Chapter 22 Ethics and Values

Organ Donation

- A person 18 years or older can make an organ donation - This is an end of life issue; it can be made in advance - A client must be legally dead to donate organs -Client must have no brain waves, no spontaneous breathing and no superficial or deep reflexes

Informed consent

-A client's agreement to allow something to happen. -Notify the patient about the diagnosis and prognosis without the recommended intervention -inform who will perform the procedure -discuss the risks and benefits In emergency situations, if it is not possible to obtain consent from client or authorized person, the procedure could be done to save a life or benefit the client. In this case the law assumes the client would wish to be treated Telephone consent requires two witnesses If a person cannot speak the language an official interpreter must be available, not a family member or acquaintance

3 stages of Moral Action

1) Decision - right or wrong 2) Moral distress - when the nurse realizes that the decision is hard to act on because of the internal/external constraints 3) Moral Action - when the nurse reflects on his/her experience of moral distress and develops the strategies to "do the right thing

Durable Medical Power of Attorney

A legal document in which an individual chooses a surrogate decision maker. in the even a patient is unable to speak for himself , this document identifies who will speak for the patient.

DNR

DNR order must be written- If the client is unable and no other is available, the MD may order if resuscitation is futile. It is reviewed every 3 days in the hospital It is reviewed every 60 days in long term care

Ethical dilemma

Ethical dilemmas, also known as a moral dilemmas, are situations in which there is a choice to be made between two options, neither of which resolves the situation in an ethically acceptable fashion.

Federal Statutory Issues

Americans with Disabilities Act EMTALA mental health purity Act Advance directives Uniform anatomical gift Act HIPAA Restraints

Nurses Act (Actions)

Collaboratively - done with other team members dependently - done with doctors orders Independently - done based on knowledge and experience. Interdependently - done base on order (Ex: PRN- cant use judgement )

Moral

Concerned with right and wrong and the distinctions between them your own believes

Difference between criminal law and civil law

Criminal = gilt, jail, 96% sure to win Civil = liable, community service, 51% sure to win

Nursing is licensed profession governed by

Law Morals Ethical behaviour

Specialty nursing organizations

Nursing specialization involves focusing on nursing practice in an identified specific area within the entire field of professional nursing. A defined specialty scope of practice statement and standards of professional practice, with accompanying competencies, are unique to each nursing specialty.

OSHA

Occupational Safety & Health Administration OSHA's mission is to "assure safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training, outreach, education and assistance".[2] The agency is also charged with enforcing a variety of whistleblower statutes and regulations. OSHA is currently headed by Acting Assistant Secretary of Labor Loren Sweatt. OSHA's workplace safety inspections have been shown to reduce injury rates and injury costs without adverse effects to employment

False imprisonment

Restraining a person without legal authorization

Slander

Spoken words that defame another

Nursing care Delivery Models

Total Patient Care - nurse is responsible for carrying out all aspects of client care for one or more pts for the entire shift Functional- Task based on needs and are divided into tasks with one nurse assuming responsibility for specific tasks Team Nursing- nurse is team leader or member of a team. The team leader delegates tasks and responsibilities

Primary nursing

Total responsibility Nurse facilitates care for the client from admission to discharge- has 24 hour accountability and responsibility. The nurse plans, coordinates and evaluates On other shifts, nurses deliver care and implement the plan by the primary nurse

UAP

Unlicensed Assistive Personnel

Mental Health parity Act

When insurances not only have to cover physical but also mental problems. (federal law)

Libel

Written defamation

2. The patient reports to the nurse of being afraid to speak up regarding a desire to end care for fear of upsetting spouse and children. Which principle in the nursing code of ethics ensures that the nurse will promote the patient's cause? a. Advocacy b. Responsibility c. Confidentiality d. Accountability

a. Advocacy Nurses advocate for patients when they support the patient's cause. A nurse's ability to adequately advocate for a patient is based on the unique relationship that develops and the opportunity to better understand the patient's point of view. Responsibility refers to respecting one's professional obligations and following through on promises. Confidentiality deals with privacy issues, and accountability refers to answering for one's actions.

Administrative Law

created by administrative bodies (state board of nursing) passing rules and regulations It is our duty to report unethical nursing conduct controls the administrative operations of government

8. The nurse values autonomy above all other principles. Which patient assignment will the nurse find most difficult to accept? a. Older-adult patient who requires dialysis b. Teenager in labor who requests epidural anesthesia c. Middle-aged father of three with an advance directive declining life support d. Family elder who is making the decisions for a young-adult female member

d. Family elder who is making the decisions for a young-adult female member Autonomy refers to freedom from external control. A person who values autonomy highly may find it difficult to accept situations where the patient is not the primary decision maker regarding his or her care. A teenager requesting an epidural, a father with an advance directive, and an elderly patient requiring dialysis all describe a patient or family who can make their own decisions and choices regarding care.

Ethics committee

made up of physicians, nurses, administrator, attorney and sometimes a lay person. may ne called on by nurse to help in decision making process

Nursing code of Ethics

provides guidelines for safe and compassionate care

Intentional tort

willful acts that violate another's rights.

Autonomy

Refers to a person's right to determine a course of action. involve client in decision making process, implement discharge reaching plans that meet individual needs. -the right to self determination -Right of the individual -Dignity -Respect for beliefs -inherent self worth - self reliance -individualism

Nursing Ethics

Refers to ethical questions that arise from nursing practice Nurses are responsible for deciding the nature of participation and support patients in their decisions Professional code of practice (code of ethics) Based on ethical principles of fidelity

Standards of Care

-Nurses Practice Acts -Federal and state laws regulating health care agencies -Professional and specialty nursing organizations -Written policies and procedures

Professional nursing organizations

Professional organizations and associations in nursing are critical for generating the energy, flow of ideas, and proactive work needed to maintain a healthy profession that advocates for the needs of its clients and nurses, and the trust of society.

ANA

American Nursing Association - Is a professional organization to advance and protect the profession of nursing. (to give high quality of care) Describes a competent level of behavior in the professional role. This is a guide for accountability(responsible). Provides guidelines for nurses actions in daily practice. The ANA states nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.[

Physician assisted suicide

Assisted suicide is suicide committed with the aid of another person, sometimes a physician. The term is often used interchangeably with physician-assisted suicide (PAS), which involves a doctor "knowingly and intentionally providing a person with the knowledge or means or both required to commit suicide, including counseling about lethal doses of drugs, prescribing such lethal doses or supplying the drugs."

Common Law

Generally arises from trials where an action is brought mainly to cover monetary damages or possession of property. sometimes a (new law) Common Law derives from common usage and custom and from court rulings in similar matters. Nursing practice is bound by common law as well as statuary law Example: No statuary law concerning patient abandonment but it is common law the part of English law that is derived from custom and judicial precedent rather than statutes. Often contrasted with statutory law

HIPAA

Health Insurance Portability and Accountability Act (HIPAA): Limits the extent to which plans may impose preexisting condition limitations It sets standards regarding the electronic exchange of private and sensitive health information

Autonomous choice

Health care providers who violate an individual's right to autonomous choice are at risk for civil and criminal prosecution

JCAHO

Joint Commissions on Accreditation of Health Care Organization (JCAHO) Requires an institution to have written policies and procedures for care. This accreditation demonstrates an acceptable level of performance Joint Commissions and ANA provide definition and offer standard of practice to achieve quality care and then evaluate this care

Law

Laws are usually based on Ethical principles Laws change over time within the same society to meet current way of life Ex: Hospital policy is designed to be in compliance with all applicable laws of the jurisdiction

Malpractice

Malpractice: It is professional negligence. Standard of malpractice is based on what another prudent nurse might do in the same situation. Duty Breach of Duty Causation Damages

Moral Model

Massage the dilemma - identify Outline the Options - to inform all parties Resolve the dilemma - discussion Act by applying the chosen Option - follow decision Look back and Evaluate - evaluate

Negligence

Negligence: Conduct that falls below the standard of care. Nursing negligence is carelessness which causes harm to a patient

Policies and Procedures

Policies and procedures are designed to influence and determine all major decisions and actions, and all activities take place within the boundaries set by them. Procedures are the specific methods employed to express policies in action in day-to-day operations of the organization.

Policies and procedures

Policies and procedures are designed to influence and determine all major decisions and actions, and all activities take place within the boundaries set by them. Procedures are the specific methods employed to express policies in action in day-to-day operations of the organization.

Defamation

Statements made about a person that are untrue may lead to personal problems and damage to a reputation

Nurse practice act (NPA)

States have a nurse practice act that define the practice of nursing in that particular state tell us what we can do or what we can't do -Establishes educational requirements for nurses --Each state has its own NPA -The major professional nursing organizations are NLN and ANA

EMTALA

The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law that requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay.

Uniform Determination of death act

The act has since been adopted by most US states and is intended "to provide a comprehensive and medically sound basis for determining death in all situations". 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.

Risk Management

The goal is to protect client and nurse from harm and to protect organization from liability related to harm They follow guidelines from Occupational Safety & Health Administration (OSHA) STEPS -Identify possible risks -Analyze risks -Act to reduce the risks -Evaluate the steps taken

Difference between common law and statutory law

The main differentiation between common law and statutory law is the way in which the laws are created. As stated above, common law comes from precedent. Statutory law is made by the Government. ... This means judges will incorporate both written statutes and case precedent when issuing a ruling

Advance directive

Two types A living will Written document that directs treatment according to client's wishes Is prepared when the individual is competent and able to make decisions regarding their specific instructions about end-of-life care. It allows people to specify their wishes as to what they do or do not want to prolong life Names a durable power of attorney Designates a person to make health care decisions if and when the client is no longer able to make decisions on their own behalf.

Uniform Anatomical Gift Act

UAGA governs organ donations for the purpose of transplantation. The Act permits any adult to become an organ donor.It also governs the making of anatomical gifts of one's cadaver to be dissected in the study of medicine. The law prescribes the forms by which such gifts can be made. it also provides that in the absence of such a document, a surviving spouse, or if there is no spouse, a list of specific relatives in order of preference, can make the gift.

Professional Values

Values that are shared by the member of a profession

1. A nurse is a member of the ethics committee. Which purposes will the nurse fulfill in this committee? (Select all that apply.) a. Education b. Case consultation c. Purchasing power d. Direct patient care e. Policy recommendation

a. Education b. Case consultation e. Policy recommendation An ethics committee devoted to the teaching and processing of ethical issues and dilemmas exists in most health care facilities. It is generally multidisciplinary and it serves several purposes: education, policy recommendation, and case consultation. It does not have purchasing power or provide direct patient care.

1. Four patients in labor all request epidural analgesia to manage their pain at the same time. Which ethical principle is most compromised when only one nurse anesthetist is on call? a. Justice b. Fidelity c. Beneficence d. Nonmaleficence

a. Justice Justice refers to fairness and is used frequently in discussion regarding access to health care resources. Here the just distribution of resources, in this case pain management, cannot be justly apportioned. Nonmaleficence refers to avoidance of harm; beneficence refers to taking positive actions to help others. Fidelity refers to the agreement to keep promises. Each of these principles is partially expressed in the question; however, justice is most comprised because not all laboring patients have equal access to pain management owing to lack of personnel resources.

14. Which action by the nurse indicates a safe and efficient use of social networks? a. Promotes support for a local health charity b. Posts a picture of a patient's infected foot c. Vents about a patient problem at work d. Friends a patient

a. Promotes support for a local health charity Social networks can be a supportive source of information about patient care or professional nursing activities. Even if you post an image of a patient without any obvious identifiers, the nature of shared media reposting can result in the image surfacing in a place where just the context of the image provides clues for friends or family to identify the patient. The ANA and NCSBN states, "Effective nurse-patient relationships are built on trust. Patients need to be confident that their most personal information and their basic dignity will be protected by the nurse." Becoming friends in online chat rooms, Facebook, or other public sites can interfere with your ability to maintain a therapeutic relationship.

7. The nurse finds it difficult to care for a patient whose advance directive states that no extraordinary resuscitation measures should be taken. Which step may help the nurse to find resolution in this assignment? a. Scrutinize personal values. b. Call for an ethical committee consult. c. Decline the assignment on religious grounds. d. Convince the family to challenge the directive.

a. Scrutinize personal values. Clarifying values—your own, your patients', your co-workers'—is an important and effective part of ethical discourse. Calling for a consult, declining the assignment, and convincing the family to challenge the patient's directive are not ideal resolutions because they do not address the reason for the nurse's discomfort, which is the conflict between the nurse's values and those of the patient. The nurse should value the patient's decisions over the nurse's personal values.

6. The nurse questions a health care provider's decision to not tell the patient about a cancer diagnosis. Which ethical principle is the nurse trying to uphold for the patient? a. Consequentialism b. Autonomy c. Fidelity d. Justice

b. Autonomy The nurse is upholding autonomy. Autonomy refers to the freedom to make decisions free of external control. Respect for patient autonomy refers to the commitment to include patients in decisions about all aspects of care. Consequentialism is focused on the outcome and is a philosophical approach. Justice refers to fairness and is most often used in discussions about access to health care resources. Fidelity refers to the agreement to keep promises.

17. A nurse is teaching a patient and family about quality of life. Which information should the nurse include in the teaching session about quality of life? a. It is deeply social. b. It is hard to define. c. It is an observed measurement for most people. d. It is consistent and stable over the course of one's lifetime.

b. It is hard to define. Quality of life remains deeply individual (not social) and difficult to predict. Quality of life is not just a measurable entity but a shared responsibility. Quality of life measures may take into account the age of the patient, the patient's ability to live independently, his or her ability to contribute to society in a gainful way, and other nuanced measures of quality.

5. A nurse is experiencing an ethical dilemma with a patient. Which information indicates the nurse has a correct understanding of the primary cause of ethical dilemmas? a. Unequal power b. Presence of conflicting values c. Judgmental perceptions of patients d. Poor communication with the patient

b. Presence of conflicting values Ethical dilemmas almost always occur in the presence of conflicting values. While unequal power, judgmental perceptions, and poor communication can contribute to the dilemma, these are not causes of a dilemma. Without clarification of values, the nurse may not be able to distinguish fact from opinion or value, and this can lead to judgmental attitudes.

11. The nurse has become aware of missing narcotics in the patient care area. Which ethical principle obligates the nurse to report the missing medications? a. Advocacy b. Responsibility c. Confidentiality d. Accountability

b. Responsibility Responsibility refers to one's willingness to respect and adhere to one's professional obligations. It is the nurse's responsibility to report missing narcotics. Accountability refers to the ability to answer for one's actions. Advocacy refers to the support of a particular cause. The concept of confidentiality is very important in health care and involves protecting patients' personal health information.

4. When professionals work together to solve ethical dilemmas, nurses must examine their own values. What is the best rationale for this step? a. So fact is separated from opinion b. So different perspectives are respected c. So judgmental attitudes can be provoked d. So the group identifies the one correct solution

b. So different perspectives are respected Values are personal beliefs that influence behavior. To negotiate differences of value, it is important to be clear about your own values: what you value, why, and how you respect your own values even as you try to respect those of others whose values differ from yours. Ethical dilemmas are a problem in that no one right solution exists. It is not to separate fact from opinion. Judgmental attitudes are not to be used, much less provoked.

16. During a severe respiratory epidemic, the local health care organizations decide to give health care workers priority access to ventilators over other members of the community who also need that resource. Which philosophy would give the strongest support for this decision? a. Deontology b. Utilitarianism c. Ethics of care d. Feminist ethics

b. Utilitarianism Utilitarianism focuses on the greatest good for the most people; the organizations decide to ensure that as many health care workers as possible will survive to care for other members of the community. Deontology defines actions as right or wrong based on their "right-making characteristics" such as fidelity to promises, truthfulness, and justice. Feminist ethics looks to the nature of relationships to guide participants in making difficult decisions, especially relationships in which power is unequal or in which a point of view has become ignored or invisible. The ethics of care and feminist ethics are closely related, but ethics of care emphasizes the role of feelings.

3. The patient's son requests to view documentation in the medical record. What is the nurse's best response to this request? a. "I'll be happy to get that for you." b. "You are not allowed to look at it." c. "You will need your mother's permission." d. "I cannot let you see the chart without a doctor's order."

c. "You will need your mother's permission." The mother's permission is needed. The nurse understands that sharing health information is governed by HIPAA legislation, which defines rights and privileges of patients for protection of privacy. Private health information cannot be shared without the patient's specific permission. The nurse cannot obtain the records without permission. The son can look at it after approval from the patient. While talking to the physician or getting an order is appropriate, the patient still has to give consent.

13. A nurse is discussing quality of life issues with another colleague. Which topic will the nurse acknowledge for increased attention paid to quality of life concerns? a. Health care disparities b. Aging of the population c. Abilities of disabled persons d. Health care financial reform

c. Abilities of disabled persons The population of disabled persons in the United States and elsewhere has reshaped the discussion about quality of life (QOL). Health care disparities, an aging population, and health care reform are components impacted by personal definitions of quality but are not the underlying reason why QOL discussions have arisen.

15. The nurse is caring for a dying patient. Which intervention is considered futile? a. Giving pain medication for pain b. Providing oral care every 5 hours c. Administering the influenza vaccine d. Supporting lower extremities with pillows

c. Administering the influenza vaccine Administering the influenza vaccine is futile. A vaccine is administered to prevent or lessen the likelihood of contracting an infectious disease at some time in the future. The term futile refers to something that is hopeless or serves no useful purpose. In health care discussions the term refers to interventions unlikely to produce benefit for a patient. Care delivered to a patient at the end of life that is focused on pain management, oral hygiene, and comfort measures is not futile.

10. A nurse agrees with regulations for mandatory immunizations of children. The nurse believes that immunizations prevent diseases as well as prevent spread of the disease to others. Which ethical framework is the nurse using? a. Deontology b. Ethics of care c. Utilitarianism d. Feminist ethics

c. Utilitarianism Utilitarianism is a system of ethics that believes that value is determined by usefulness. This system of ethics focuses on the outcome of the greatest good for the greatest number of people. Deontology would not look to consequences of actions but on the "right-making characteristic" such as fidelity and justice. The ethics of care emphasizes the role of feelings. Relationships, which are an important component of feminist ethics, are not addressed in this case.

18. The nurse is caring for a patient supported with a ventilator who has been unresponsive since arrival via ambulance 8 days ago. The patient has not been identified, and no family members have been found. The nurse is concerned about the plan of care regarding maintenance or withdrawal of life support measures. Place the steps the nurse will use to resolve this ethical dilemma in the correct order. 1. The nurse identifies possible solutions or actions to resolve the dilemma. 2. The nurse reviews the medical record, including entries by all health care disciplines, to gather information relevant to this patient's situation. 3. Health care providers use negotiation to redefine the patient's plan of care. 4. The nurse evaluates the plan and revises it with input from other health care providers as necessary. 5. The nurse examines the issue to clarify opinions, values, and facts. 6. The nurse states the problem. a. 6, 1, 2, 5, 4, 3 b. 5, 6, 2, 3, 4, 1 c. 1, 2, 5, 4, 3, 6 d. 2, 5, 6, 1, 3, 4

d. 2, 5, 6, 1, 3, 4 Step 1. Gather as much information as possible that is relevant to the case. Step 2. Examine and determine your values about the issues. Step 3. Verbalize the problem. Step 4. Consider possible courses of action. Step 5. Negotiate the outcome. Step 6. Evaluate the action.

9. A nurse must make an ethical decision concerning vulnerable patient populations. Which philosophy of health care ethics would be particularly useful for this nurse? a. Teleology b. Deontology c. Utilitarianism d. Feminist ethics

d. Feminist ethics Feminist ethics particularly focuses on the nature of relationships, especially those where there is a power imbalance or a point of view that is ignored or invisible. Deontology refers to making decisions or "right-making characteristics," bioethics focuses on consensus building, while utilitarianism and teleology speak to the greatest good for the greatest number.

12. A young woman who is pregnant with a fetus exposed to multiple teratogens consents to have her fetus undergo serial PUBS (percutaneous umbilical blood sampling) to examine how exposure affects the fetus over time. Although these tests will not improve the fetus's outcomes and will expose it to some risks, the information gathered may help infants in the future. Which ethical principle is at greatest risk? a. Fidelity b. Autonomy c. Beneficence d. Nonmaleficence

d. Nonmaleficence Nonmaleficence is the ethical principle that focuses on avoidance of harm or hurt. Repeated PUBS may expose the mother and fetus to some risks. Fidelity refers to the agreement to keep promises (obtain serial PUBS). Autonomy refers to freedom from external control (mother consented), and beneficence refers to taking positive actions to help others (may help infants in the future).

Americans with Disabilities Act

is a civil rights law that prohibits discrimination against individuals with disabilities in all areas of public life, including jobs, schools, transportation, and all public and private places that are open to the general public. The purpose of the law is to make sure that people with disabilities have the same rights and opportunities as everyone else. The ADA gives civil rights protections to individuals with disabilities similar to those provided to individuals on the basis of race, color, sex, national origin, age, and religion.

Tort

is a civil wrong made against a person or property- It may be intentional or unintentional

Statutory law

is the term used to define written laws created by elective legislative bodies - state legislature- Nurse practice Act Consists of constitutional law, federal law and takes precedence over the laws of states and jurisdictions civil criminal

Types of law

local- local authority state- enacted by individual state government federal - enacted by the federal government and pertain to all states and localities