1. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 07: Ethical Issues in Critical Care Nursing

2. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins ANA’s Code of Ethics for Nurses See Box 7-1.

3. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Bioethical Principles

4. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Risk-Benefit Analysis Identify the benefits and risks involved. Do the risks outweigh the potential benefits? What are the overall goals for caring for the patient? What alternatives instead of the proposed care exist? Is the comfort of the patient compromised?

5. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins The Five Steps of Ethical Decision Making

6. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Resources Available to the Nurse to Resolve Ethical Dilemmas Institutional ethics committee Nursing ethics committee Pastoral care Peer support Quality assurance Professional organizations

7. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Case Study 1 A disaster has brought 35 new patients to the hospital. Many of the new patients are being treated and kept in the cafeteria. You are the charge nurse and need to decide what to do with the seven ICU patients that you have. There are two beds available on the step-down unit and there is one bed on the medical-surgical unit. Using the principles of ethics, decide who will go to the step- down beds and who will go to the medical-surgical bed so that you can take three critically ill patients who qualify using the triage guidelines. All seven patients in the ICU are equally unstable. How could you ethically make the decision? What are your options?

8. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Case Study 2 Two clients are on a transplant waiting list, and both qualify for the one heart that is available. Which of the following clients would you choose, using ethics to guide you? Give your rationale. Client 1 is a 34-year-old single mother of one child who had a heart transplant 6 months ago; the heart transplant is failing and she needs another. She is an active IV drug abuser who has not been successful with drug rehabilitation. Client 2 is a 55-year-old woman who was placed on the list 3 weeks ago. She has two teenage children to raise.

9. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following is the ethical approach that considers the emotions and character traits of a relationship between people as essential when determining the right thing to do? A. Utilitarianism B. Deontological C. Ethics of care D. Virtue ethics

10. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. Ethics of care Rationale: Ethics of care emphasizes the characteristics of a caring relationship as essential in determining the right thing to do. According to utilitarianism, the right action is the one that provides the greatest benefit with the least burden to all parties involved. The deontological approach considers conformity to the action of moral rules. According to virtual ethics, what matters is what agents do and whether their actions reflect their virtues.

11. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following statements about the ethics committee at an institution is correct? A. The committee is made up entirely of physicians. B. The Joint Commission requires an institution to have guidelines pertaining to decisions about end-of-life care. C. A physician must write an order before the ethics committee becomes involved in a situation. D. The family must give permission before the ethics committee is consulted.

12. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer B. The Joint Commission requires an institution to have guidelines pertaining to decisions about end-of-life care. Rationale: The Joint Commission requires an institution to establish guidelines pertaining to end-of-life care, including the process to address ethical situations, informed consent, and surrogate decision making. The ethics committee is made up of doctors, nurses, social workers, clergy, and laypersons from the community. No order is needed to consult the ethics committee. The family does not have to grant permission for the ethics committee to be consulted, but the family should be made aware.

13. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question The American Association of Critical Care Nurses directly addresses moral distress in the critical care work environment through: A. The healthy work environment B. Crucial conversations C. Ask, affirm, assess, act D. Code of Ethics for Nurses

14. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. Ask, Affirm, Assess, Act. Rationale: The AACN proposes the use of the four A’s (ask, affirm, assess, and act) to help the nurse to deal with moral distress. The healthy work environment initiative involves open communication among health care professionals and the administration. Crucial conversations help the nurse to be assertive and to be able to hold needed conversations with others, keeping the interest of the patient as a top priority. The ANA’s Code of Ethics provides guidelines for ethical decision making.