients the truth about their diagnosis, treatments, or prognosis. Although veracity is an obligation for nurses, it is a right of clients to know the information about their conditions.
One common situation in which veracity is violated is in the use of placebo medications. At some point during their careers, most health-care providers will observe the placebo effect among some clients. Sometimes, when a client is given a gel capsule filled with sugar powder and it seems to relieve the pain, the placebo has the same effect as a narcotic, but without the side effects or potential for addiction. Of course, if the client is told that it was just a sugar pill (veracity), it would not have the same effect. How should nurses feel about this practice?
Issues in Practice
A Question of Distributive Justice
Jessica B was diagnosed with acute lymphocytic leukemia at age 4. She is now 7 years old and has been treated with chemotherapy for the past 3 years with varying degrees of success. She is currently in a state of relapse, and a bone marrow transplant seems to be the only treatment that might improve her condition and save her life. Her father is a day laborer who has no health insurance, so Jessica’s health care is being paid for mainly by the Medicaid system of her small state in the Southwest.The current cost of a bone marrow transplant at the state’s central teaching hospital is $1.5 million, representing about half of the state’s entire annual Medicaid budget. Although bone marrow transplants are an accepted treatment for leukemia, this therapy offers only a slim chance for a total cure of the disease. The procedure is risky, and there is a chance that it may cause death. The procedure will involve several months of post-transplant treatment and recovery in an intensive care unit far away from the family’s home and will require the child to take costly antirejection medications for many years.
The family understands the risks and benefits. They ask the nurse caring for Jessica what they should do.
Questions for Thought
- 1. How should the nurse respond?
- 2. Does the nurse have any obligations toward the Medicaid system as a whole?
Another issue that has come into the public eye recently is medical errors. According to an Institute of Medicine Report, the incidence of medical errors in the current health-care system is extremely high and accounts for as many as 98,000 deaths per year. Nurses are often involved in these incidents.7 What is the nurse’s ethical obligation to reveal this information? Some believe that if there is no injury to clients, the error need not be revealed; however, the reporting of errors or near errors has become a quality-control issue in the prevention of medical mistakes. (See Chapter 14 for more detail.)
Consider the following case study from the viewpoint of the principle of veracity:
- Tisha S, a senior nursing student, was acting as the team leader during her final clinical experience. Jamie D, a close friend of Tisha’s, was one of three junior nursing students on Tisha’s team that day. Because of some personal problems, Jamie had been late and unprepared for several clinical experiences. She was informed by her instructor that she might fail unless she showed marked improvement during clinical training.
- Claire B, a 64-year-old woman with diabetes and possible renal failure, was one of Jamie’s clients. Mrs. B was having a 24-hour urine test to help determine her renal function. After the test was completed later that afternoon, she was to be discharged and treated through the renal clinic. Jamie understood the principles of the 24-hour urine test and realized that all the urine for the full 24 hours needed to be saved, but she became busy caring for another client and accidentally threw away the last specimen before the test ended. She took the specimen container to the laboratory anyway.
- At the end of the shift, when Jamie was giving her report to Tisha, she confided that she had thrown away the last urine specimen but begged Tisha not to tell the instructor. This mistake meant that the test would have to be started over again, and Mrs. B would have to spend an extra day in the hospital. Out of friendship, Tisha agreed not to tell the instructor, rationalizing that they had collected almost all the urine and she was going to be treated for renal failure anyway. When the instructor asked Tisha for her final report for the day, she specifically asked if there had been any problems with the 24-hour urine test.
In this case, it is pretty clear that Jamie’s and Tisha’s obligation to veracity significantly outweighs Tisha’s obligation of friendship to Jamie. The reporting of medical errors is important in identifying areas in the system that need to be corrected. In this case, the instructor should have supervised the student more closely.
“Using the standard of best interest requires that a good faith decision is made about what treatment(s) or actions would lead to the best results for the client after considering all the relevant information.”
Standard of Best Interest
Originally designed as a standard of surrogate decision-making, the standard of best interest was first used by courts for making end-of-life decisions regarding incompetent clients. Using the standard of best interest requires that a good faith decision is made about what treatment(s) or actions would lead to the best results for the client after considering all the relevant information. The decision must be made in accordance with ethical and medical standards. This is generally considered a “quality of life” issue and is strongly opposed by groups who advocate for right to life at any cost.
The Client’s Wishes
Standard of best interest describes a type of decision made about a client’s health care when the client is unable to make the informed decision themselves. The standard of best interest is used on the basis of what health-care providers and the family decides is best for that individual. It is very important to consider the individual client’s expressed wishes, either formally in a written declaration (e.g., a living will) or informally in conversation with family members.
A Designated Person
Individuals can also legally designate a specific person to make health-care decisions for them in case they become unable to make decisions for themselves. The designated person then has what is called durable power of attorney for health care (DPOAHC).8 The Omnibus Budget Reconciliation Act (OBRA) of 1990 made it mandatory for all health-care facilities, such as hospitals, nursing homes, and home health-care agencies, to provide information to clients about the living will and DPOAHC.
In determining what is in the client’s best interest, the DPOAHC, in consultation with medical professionals, should consider:
- • the client’s current level of physical, sensory, emotional, and cognitive abilities.
- • the level of pain resulting from the client’s disease process, treatments, or termination of the treatment.
- • how much loss of dignity and humiliation the client will experience as a result of the illness and/or treatments.
- • the client’s life expectancy and chance for recovery both with and without the treatment.
- • all the treatment options available to the client.
- • the risks, side effects, and benefits of each of the treatment options.
The standard of best interest should be based on the principles of beneficence and nonmaleficence. Unfortunately, when clients are unable to make decisions for themselves and no DPOAHC has been designated, the resolution of the dilemma can be a unilateral decision made by health-care providers. Health-care providers making a unilateral decision that disregards the client’s wishes implies that the providers alone know what is best for the client; this is called paternalism.
Obligations are demands made on an individual, a profession, a society, or a government to fulfill and honor the rights of others. Obligations are often divided into two categories: legal and moral.
Legal obligations are those that have become formal statements of law and are enforceable under the law. For instance, nurses have a legal obligation to provide safe and adequate care for clients assigned to them.
Issues in Practice
The nurse is caring for a critically ill client in the surgical intensive care unit (ICU) after radical neck surgery. The client is connected to a ventilator and is on a sedation protocol with continuous IV infusion of midazolam (Versed), a powerful sedative that requires constant monitoring and titration to maintain the required level of sedation. During the night shift, the nurse discovers that the medication bag is almost empty, and the pharmacy, which is closed, did not send up another bag. She looks the medication up in a drug guide and proceeds to mix the drip herself. The night charge nurse is busy supervising a cardiac arrest situation out of the ICU and is unavailable to double-check how the medication was mixed.Inadvertently, the nurse mixes a double-strength dose of the medication. Thirty minutes after she hangs the new drip, the client’s blood pressure is 44/20 mm Hg. The client requires a saline bolus and a dopamine drip to stabilize the blood pressure. The family is notified that the client has “taken a turn for the worse” and that they should come to the hospital immediately. In backtracking for the cause of the hypotension, the nurse realizes that she has mixed the sedative double strength and reduces the rate by half.
When the family arrives, the client’s blood pressure has started to return to normal. They ask the nurse what happened and why their mother was on the new IV medication.
Questions for Thought
- 1. Should the family be told about the error?
- 2. Who should tell them? The nurse? The physician?
- 3. What approach should be used?
- 4. What ethical principles are involved in resolving this dilemma?
Source: Gallagher TH. Disclosing harmful medical errors to patients. New England Journal of Medicine, 356(26):2713–2719, 2007.
Glossary (please summarize in own words
|accountability||being answerable to self and others for one’s actions, includes the concept of responsibility, a specific type of accountability for duties performed|
|2.||ANA code of ethics||Formal statements:
Inform the public of minimal standards
Outline the ethical considerations of the profession
Provide members guidelines for professional practice
Serve as a guide for the discipline’s self-regulation
The Code, previously called The Code of Ethics for Nurses was developed as a guide for carrying out nursing responsibilities in a manner consistent with quality in nursing care and the ethical obligations of the profession.
to delineate the code of responsibilities and conduct expected of nurses in their practice.
Nurses are held responsible to comply with the standards of ethical practice and to ensure that other nurses also comply.
|3.||autonomy||is agreement to respect another’s right to self-determine a course of action; it stands for independence and the ability to be self-directed. Clients have the right of self-determination and are entitled to decide what happens to them; therefore, competent adults have the capacity to consent to or refuse treatment. Nurses must respect the client’s wishes, even if they don’t agree with them|
|4.||beneficence||means promoting or doing good. It is about compassion and is a core principle of patient advocacy. Nurses work to promote their clients’ best interests and strive to achieve optimal outcomes.|
|5.||cont. of code of ethics||Revisions were made in response to the complexities of modern nursing, to simplify and more clearly articulate the content, to anticipate advances in health care, and to incorporate aids that would make it richer, more accessible, and easier to use.
The Code, consisting of nine provisions and the accompanying interpretive statements:
Provides a succinct statement of the ethical values, obligations, and duties of every individual who enters the nursing profession.
Serves as the profession’s nonnegotiable ethical standard.
Expresses nursing’s own understanding of its commitment to society.
The Code is particularly useful to in today’s health care environment because it reiterates the fundamental values and commitments of the nurse (Provisions 1-3), identifies the boundaries of duty and loyalty (Provisions 4-6), and describes the duties and accountability of the nurse that extend beyond individual patient encounters (Provisions 7-9).
|6.||ethical principles in nursing||Autonomy
|7.||ethics committees||Moral distress: occurs when ethical principles compete; disagreement among family members and healthcare providers; actions that violate our personal beliefs
Ethics Committees: provide structure and guidelines for potential problems (a framework); forums for decision-making
|8.||ethics def.||branch of philosophy, seeks to utilize a body of knowledge to determine what is right or wrong|
|9.||fidelity||the principle requires loyalty, fairness, truthfulness, advocacy, and dedication to our patients. It is an agreement to do as we have promised. Fidelity refers to the concept of keeping a commitment based upon the virtue of caring.|
|10.||justice||Justice requires that all clients be treated equally and fairly regardless of what they have contributed or who they are. Nurses face issues of justice daily when organizing care for their clients and deciding how much time they will spend with each based on client needs and a fair distribution of resources.|
|11.||key elements of code of ethics (CRCAA)||compassion and respect, commitment, advocacy, and accountability when working with clients, families and communities, as well as responsibility to the profession|
|12.||moral def.||personal philosophy based on what is right or wrong (ethical considerations help define morals essential to practice)|
|13.||nonmaleficence||means avoiding harm or hurt. It is the core of the medical oath and nursing ethics. Nurses must maintain a competent practice level to avoid causing injury or suffering to clients. The principle of nonmaleficence also covers reporting suspected abuse to prevent further victimization and protecting clients from chemically impaired nurses and other healthcare practitioners.|
|14.||paternalism||as healthcare providers we make decisions about care for the patient, based upon what we believe as in the best interest of the patient; this principle is heavily laden as an application of power over the patient.|
|15.||process of ethical decision making||It is a process that considers:
Who should make the choice
Possible options or courses of actions
Consequences of the options
Rules, obligations and values
Desired goals or outcomes
|16.||values def.||personally & professionally developed; based on philosophy and principles; helps define actions to issues and problems|