Ethics

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University of Massachusetts, Boston *

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Philosophy

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Feb 20, 2024

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Ethics Weeks 1 & 2 NU470 https://quizlet.com/416276199/204-summer-2019-final-exam-flash-cards/ Ethical Principles Patient’s Bill of Rights Videbeck’s Your Videbeck’s discussed HIPPA. As level 3 students, it is your responsibility to understand the HIPPA requirements Values Values are beliefs about what something is worth, about what is important/what matters, and is a guide for behavior Values formed over time, and with influence from their environment, family, and culture Value system is an organization of values Each value is ranked according to importance This can culminate to a personal code of conduct Can influence beliefs about needs Value Transmission • Modeling • Moralizing • Laissez-faire • Rewards • Punishments • Responsible choice From your fundamentals text Modeling: learning value through observation of important people in lives Moralizing: taught complete value system by authority figures allowing little opportunity for weighing different values

L-F: children explore on their own and develop personal values. Little to no guidance. May bring confusion and conflict Rewards/punishments Responsible choice: explore competing values and weigh consequences. Support and guidance are given to help guide personal value system Think about your values and how you developed them – will they serve your patients? Depriving or giving a child their favorite TV show if they allow a tx – reward/punishment Professional Values Professional Values Sample Behaviors Self-Reflection Altruism Demonstrating understanding of cultures, beliefs, and perspectives of others Am I willing to be out of my comfort zone to advocate for patients? Is my primary commitment to my patients? Autonomy Honoring patients’ and families' rights in decision making Being a partner with patients Do I find time to give information to patients to make their own choices? Human Dignity Culturally respective care Protecting privacy Preserving confidentiality Do I demonstrate the same respect and compassion for all, even when challenging? Integrity Provide honest information Documenting accurately Can I feel confident that I have acted in accordance with my values Social Justice Supporting fairness and nondiscrimination in care delivery Universal access to healthcare Am I aware when people are not treated fairly or when they lack access to quality care? Altruism: concern for well-being of others Autonomy: right to self-determination H Dignity: respect for inherent worth and uniqueness of indiv and populations Integrity: Acting in accordance with an appropr code of ethics and accepted std of practice Social Justice: Upholding moral, legal, and humanistic principles. Nurse works to assure equal access Value Clarification Choosing Prizing Acting Understanding your own values and your value system. As an RN, try to understand what motivates your patients decisions and behaviors –use this knowledge to tailor teaching and counseling Value theorists describe this process of valuing as focusing on 3 main activities: Think about human respect and dignity when considering

Choosing considering alternatives and their consequences – you can choose as an RN to value all, or those most like you prizing (treasuring) involves pride, happiness, and public affirmation – you can enjoy when you’re complimented and acting combining choice, behavior with consistency and regularity Reaction to bullying should be considered here, too Ethics Ethics is a system that deals with standards in character and behavior related to what is considered “right” and “wrong” (Taylor, 2019) Colbert (2017) simplifies this as principles that guide actions Being ethical and acting ethical takes a long time to develop Bioethics What kind of person should I be to live a moral life and to make ethical decisions? What are my duties and obligations to other people whose life and well being may be impacted by my actions? What do I owe the common good or public interest in my life as a member of society? Ethics may sound like a clear-cut concept, but what is “right” and “wrong” can be subjective to person, situation, etc . This is at the center of patient care decision making Morals are personal or communcal stds of right and wrong Ethics is not religion, law, custom, and institutional practice Nursing ethics is a specific subset of bioethics: breach in confidentiality, illegal practice of colleagues, beginning and end of life decision making Principle-Based Approach • Autonomy • Nonmaleficence • Beneficence • Justice • Principle based approach to ethics combines utilitarian and deontologic theories to give specifics for practice with 4 key principles • Autonomy: respect patients or surrogates to make their own decisions in HC. RNs should provide information and support, collaborate • Nonmalef: Avoid causing harm. Harm prevention is critical. Emphasize good qualities of the staff and positive growth direction. • Beneficience: balance benefits against risks. Promote health, taking the individual into account. Examples include medicating for pain. • Justice: act fairly, distribute benefits, risks, and costs. This may involve recognizing subtle bias and discrimination • Many RNs add fidelity (keep promises, no patient abandonment), veracity, accountability, privacy, and confidentiality (HIPPA)

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Examples of Principle-Based Approaches Autonomy Consent Advocacy Nonmalfeacence Recognizing good qualities Beneficence Assessing and medicating for pain Justice Equitable access to care Ethical Conduct  Ethical decision making needs a framework, and needs to be developed. • Competence • Know what you are doing or know where to find the information. • Compassionate caring • Subordination of self-interest to patient interest • Arrange your lunch time basing on working schedule and time • Self-effacement • Trustworthiness • Conscientiousness • Intelligence • Practice wisdom • Be humble • Humility • Courage • Integrity Nursing Code of Ethics International Council of Nurses’ (ICN) ICN Code of Ethics for Nurses ANA Code for Nurses with Interpretive Statements Canadian Nurses Association (CNA) Code of Ethics for Registered Nurses Specifically for students: National Student Nurses’ Association (NSNA) Code of Academic and Clinical Conduct Moral Distress and Resiliency - moral distress – when you know the right thing but personal or institutional factors make it difficult to follow the correct course of action - Picture is rise above moral distress from Amer assoc of Critical-care nurses - Resiliency – the developed capacity to respond well to morally distressing experiences and to come out strong. - If you feel compromised by what you’re asked to do – consider conscientious objection. The nurse then does not participate in ertain tx, care, situations based on it violating the RNs personal and prof ethical beliefs

How to Make an Ethical Decision? 1. Assess the situation (gather data) 2. Diagnose the ethical problem (identify) 3. Plan (identify and weigh alternatives) 4. Implement decision 5. Evaluate the decision Ethics must be the center of decision-making

Use the nursing process to guide you. Slow down, if possible and consider all relevant components #3 – consider discussing with institutional ethics group/board Assessing patients is a critical responsibility for an RN only. Ethically Relevant Considerations 1. balance between benefit and harm 2. Disclosure, informed consent, and shared decision-making 3. Norms of family life 4. Relationship between clinicians and patients 5. Professional integrity of clinicians 6. Cost effectiveness and allocation 7. Issues of cultural and/or religious variation 8. Consideration of power Ethical Problems • Paternalism • Deception • Privacy and Social Media • Confidentiality • Allocation of scarce nursing resources • Valid consent or refusal • Conflicts concerning new technology • Unprofessional, incompetent, unethical, or illegal physician practice • Unprofessional, incompetent, unethical, or illegal nurse practice • Short staffing issues • Beginning of life issues • End of life issues Children and Consent For unemancipated, children < 18 y/o, consent can be given by Guardian Parent If parents aren’t present, an adult sibling Emancipated minors can consent for themselves Consent and assent are different In the circumstance of children, assent is verbal but consent is an active process with signatures. Advocacy Protecting and supporting other’s rights Client-focused and provider-facilitated Includes self-determination and assisting other’s to make their own independent choices Balancing resources

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Whistle blowing Being politically active Advocacy Empowering: contemporary, client’s are able to be their own advocate, CM as supporter and educator Shared responsibility: contemporary, objectivity is relative, joint-decision making Engaging: contemporary, influence individual and pop health, counseling and support, clients in control of their own health and CM as catalyst for change Paternalistic: traditional, assumes client is powerless, assumes case manager is the boss and is directive Shared resp: contemporary, objectivity is relative, joint-decision making Ethical and Legal Issues Affecting the Older Adult The nurse’s role is to support and inform patients and families around treatment decision making Advanced Directive Formal, legally endorsed document providing instructions for care (living will) or names a proxy decision maker Can be implemented if the signer becomes incapacitated Must be signed by the person and 2 witnesses , with a copy given to the PCP and placed in the medial record It is a description of health care preferences, including electing all available medical treatment HCP can interpret this information, if needed Ethical Issues and End-of-Life Care Client’s may not be able to effectively communicate Interventions may seem futile Outcome predictions may not seem accurate Different opinions regarding the worth of an outcome Older adults may not be familiar with autonomy and may have difficulty contradicting HCP Diminished cognitive ability due to disease and medications Advanced Directives Decision making is increasingly complex Advanced Care Planning (ACP) helps future planning in the event the person cannot make their own decisions ACP is recommended for all adults, regardless of age There are 2 types: living will and durable power of attorney for health care Advanced Directives Living will

Provide specific instructions about the kinds of health care to be provided, or not provided Durable power of attorney for health care Appoints an agent to make decisions Decision maker = durable power of attorney Life-Sustaining Wishes Physician Order for Life-Sustaining form (POLST) Indicates a patient’s wishes about treatment in a medical crisis Completed and signed by a health care professional, and not by the patient Completed in close consultation with the patient to ensure patients’ goals of care are accurate Medical Orders for Life-Sustaining form (MOLST) AKA POLST, and depends on the state AD: 18 or older, indications for future tx, appts HC proxy, doesn’t guide EMS, guides inpatient tx POLTS: Any age, current tx, guides EMS when it is available, can guide inpatient tx Last page 1694 Ethical and Legal Issues Affecting the Older Adult There can be conflict of values among patients, family members, HCP, and legal reps Directives must be focused on the patient’s wishes and not the wishes of the family or designated proxy Without a HCP Court can be petitioned to appt a guardian who is given certain decision making authority As a cultural reflection Autonomy and self-determination are Western concepts Some may have difficulty conceptualizing the future Guardian isn’t always given full decision making ability. Knowing where the legal docs are is critical for the RN AD Vs POLST Advanced Directive At least 18 y/o Instructions for future treatment Appoints a health care representative Does NOT guide emergency medical personnel Guides inpatient treatment decisions when made available POLST Any age, person with serious illness Provides medical orders for current treatment Can guide EMS, when available Guides inpatient treatment decisions, when available

physician order for life sustaining treatment AND (Allow natural death), DNR, No Code Order Ordered when patient, or surrogate, expresses a wish that no attempts should be made to resuscitate patient whose breathing or heart rate stops AND is often perceived to carry less burden for patients and families/surrogates This is different from a “slow code” It is crucial that code status be clarified during and throughout health care encounters POLST/MOLST orders should be clarified regarding when/where they apply CMO CMO (comfort measure only) Goal of treatment is comfort, dignity Generally, further life-sustaining measures are not continued Patient’s wishes, and their perception about comfort, is critical to clarify This may not include palliative surgeries, dialysis Do Not Hospitalize These orders are used for patients that do not wish to escalate their care Consider laws that vary state-to-state Palliative Sedation Lowering consciousness, with medications, to limit suffering Terminal Weaning This scenario is often seen for patients when they were provided with mechanical ventilatory support, for example, and then they were unable to recover their condition They can be extubated, or weaned from mechanical ventilation It is critical that health care team members, patients, and their families/surrogates, understand that the person is Unlikely to recover The timing for their death is likely unpredictable Voluntary Cessation of Eating and Drinking While some may consider this as a form of suicide, the process of death is associated with cessation of thirst and hunger Not continuing/offering IV fluids, tube feedings is part of allowing AND This should be entirely voluntary, and support from all involved is critical Active and Passive Euthanasia (euthanasia is good dying) Active is taking specific steps to cause a patient’s death Passive is withdrawing treatment to allow for death Assisted suicide As of 2017 there are 5 states and the District of Columbia have passed laws that legalize assisted suicide

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Organ Donation - NEOB (new England organ bank)should be notified PRIOR to death , when able (provider called) - Patients can fill out donor cards, add to license - Organs and tissues can come from patients who have had brain-death or non-heart- beating cadevors Autopsy (second things prior or after death) • Examination of organs and tissues following death • Document any abuse, disease • Consent for autopsy is legally required, unless mandated by the ME(mandates) • Some religious rules around not performing autopsies Death Certificate Each person who dies in the US must have a death certificate Specific information is required, including identification, cause(s) of death, and more Your book states that it is the RNs responsibility to ensure the death certificate is signed Client Rights Clients receiving care for mental health conditions retain all civil rights Exceptions include inability to leave hospital/treatment in the case of involuntary commitment They have the right to refuse treatment, send and receive sealed mail, have or refuse visitors Restrictions for these must be justified, are verifiable and for documented reasons These decisions can be made by a court or designated decision-maker Examples: Denying a person with suicidal ideation their belt, shoelaces, scissors due to concern for self-harm Aggression after certain visitor, client may have that visitor restricted Client making threatening phone calls may only be allowed to make supervised phone calls until the condition improves Duty to Warn If specific threats made to a third party, even in the care of warning coming from therapy session Clients should be managed in the least restrictive environment as possible – central to the deinstitutionalization mvmt Release from the Hospital If they do not represent a danger to themselves, or others, they can sign out against medical advice (AMA) AMA can be in the case of mental health disorders, or non-mental health disorders Ensure IV lines are removed for ANY patient leaving the hospital

Involuntary Hospitalization and Mandatory Outpatient Treatment This is used in the case when a client is a danger to themselves or others All client’s rights remain intact, except the ability to leave the hospital Persons may be detained for 48-72 hours until a hearing can be conducted to determine length of treatment Legally assisted or Mandatory Outpatient Treatment requires treatment to continue following inpatient hospitalization Considered a civil commitment May states have laws about SUD, and some particular infectious diseases Mass is one of 4 states that do not have mand outpatient treatment Your book discusses conservatorship, guardianship – it is always important to understand who and when people can make decisions for your patient, if not the patient themselves Restraint and Seclusion Restraint Application of physical force to a person without their permission, and intends to restrict their freedom Can be human, mechanical, or both Seclusion Involuntary confinement in a tightly controlled and monitored space intended to provide privacy, and helps the patient gain physical and emotional self-control Restraint and seclusion requires am indep practitioner face-toface eval within 1 hour, and every 8 hours thereafter, an MD order q4 hours, assessment by the RN documented every 1-2 hours, and close 1:1 supervision For children, MD order q2 hours with face-to-face eval q4 hours Seclusion montored 1:1 for first hour and then by A/V RN documents client’s skin condition, circulation in hands and feet, emotional well- being, and readiness to d/c seclusion or restraint Offer food, fluids, bathroom. Ensures dignity If client in 1-2 hours, release one limb at a time for movement

Ethics

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