Ethics in Professional Nursing Practice
Values in Nursing
Values emphasized in the Code of Ethics with Interpretive Statements (ANA, 2001)
Wholeness of character
Integrity
Basic dignity
Personal dignity
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Ethical Theories and Approaches
Virtue ethics
Natural law theory
Deontology
Utilitarianism
Ethics of care
Ethical principlism
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Ethical Principlism
Autonomy
Beneficence
Nonmaleficence
Justice
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Professional Ethics and Codes
The Nightingale Pledge (1893)
Nursing Ethics: For Hospital and Private Use (1900)
ICN’s Code of Ethics for Nurses (1953)
ANA’s Code of Ethics for Nurses (1950)
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ANA’s Code of Ethics for Nurses
Nine provisions with interpretive statements containing specific guidelines for clinical practice, education, research, and administration
The code is considered to be nonnegotiable in regard to nursing practice
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Examples of Themes in the Code of Ethics with Interpretive Statements
Respect for autonomy
Relationships
Patients’ interests
Collaboration
Privacy
Competent practice
Accountability and delegation
Self-preservation
Environment and moral obligation
Contributions to the nursing profession
Human rights
Articulation of professional codes by organizations
The ICN Code of Ethics for Nurses
Nurses have 4 fundamental responsibilities:
To promote health
To prevent illness
To restore health
To alleviate suffering
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Common Themes of ANA and ICN Codes
Focus on the importance of nurses delivering compassionate patient care aimed at alleviating suffering; patient is the central focus of nurses’ work.
Applies to all nurses in all settings and roles; nonnegotiable ethical nursing standards with a focus on social values, people, relationships, and professional ideals.
Share values of respect, privacy, equality, and advocacy.
Both codes illustrate idea of nurses’ moral self-respect.
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Ethical Analysis and Decision Making in Nursing
Ethical dilemmas and conflicts
Moral suffering
Team approach
Case-based approach using 4 topics method
Medical indications
Patient preferences
Quality of life
Contextual features
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Medical Indications
What is the patient’s medical problem? History? Diagnosis? Prognosis?
Is the problem acute? Chronic? Critical? Emergent? Reversible?
What are the goals of treatment?
What are the probabilities of success?
What are the plans in case of therapeutic failure?
In sum, how can this patient be benefited by medical and nursing care, and how can harm be avoided?
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Patient Preferences
Is the patient mentally capable and legally competent? Is there evidence of incapacity?
If competent, what is the patient stating about preferences for treatment?
Has the patient been informed of benefits and risks, understood this information, and given consent?
If incapacitated, who is the appropriate surrogate? Is the surrogate using appropriate standards for decision making?
Has the patient expressed prior preferences?
Is the patient unwilling or unable to cooperate with medical treatment? If so, why?
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Quality of Life
What are the prospects, with or without treatment, for a return to normal life?
What physical, mental, and social deficits is the patient likely to experience if treatment succeeds?
Are there biases that might prejudice the provider’s evaluation of the patient’s quality of life?
Is the patient’s present or future condition such that his or her continued life might be judged undesirable?
Is there any plan and rationale to forgo treatment?
Are there plans for comfort and palliative care?
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Contextual Features (1 of 2)
Are there family issues that might influence treatment decisions?
Are there provider (physicians and nurses) issues that might influence treatment decisions?
Are there financial and economic factors?
Are there religious and cultural factors?
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Contextual Features (2 of 2)
Are there limits on confidentiality?
Are there problems of allocations or resources?
How does the law affect treatment decisions?
Is clinical research or teaching involved?
Is there any conflict of interest on the part of the providers or the institution?
Relationships and Professional Ethics
Nurse–physician relationships
Nurse–patient–family relationships
Unavoidable trust
Boundaries
Dignity
Patient advocacy
Nurse–nurse relationships
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The National Council of State Boards of Nursing’s Professional Boundaries in Nursing Video
Moral Rights and Autonomy (1 of 2)
Moral rights are defined as rights to perform certain activities.
Because they conform to accepted standards or ideas of a community
Because they will not harm, coerce, restrain, or infringe on the interests of others
Because there are good rational arguments in support of the value of such activities
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Moral Rights and Autonomy (2 of 2)
Two types of moral rights
Welfare rights
Liberty rights
Informed consent
Patient Self-Determination Act
Advance directives
Living will
Durable power of attorney
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Social Justice
Sicilian priest first used term in 1840; in 1848, popularized by Antonio Rosmini-Serbati
Center for Economic and Social Justice definition
John Rawls’s concept of veil of ignorance
Robert Nozick’s concepts of entitlement system
Allocation and Rationing of Healthcare Resources
Does every person have a right to health care?
How should resources be distributed so everyone receives a fair and equitable share of health care?
Should healthcare rationing ever be considered as an option in the face of scarce healthcare resources? If so, how?
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Organ Transplant Ethical Issues
Moral acceptability of transplanting an organ from one person to another
Procurement of organs
Allocation of organs
Justice
Medical utility
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Balanced Caring and Fairness Approach for Nurses (1 of 2)
Encourage patients and families to express their feelings and attitudes about ethical issues involving end-of-life, organ donation, and organ transplantation.
Support, listen, and maintain confidentiality with patients and families.
Assist in monitoring patients for organ needs.
Balanced Caring and Fairness Approach for Nurses (2 of 2)
Be continually mindful of inequalities and injustices in the healthcare system and how the nurse might help balance the care.
Assist in the care of patients undergoing surgery for organ transplant and donation patients and their families.
Provide educational programs for particular target populations at a broader community level.
Definitions of Death
Uniform Determination of Death Act definition of death: “An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions or (2) irreversible cessation of all functions of the entire brain, including the brain stem is dead. A determination of death must be made in accordance with accepted medical standards.”
Traditional, whole-brain, higher brain, personhood.
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Euthanasia
Types of euthanasia:
Active euthanasia
Passive euthanasia
Voluntary euthanasia
Nonvoluntary euthanasia
Blending of types may occur
“Is there a moral difference between actively killing and letting die?”
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Rational Suicide
Self-slaying
Categorized as voluntary active euthanasia
Person has made a reasoned choice of rational suicide, which seems to make sense to others at the time:
Realistic assessment of life circumstances
Free from severe emotional distress
Has motivation that would seem understandable to most uninvolved people within the community
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Palliative Care
Approach that improves the quality of life of patients associated with life-threatening illness, through prevention and relief of suffering
Do-not-resuscitate order:
There is no medical benefit that can come from cardiopulmonary resuscitation (CPR).
The person has a very poor quality of life before CPR.
The person’s life after CPR is anticipated to be very poor.
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Rule of Double Effect
Use of high doses of pain medication to lessen the chronic and intractable pain of terminally ill patients even if doing so hastens death
Critical aspects of the rule:
The act must be good or at lease morally neutral.
The agent must intend the good effect not the evil.
The evil effect must not be the means to the good effect.
There must be a proportionally grave reason to risk the evil effect.
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Deciding for Others
A surrogate, or proxy, either is chosen by the patient, is court appointed, or has other authority to make decisions
Three types of surrogate decision makers:
Standard of substituted judgment
Pure autonomy standard
Best interest standard
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Withholding and Withdrawing Treatment: 3 Cases
Case 1: Karen Ann Quinlan
Case 2: Nancy Cruzan
Case 3: Terri Schiavo
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Terminal Sedation
“When a suffering patient is sedated to unconsciousness…the patient then dies of dehydration, starvation, or some other intervening complication, as all other life-sustaining interventions are withheld.”
Has been used in situations when patients need relief of pain to the point of unconsciousness.
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Physician-Assisted Suicide
Act of providing a lethal dose of medication for the patient to self-administer
Oregon Nurses Association special guidelines related to the Death with Dignity Act
Maintaining support, comfort, and confidentiality.
Discussing end-of-life options with patient and family.
Being present for patient’s self-administration of medication and death.
Nurses may not administer the medication.
Nurses may not refuse care to the patient or breach confidentiality.
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End-of-Life Decisions and Moral Conflicts with the Nurse
Communicating truthfully with patients about death due to fear of destroying all hope
Managing pain symptoms because of fear of hastening death
Feeling forced to collaborate relative to medical treatments that in the nurses’ opinion are futile or too burdensome
Feeling insecure and not adequately informed about reasons for treatment
Trying to maintain their own moral integrity
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