Ch 22 Flashcards
Ethics
- the study of what is right and wrong with our conduct
-concerns our obligations to individuals, groups, and society
-The right thing to do can be difficult to determine, particularly when individual values, beliefs, and perceptions conflict. - Use your critical thinking and clinical judgment skills with ethical decision making when working through ethical problems with patients and families
Morals
Ethics
-refer to judgment about behavior, based on specific beliefs
-ethics refers to the study of the ideals of right and wrong behavior.
Value
-deeply held personal belief about the worth a person holds for an idea, a custom, or an object.
-values that a person holds reflect cultural and social influences.
bioethics
-represents a branch of ethics within the field of health care
-In the study of bioethics, health care professionals agree to negotiate these difficult and important questions by referring to a common set of ethical principle
Autonomy
-applies to respect for the autonomy of patients
-can also apply to agency respect for the autonomy of health care professionals
-A commitment to respect the autonomy of others is a fundamental principle of ethical practice.
Beneficence
-refers to taking positive actions to help others
-the best interests of the patient remain more important than self-interest. It implies that nurses practice primarily as a service to others, even in the details of daily work.
Nonmaleficence
-the avoidance of harm or hurt
-health care professional tries to bal- ance the risks and benefits of care while striving at the same time to do the least harm possible
Justice
-refers to fairness and the distribution of resources
-Discussions about health insurance, hospital locations and services, and organ transplants generally are among the issues that cite the concept of justice
-just culture refers to the promotion of open discussion without fear of recrimination whenever mistakes, especially those in- volving adverse events, occur or nearly occur.
Fidelity
- faithfulness or the agreement to keep promises
- a duty to be faithful to the patients you care for, to the health care agency you work for, and to yourself.
-Fidelity is honored when we strive to provide excellent care to all patients, including those whose values are different from our own
Code of ethics
-set of guiding principles that all members of a profession accept
-describe the nurse’s obligation to the patient, the role of the nurse as a member of the health care team, and the duties of the nurse to the profession and to society
-A few of the key principles in the code include advocacy, responsibility, accountability, and confidentiality.
Advocacy
Responsibility
-a willingness to respect one’s professional obligations and to follow through
- As a nurse you are responsible for your actions, the care you provide, and the tasks that you delegate to others.
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Accountability
-refers to answering for your own actions.
Confidentiality
-refers to the health care team’s obligation to respect patient privacy
Values
-A value is a deeply held belief about the worth of an idea, attitude, custom, or object that affects choices and behaviors.
-Clarifying values—your own, your patients’, your co-workers’— is an important and effective part of ethical discourse.
Deontology
-defines actions as right or wrong based on their adherence to rules and principles such as fidelity to promises, truthfulness, and justice
-does not look at consequences of actions to determine right or wrong, rather it examines a situation for the existence of essential right or wrong
-requires a mutual understanding of justice, autonomy, and goodness.
Utilitarianism
- proposes that the value of something is determined by its usefulness.
-main emphasis is on the outcome or conse- quence of action.
-The greatest good for the greatest number of people is the guiding principle for determining right action in a utilitarian system
-The difference between utilitarianism and deontology is the focus on outcomes. Utilitarianism measures the effect that an act will have; deontology looks at the act itself and judges its “rightness” by the rules or principles it upholds.
Casuistry
-case-based reasoning, turns away from conventional principles of ethics as a way to determine best actions and focuses instead on the details of a situation.
-People who take this approach to ethics find similar precedent cases and determine a course of action on the basis of what was done to manage that prior situation
-A weakness of the casuistry approach is that finding a similar precedent case may be challenging, particularly in complex situations with unique features.
Feminist ethics
- this view holds that the natural caring for others is the basis for moral behavior; it places an emphasis on caring relationships and a strong sense of responsibility
-Those with a feminist perspective tend to concentrate more on practical solutions than on theory and to ask questions about the people involved and their relationships rather than looking to underlying principles.
-Critics of feminist ethics worry about the lack of appeal to tradi- tional ethical principles. Without guidance from concepts such as autonomy and beneficence, they argue, solutions to ethical questions will depend too much on subjective judgment.
Ethics of Care
-offers an alternative view to utilitarianism and deontology.
-Similar to feminist ethics, care-based ethics focuses on understanding relationships, personal narratives, and the context in which ethical problems arise.
-Unlike feminist ethics, ethics of care emphasizes the role of the decision maker in the situation.
-In the ethics of care, nurses participate in clinical ethics consultation, with patient advocacy being a top priority
-An ethical problem is called a dilemma when two opposing courses of action can both be justified by ethical principles
Moral distress
- In moral distress, instead of competing options for action, the nurse feels the need to take a spe- cific action while believing that action to be wrong
-Distinguishing between ethical dilemmas and moral distress is important to achieving resolution. When the problem is a dilemma, with two opposing but justifiable options, often the application of the nursing process will include identifying more options.
Processing an Ethical Problem
-similar to the nursing process in its methodical approach to a clinical issue
- differs from the nursing process in that it requires negotiation of differences of opinion and clarity about situations where there may not be a single right answer
- Finding clarity and consensus can occur when the following elements remain essential to the process: the presumption of goodwill on the part of all participants, strict adherence to confidentiality, patient-centered decision making, and the welcome participation of families and primary caregivers.
1. Processing an ethical problem begins with recognizing that an ethical problem exists
2. You then gather pertinent information about the case, including recent clinical evaluations, the views of colleagues, and the values and perspectives of the patient and family involved.
3. Examining your personal values at this point can help to differentiate between fact and opinion, an important part of the process.
4. Once information is gathered and ethical elements identified, developing a statement of the problem will facilitate discus- sion.
5. The next step, listing all possible courses of action, requires some creativity and is best done in a conversation with others.
6. The final step is an evaluation of the outcome
7. If the process involves a family conference or changes in the treat- ment plan, you document all relevant information in the medical record.
PICOT Question: Do strategies that build moral resilience reduce moral distress among acute care nurses?
Evidence Summary
Moral distress describes the anguish experienced when a person feels unable to act according to closely held core values. Evidence indicates that causes of moral distress among critical care nurses include quality of life concerns for patients, lacking a voice in documentation, difficulty with their advocacy role, ambiguity between the guidelines of care and limitation of licensure, trying to implement personal values to provide care, communication issues when full disclosure has not been implemented with the patient and family, and role conflict between goals of care and barriers to care delivery (Burton et al., 2020). Nurses need to be aware of moral distress, which is foundational to developing strategies for moral resilience (Burton et al., 2020). While multiple studies document the existence of moral distress and its association with aspects of the work environment, interventions to address moral distress are an area of evolving research (Burton et al., 2020). Strategies to address moral distress consider not only the individual experiencing the problem but also the work environment. Health care agencies often offer services such as an ethics resource or a moral distress service to specifically address the needs of nurses. Sonya et al. (2020) described a Moral Distress Consult Service that is accessible in the hospital and helps address pervasive or persistent issues that are causing moral distress. The American Association of Critical-Care Nurses (AACN) created the Standards for Establishing and Sustaining Healthy Work Environments and an Assessment Tool that health care teams can use to identify and address gaps (AACN, 2016). Moral resilience is the ability to grow and even gain confidence from adverse and complex ethical problems. While further study is needed, deliberate attention to building moral resilience among nurses may reduce their susceptibility to moral distress.
Application to Nursing Practice
• Develop and practice skilled communication. Learning to talk with col- leagues, patients, and families in a professional manner that conveys a desire to share your own views and an openness to theirs can help prevent conflicts and reduce moral distress.
• Identify resources available to help you reduce moral distress. Find out whether your hospital has an ethics committee or other resource for support and how that resource is consulted.
• Find a mentor or leader on your unit with a particular skill in examining ethical problems to help you process ethical situations.
•Create a culture of moral resiliency w targeted formal and informal support and education for staff
• Collaborate with health care administrators regarding ways to better inkstand, recognize, and manage patient and nurse factors related to moral distress
• Design education programs to assist nurses to recognize and respond to stressful situations
• Educate staff members on how to use their voices to communicate constructively and confidently about morally challenging situations.
• Evaluate existing programs, including just-in-time support, a health care ethics residency, and moral resiliency training.
Key Steps in the Resolution of an Ethical Dilemma
Step 1: Ask: Is this an ethical problem?
Step 2: Gather information relevant to the case. Patient, family, health care agency, and social perspectives are important sources of relevant information.
Step 3: Identify the ethical elements in the situation by clarifying values and recognizing the principals involved. Distinguish among fact, opinion, and
values.
Step 4: Name the problem. A clear, simple statement of the problem is not
always easy, but it helps to ensure effectiveness in the final plan and facilitates discussion.
Step 5: Identify possible courses of action. Access others for their input and
be creative in identifying different options.
Step 6: Create and implement an action plan. Gather support from others and
identify an alternative action if the chosen one does not achieve resolution.
Step 7: Evaluate the action plan to determine whether further action is needed
or if lessons learned in this experience can be applied forward.
Resources to Address Ethical Problems
-Nursing colleagues—to listen to the problem, offer alternative actions, and help you articulate the issue. Giving and receiving support from other nurses promotes a positive work environment.
-Nurse leaders—may include a preceptor, charge nurse, manager, educator, or advanced practice registered nurse. They may have faced and managed similar situations and so have guidance to offer. They can also access other resources within the hospital.
-Members of the interprofessional team—includes physicians, social workers, registered dietitians, therapists, pharmacists, and chaplains. All may be interacting with the patient or are aware of the situation that you are facing. Hearing their perspectives can help you to identify the problem and consider solutions.
-Consultation services—may include ethics committees and palliative care specialists. Ethics committees often gather members of the team with diver-gent views and facilitate productive conversation. Palliative care consult services are a resource in some health care agencies for the management of seriously ill patients.
-Professional organizations—often set standards for nursing practice and have web-based resources to help you develop knowledge and skills in ethical analysis.
-Boards of Nursing—can help address questions about scope of practice and competency.
Ethics committees
-Most hospitals have an ethics committee devoted to the teaching and processing of ethical issues and dilemmas
- involves individuals from different disciplines and backgrounds who support health care agencies with three major functions: providing clinical ethics consultation, developing and/or revising policies pertaining to clinical ethics and hospital policy (e.g., advance directives, withholding and withdrawing life-sustaining treatments, informed consent, organ procurement), and facilitating education about topical issues in clinical ethics.
-In most agencies, any person seeking ethical advice, including nurses, physicians, health care providers, patients, and family members, can request access to an ethics committee.
-A successful meeting is one in which every perspective is heard. Sometimes these meetings result in consensus around a specific course of action; other times the meeting ends without a clear plan but with an improved understanding of one another’s perspectives.
QSEN. Building Competency in Patient-Centered Care You are assigned to care for a 75-year-old patient who is readmitted to the hospital after having knee surgery a week ago. He was brought to the hospital by ambu- lance because his family could not wake him up. In the emergency department, he responds well to treatment for opioid overdose, becoming more awake and alert. When you enter the room to do an initial assessment, the daughter ex- presses anger at her father’s situation, namely that he was discharged after surgery with “too much medication.” She states her belief that the care on the last hospital stay was “really inappropriate, especially since the news tells us we are in an opioid crisis.” How will a focus on patient-centered care help you address this patient’s needs and the daughter’s concern?
What matters most to you and so should be included in your own personal definition of quality of life?
What roles, relationships, or activities are you engaged in that are most meaningful to you?
futile
-futile refers to interventions unlikely to produce benefit for a patient
-For example, if a patient is dying of a condition with little or no hope of recovery, almost any intervention beyond symptom man- agement and comfort measures is seen as futile.
- In this situation an agreement to label an intervention as futile can help the health care team members, families, and patients turn to palliative care measures as a more constructive approach to the situation
Access to Affordable Health Care
Since the implementation of the Affordable Care Act, more residents in the United States have access to care than ever before. But according to the 2018 National Healthcare Quality and Disparities Report (QDR), people of color, ethnic minorities, and low-income residents are “disproportionately represented among those with access problems.” Reports from the QDR reveal that lack of health insurance is the most significant contributing factor to poor quality of care (AHRQ, 2020).
Implications for Patient-Centered Care
• Issues of justice and the just distribution of resources help to inform the discussion about access to care and its effect on health care outcomes.
•Health outcomes often correlate directly to health care outcomes.
• Know and respect patients’ cultural practices regarding health promotion
and health care needs
• Identify culturally appropriate resources for patients and families in their communities.
Summary
• Learning and applying the language of ethics is an essential element of nursing practice.
• Understanding our own values and encouraging patients, families, and colleagues to clarify their values promote productive discussion of ethical problems.
• You apply fundamental concepts such as autonomy, justice, fidelity, and beneficence to ethical decision making.
• Approaches to ethics include deontology, utilitarianism, and a relationship-based perspective.
• In an ethical dilemma, a nurse faces two equally justifiable courses of action, whereas in moral distress the nurse feels unable to take the action that is correct.
• Using a systematic approach similar to the nursing process pro- motes resolution of ethical issues. While the specific ethical issues nurses face evolve and change over time, the values and obligations remain constant.
• Although ethical issues often change with changes in technology and society, common ethical issues surrounding nursing practice include the use of social media as a nursing professional, determining the burdens and benefits of treatment on a patient’s quality of life, providing care at the end of life, and challenges regarding patients’ access to health care.
Reflective Learning
• Do you think there are situations in which maintaining confidenti- ality and withholding private information are not the right actions? Discuss why.
• Think about your first impression of a patient early in the day, when you first met. How did this impression change over the course of spending a shift involved in that patient’s care? How do you think this change in your perspective relates to your ethical obligations as a nurse?
• What questions might you ask a patient if you wanted to better understand the patient’s view of quality of life?
The nurse is caring for a patient who needs a liver transplant to survive. This patient has been out of work for several months, does not have health insurance, and cannot afford the procedure. Which of the following statements speaks to the ethical elements of this case?
1. The health care team should select a plan that considers the principle of justice as it pertains to the distribution of health care resources.
2. The patient should enroll in a clinical trial of a new technology that can do the work of the liver, similar to the way dialysis treats kidney disease. that can do the work of the liver, similar to the way dialysis treats kidney disease.
3. The social worker should look into enrolling the patient in Medicaid, since many states offer expanded coverage.
4. A family meeting should take place in which the details of the patient’s poor prognosis are made clear to his family so that they can adopt a palliative approach.
1
When designing a plan for pain management for a patient following surgery, the nurse assesses that the patient’s priority is to be as free of pain as possible. The nurse and patient work together to identify a plan to manage the pain. The nurse continually reviews the plan with the patient to ensure that the patient’s priority is met. If the nurse’s actions are driven by respect for autonomy, what aspect of this scenario best demonstrates this action?
1. Assessing the patient’s pain on a numeric scale every 2 hours
2. Asking the patient to establish the goal for pain control
3. Using alternative measures such as distraction or repositioning to relieve the pain
4. Monitoring the patient for oversedation as a side effect of his pain medication
2
The application of deontology does not always resolve an ethical problem. Which of the following statements best explains one of the limitations of deontology?
1. The emphasis on relationships feels uncomfortable to decision makers who want more structure in deciding the best action.
2. The single focus on power imbalances does not apply to all situations in which ethical problems occur.
3. In a diverse community it can be difficult to find agreement on which principles or rules are most important.
4. The focus on consequences rather than on the “goodness” of an action makes decision makers uncomfortable.
3
The ethics of care suggests that ethical dilemmas can best be solved by attention to relationships. How does this differ from other approaches to ethical problems? (Select all that apply.) Ethics of care:
1. pays attention to the context in which caring occurs.
2. is used only by nurses because it is part of the Nursing Code of Ethics.
3. requires understanding the relationships between involved parties.
4. considers the decision maker’s relationships with other involved parties.
5. is an approach that suggests a greater commitment to patient care.
6. considers the decision maker to be in a detached position outside the ethical problem.
1, 3, 4
The following are steps in the process to help resolve an ethical problem. What is the best order of these steps to achieve resolution?
1. List all the possible actions that could be taken to resolve the problem.
2. Articulate a statement of the problem or dilemma that you are trying to resolve.
3. Develop and implement a plan to address the problem.
4. Gather all relevant information regarding the clinical, social,
and spiritual aspects of the problem.
5. Take time to clarify values and identify the ethical elements,
such as principles and key relationships involved.
6. Recognize that the problem requires ethics.
6, 4, 5, 2, 1, 3
Which social media uses can be implemented with patients and families without violating confidentiality? (Select all that apply.)
1. Social media can be used to provide supportive information.
2. Results such as x-ray results can easily be sent via social media.
3. Family and friends who cannot be present can connect with the patient.
4. All health information can be shared on social media.
5. Social media should never be used with patients and families.
1, 3
Resolution of an ethical problem involves discussion with the patient, the patient’s family, and participants from appropriate health care disciplines. Which statement best describes the role of the nurse in the resolution of ethical problems?
1. To articulate the nurse’s unique point of view, including knowledge based on clinical and psychosocial observations
2. To study the literature on current research about the possible clinical interventions available for the patient in question
3. To hold a point of view but realize that respect for the authority of administrators and health care providers takes precedence over personal views
4. To allow the patient and the health care provider private time to resolve the dilemma on the basis of ethical principles
1
Which statements reflect the difficulty that can occur for agreement on a common definition of the word quality when it comes to quality of life? (Select all that apply.)
1.Community values influence definitions of quality, and they are subject to change over time.
2.Individual experiences influence perceptions of quality in different ways, making consensus difficult.
3. The value of elements such as cognitive skills, ability to perform meaningful work, and relationship to family is difficult to quantify using objective measures.
4. Statistical analysis is difficult to apply when the outcome cannot be quantified.
5.Whether a person has a job is an objective measure, but it does not play a role in understanding quality of life.
1, 2, 4
Match the following actions (1 through 4) with the terms (a through d) listed below:
- You see an open medical record on the computer and close it so that no one else can read the record without proper access.
- You administer a once-a-day cardiac medication at the wrong time, but nobody sees it. However, you contact the provider and your nurse manager and follow agency procedure.
- A patient at the end of life wants to go home to die, but the family wants every care possible. The nurse contacts the primary care provider about the patient’s request.
- You tell your patient that you will return in 30 minutes to give him his next pain medication.
a. Advocacy
b. Responsibility
c. Accountability
d. Confidentiality
1d
2c
3a
4b
Which statements properly apply an ethical principle to justify access to health care? (Select all that apply.)
1. Access to health care reflects the commitment of society to principles of beneficence and justice.
2. If low income compromises access to care, respect for autonomy is compromised.
3. Access to health care is a privilege in the United States, not a right.
4. Poor access to affordable health care causes harm that is ethi- cally troubling because nonmaleficence is a basic principle of
health care ethics.
5. If a new drug is discovered that cures a disease but at great cost
per patient, the principle of justice suggests that the drug should be made available to those who can afford it.
1, 2, 4
