Ethics and End-of-Life care

Samantha is applying the American Nurses Association Code of Ethics for Nurses when planning the next steps of Mary's care. When applying the principles of the Code, Samantha should prioritize what factor?

Protecting and promoting Mary's rights, dignity, and well-being The overarching principle of the Code of Ethics for Nurses is that the patient's health, safety, and rights are the highest good. Each nursing action must be motivated by the need to prioritize the commitment to the patient above all. In some cases, this may pose a threat to interprofessional relationships, such as Samantha's relationship with Dr. Gonzalez. Samantha's NPA defines what nursing actions are legally permitted, but it does not provide direct guidance for ethical decision making. Samantha should make every effort to spare Mary from pain, distress, or uncertainty, but this is not always possible, nor does it supersede Mary's other rights. For example, a patient may choose a course of action that causes pain, but the nurse does not have the right to override this decision solely on the basis that doing so would prevent pain. The patient has the right to define "well-being" as she or he sees fit. Uncertainty is often inevitable and is not necessarily a violation of ethical principles.

Samantha has approached Dr. Gonzalez in an effort to discuss Mary's care, and it is clear that they disagree about the necessary approach. What should Samantha do in order to promote a collaborative approach to conflict management?

Discuss Mary's situation with Dr. Gonzalez and try to agree on a common goal for her care. Collaboration is premised on each party setting aside their disparate goals and choosing a common goal that will be prioritized. Effective collaboration does not require mediation or withdrawing from the decision-making process. The process of negotiation implies a win-lose situation, in contrast to collaboration which aims for a win-win goal.

A nurse is travelling to work on the highway. The nurse sees a car get hit from the rear. The car spins out of control and hits the median. The nurse stops to help at the scene. Legally, the nurse may do this based on the Good Samaritan Law. What ethical framework is the Good Samaritan Law based upon?

Duty based The Good Samaritan Law is based on a duty-based ethical framework. This refers to the fact that the nurse has a duty to perform within her knowledge base and should act upon that duty. Utilitarian frameworks state the greatest good is for the greatest number of people. The rights-based ethical framework refers to the belief that individuals have inherent rights that should not be interfered with. Lastly, the intuitionist ethical framework refers to the belief that each case is weighed separately from another.

The nurse manager on the unit where Mary is receiving care is applying Crisham's (1985) MORAL decision-making model to Mary's care planning. What is the nurse manager's best initial action?

Gather as much specific information about Mary's status and circumstances as possible. Crisham's MORAL decision-making model begins with collecting data about the ethical problem. This would involve speaking with her provider and possibly assessing the patient, but these actions would be smaller components of a broader effort to gather as much data as possible. Educating staff about the principles of ethical reasoning should take place outside of the confines of an acute, time-dependent ethical dilemma.

Samantha's assessment of Mary reveals that Physician Orders for Life-Sustaining Treatment (POLST) would be beneficial. How should Samantha best address Mary's need for POLST?

Assess Mary's ability to have an informed dialogue about POLST. One of the reasons why end-of-life care planning should begin well before a patient reaches the terminal stage of disease is that it requires informed consent. Without the patient's sound understanding of the content and implications of POLST, its directives are neither legal nor ethical. For this reason, Samantha should assess and monitor Mary's cognition to determine whether such a discussion will become possible. This assessment must precede the discussion. A staff member cannot establish parameters of a patient's POLST, even if the staff member knows the patient well and has the patient's best interests in mind. Contacting Dr. Gonzalez would be pointless if Mary's level of consciousness precludes a meaningful and valid discussion.

Samantha recognizes the need to adhere to the ethical principle of beneficence when addressing this challenge in Mary's care. Samantha can best promote beneficence in Mary's care by:

ensuring that Mary's best interests inform any decisions that are made. The essence of the concept of beneficence is doing good for the patient. This principle is best demonstrated by ensuring that the patient's good is the primary motivation for any decisions that are made. Eliciting input from other staff members can benefit the decision-making process but does not necessarily ensure that the patient's good is the motivation behind every action. Similarly, identifying alternatives is a prudent action but does not always mean that the patient's well-being is prioritized. Samantha should dialogue with Dr. Gonzalez about the proposed transfer, but this discussion will not necessarily lead to the prioritization of Mary's good.

The nurse is caring for a patient whose vital signs are not stable and who seems to be nearing the end of life. The provider orders the patient to be placed on life-sustaining treatments, but the nurse questions this order. The nurse is operating within which type of ethical framework?

Rights based—deontological The rights-based ethical framework refers to the belief that individuals have inherent rights that should not be interfered with. Utilitarian frameworks state the greatest good is for the greatest number of people. The duty-based ethical framework refers to a duty to do something or to refrain from doing something. Lastly, the intuitionist ethical framework refers to the belief that each case is weighed separately from another.

A new nurse is working in the operating room suite. The nurse notices that the surgeon uses inappropriate humor concerning the patient while the patient is under anesthesia. What is the nurse experiencing?

Moral outrage Moral outrage occurs when the witness to an immoral act feels powerless to stop it. Moral indifference occurs when an individual questions why morality in practice is necessary. Moral uncertainty (or moral conflict) occurs when an individual is unsure which moral principles apply and may include uncertainty as to what the moral issue is. Moral distress is when the individual knows the right thing to do but organizational constraints make it difficult to take the right action.

An elderly patient is admitted to the cardiac floor for worsening congestive heart failure. As the nurse is obtaining baseline vital signs, the patient states, "My neighbor is in the ICU on one of those machines that keep people breathing forever. I never want to end up like that." Which response by the nurse is best?

It sounds likes you have given this a lot of thought. Would you like me to arrange for you to complete an advance directive and share this with your family? An advance directive is the legal document that will ensure the patient's wishes are carried out. The nurse is acting as a patient advocate in assisting the patient in getting this completed and sharing it with the family.

The nurse must get a consent signed by the patient regarding their upcoming surgery. She notes in the chart that the patient was medicated for pain one hour ago with hydromorphone. Ethically, what should the nurse do?

Withhold the consent until another time. It is important for the nurse to obtain a consent form from a patient who is not impaired by medications. If a patient is premedicated or using a narcotic, the patient cannot ethically be deemed competent to sign a consent form.