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Ethical Decision-Making Abilities: Reflection on Moral Accountability

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1 Ethical Decision-Making Abilities: Reflection on Moral Accountability
Ethical Decision-Making Abilities: Reflection on Moral Accountability By Dr. Eileen Watson, EdD, RN, MSN, ANP,GNP,LNC-C Associate Professor of Nursing CSULB, School of Nursing

2 Purposes of Module 1. To increase the student nurse’s knowledge of the distinction between ethics and law, ethical theories and principles 2. To assess one’s moral attitudes, beliefs, and values 3. To increase the student nurse’s knowledge of current ethical issues occurring in clinical practice settings 4. To promote the development of student nurse’ skills in ethical decision-making, moral reasoning, moral judgment and ethical reflection 5. To examine Professional Code of Ethics

3 Module Objectives Upon completion of this learning module with its assigned readings and learning activities, the student nurse will be able to: 1. Define the terms: ethics, morals, attitudes, beliefs, values, ethical dilemma, and moral accountability Discuss Kohlberg’s (1971) Theory/Stages of Moral Development 3. Differentiate ethical theories of deontology, teleology, and principalism

4 Module Objectives cont.
4. Apply to nursing practice eight ethical principles 5. Identify the nine provisions and the key interpretive statements for each provision of the American Nurses Association (ANA) Code of Ethics for Nurses With Interpretive Statements (2001) and discuss how each provision may effect the practice of nursing 6. Identify ethical issues frequently seen in clinical settings

5 Module Objectives cont.
7. Identify symptoms of moral distress experienced by nurses in clinical practice 8. Identify moral distress activity sources in clinical practice and academic settings 9. Identify negative impacts in health care work environments caused by moral distress 10. Analyze the MORAL model in ethical decision-making 11. Discuss the pros and cons of selected ethical issues such as medical futility, foregoing nutrition and hydration, social justice, abortion, active euthanasia, and assisted suicide

6 Module Objectives cont.
12. Identify California state laws associated with selected ethical issues in objective #11, if applicable 13.Guided by the influence of one’s personal values, professional codes, and patient care preferences, debate the legal and ethical principles in the analysis of selected ethical issues in objective # Discuss ANA’s Position on Ethics and Human Rights

7 Definition of Terms Ethics: branch of philosophy that examines the moral value of human conduct. Source is internal to oneself Values: personal beliefs about truth, thoughts, action, or objects Values Clarification; “a process aimed at understanding the nature of one’s own value system and its vast impact on the individual” (Guido, 2010, p. 3). Why is this important to nursing? Value Systems: personal, professional, societal Ref. Guido, 2010, Ch.1 Values—influenced by experience, education, environment, religion, culture, peers. Value clarification is important to nursing—knowing one’s values helps guide actions taken by the nurse in clinical practice. 7 emw

8 Definition of Terms cont.
Ethical Dilemma: when an individual must choose between two equally unfavorable alternatives. Occurs when there is conflict between 2 or more ethical principles and there is no obvious “right” decision (Kelly, 2010). Jameton (1984)—Initial dimension and reactive dimension. Personal values and professional experiences influence attitudes of nurses when pondering ethical dilemmas (Winland-Brown & Dobrin, 2009) Ethical Reflection: Schon (1967). Reflection on Action Nursing Code of Ethics: Defines the profession’s values and standards of conduct Reflection On Action: Allows the individual to spend time exploring back on why he or she behaved the way he or she did and what was going on at the time—outcome the individual develops sets of questions and ideas about his or her activities and practice—promoting critical thinking and clinical decision-making abilities. Jameton (1984) “ initial moral distress is the distress nurses experience when they are faced with interpersonal value conflicts. It is experienced by feelings of frustration, anxiety, anger, and an inability to act as one sees fit due to organizational constraints. Reactive moral distress is the distress nurses experience when they do not act upon the initial distressing situation to bring about resolution”……….Jameton’s “sentinal work framed the concept of moral distress as arising when one knows the morally right thing to do, but cannot do so because of organizational constraints” (Edmonson, 2010)

9 Definition of Terms cont.
Morals: are personal principles Morality: is one’s exhibited behavior influenced by personal principles Moral Distress: occurs when a situation involves conflict between 2 ethical principles Moral Reasoning: is thinking and reasoning about what one ought to do based on ones morality Moral Judgment: a decision to act or not act based on what an individual believes is good/bad—right or wrong Moral Accountability: Being responsible for one’s actions== (Duty To Oneself) Ref. Guido (2010) Ch. 1 and 2 Moral Distress—scenario—patient asks daily about her medication—what is it and what is it used for. Nurse comes on duty and must give patient a new medication AZT—for treating HIV. Medical orders are written that state “patient is not to be told of diagnosis of HIV.” AZT is a medication to treat HIV. Two ethical principles collide for the nurse: patient autonomy (right to decide what decisions to make) and veracity (telling the truth). Nurse must work through how to deal with this. She might call MD and ask him to explain why patient cannot be told; ask charge nurse how to deal with it as patient always asks questions about medication and nurse does not want to lie or appear dumb.

10 Symptoms of Moral Distress
Physical: headaches, tiredness, gastrointestinal symptoms, shaking, pain Psychological: feelings of guilt, anxiety, frustration, anguish, confusion Ref. Ganske (2010), p. 3

11 Moral Distress Activity Sources For Nurses, Administration, Educators and/or Students
Clinical Practice Settings Academic Settings Nonsupportive/nonrespect-ful ethical climate Nurses core personal values and ethical obligations conflict End-of-life situations Protection of patient rights Unfair distribution of resources Cheating Plagiarism Grade inflation Student/Colleague incivility Academic admission standards Cultural issues Standards of profession Ref. Ganske, (2010), p. 3

12 Impact on Health Care Work Environments Caused by Moral Distress
Nurses lose capacity for caring Nurses withdraw from bedside Nurses avoid patient contact Nurses fail to give good physical care Nurses leave the profession Nurses feel loss of integrity and dissatisfaction Ref. AACN Position Paper on Moral Distress (2008) AACN—American Association of Critical Care Nurses (Aug. 2008), p Sources recognized by AACN to help each nurse reduce moral distress: be knowledgeable about and use professional and environmental resources to address moral distress: examples: ANA Code of Ethics for Nurses with Interpretive statements (2001) International Council of Nurses Code of Ethics for Nurses (ICN) (2006) AACN 4 A’s to Rise Above Moral Distress Handbook AACN 4 A’s to Rise Above Moral Distress Facilitators Toolkit

13 Kohlberg’s Theory/Stages of Moral Development
Kohlberg’s theory holds that moral reasoning, which is the basis for ethical behavior, has six identifiable developmental stages (Psychology Wiki, 2011) Level One—Preconventional: Stage 1-Obedience and punishment orientation Stage 2-Self-interest orientation “Reasoners in pre-conventional level judge the morality of an action by its direct consequences” (Psychology Wiki, 2011,p. 3)

14 Kohlberg’s Theory/Stages of Moral Development cont.
Level Two—Conventional: Stage 3—Interpersonal accord and conformity orientation Stage 4—Authority and social-order maintaining orientation “Persons who reason in a conventional way judge the morality of actions by comparing these actions to societal views and expectations” (Psychology Wiki, 2011, p. 3) Majority of American society use conventional moral judgment(Kohlberg, 1981; Rest, Turiel, & Kohlberg, 1969; Winland-Brown & Dobrin, 2009)

15 Kohlberg’s Theory/Stages of Moral Development cont.
Decasterle, Grypdonck, Vuylsteke-Wauters, & Janssen (1997) studied 2,624 nursing students’ ethical behavior for five different nursing dilemmas. Guided by Kohlberg’s theory, results indicated that most nursing students are at the conventional level of moral development that is “students are guided by professional rules, norms and duties, and have yet succeeded in making personal ethical decisions on the basis of their own principles and acting according to such decisions” (p. 12) Conventions and/or laws are used by nurses as their predominant decision-making criteria in ethical dilemmas (Carmel,et al.2007; DeCasterle, et al. 2008; Winland-Brown & Dobrin, 2009.)

16 Kohlberg’s Theory/Stages of Moral Development cont.
Level Three—Postconventional: (Principled Level) Stage 5—Social contract orientation Stage 6—Universal ethical principle orientation “A person at this level attempts to clearly define universal morals in terms of self-chosen principles. In health care, those principles include autonomy, beneficence, nonmaleficence, justice, veracity, fidelity, and justice. The stages of moral development are hierarchical and attainment of each stage of moral judgment is prerequisite to attainment of the next higher stage (Kohlberg, 1976)” (Winland-Brown & Dobrin, 2009, p. 2) Kohlberg’s theory—”does not predict what action a person will take, it does serve to clarify ethical reasoning, which permits more effective discussions of moral issues” (Winland-Brown & Dobrin, 2009, p. 3). Murphy (1976) as cited in Ketefian (1981) “…contended that nurses need to be at a postconventional level of moral judgment if they are to be agents of change and contribute to new norms in health care” (p. 102).

17 Kohlberg’s Theory/Stages of Moral Development cont.
Murphy (1976) as cite in Ketefian (1981) “….to function optimally and independently in a complex milieu and to act as a responsible and accountable moral agents, nurses need to have attained a postconventional level of morality and that conventional morality is dysfunctional. At the conventional level of moral development the nurse would be oriented toward maintaining institutional expectations and harmonious interpersonal relationships. A nurse at this level is unable to function adequately when important values compete in individual situations or when conflicts of duty arise” (p. 102).

18 Summary of Kohlberg’s Theory/Stages of Moral Development
Moving from one stage to the next “rest not only on exposure to the next level of thought, but to experiences of conflict of the individual’s current level of thought with ethical situations (Kohlberg & Blatt, 1973). Higher state reasoning is assimilated only if cognitive conflict is stimulated. Moral reasoning at a stage higher than one’s own leads to increased moral thinking at the next higher stage, only if it disagrees with, or introduces uncertainty into, the individual’s own decision on moral dilemmas (Kohlberg & Blatt, 1973; Rest, Turiel, & Kohlberg, 1969) “ (Winland-Brown & Dobrin, 2009, p. 2) Ethical Debates—an intervention to create uncertainty/conflict on ethical issues “Whenever the educational process intentionally creates cognitive conflict and disequiilbrium by showing inadequacies of a person’s mode of thinking, the individual is stimulated to seek higher and more adequate levels of moral reasoning (Rest, Turiel, and Kohlberg, 1969)” (cited in Ketefian, 1981, p. 99). Ketefian (1981) found that nurses who had professional education (BSN or higher) had more advanced levels or moral reasoning than nurses prepared at ADN or Diploma levels. Wirtz (2007) found that nurses’ education from first semester to last semester of a two-year associate degree nursing program promoted the development of moral development as the nursing student progress through the program. Factors found in the literature which may effect an individual’s moral development : age, gender, prior schooling, academic level, grade point average, work experience, religion, culture (Duckett, 1997; Hirschmann, 1991; Roell, 1982; Wirtz, 2007)

19 Ethical Theories Deontological: intention factor with humanism; there are aspects of an act other than its consequences which determine its morality (nonconsequentialist) Teleological: intention factor with rules and principles; the consequences of an act are the most important factors in determining morality (consequential, utilitarian, situational). Principalism: incorporates combinations of ethical principles and attempts to resolve ethical dilemmas by applying one or more ethical principles Ref. Guido, 2010, Ch. 1 Deontological—fulfilling one’s duty to another; emphasis on dignity of human beings (Guido, 2010, Ch. 1) Teleological—what determines if an action is right or wrong is in its utility (Guido, 2010, Ch. 1) 19 emw

20 Ethical Principles: Nursing Profession
“Reasoning using ethical principles as a guide reflects reasoning at a principled level, the highest level in moral development” (Winland-Brown &Dobrin, 2009, p. 2) 1. Autonomy—addresses personal rights of freedom and self-determination; the right for someone to control their health care decision, even if someone else does not agree--**How can this this right be taken away? 2. Beneficience—promoting good to others. Problem is in defining “good.” Autonomy—Autonomy can be taken away—example: Communicable disease threat to society--a person with active tuberculosis not taking meds; informed consent- patient may make decision to do or not do something Beneficence—is it good for the patient to undergo more chemotherapy or is it good to let the patient die with dignity without more chemotherapy? Each nurse must honor the patient’s wishes.

21 Ethical Principles: Nursing Profession cont.
3. Nonmaleficience—states that one should do no harm. What about pain with procedures? 4. Fidelity—is keeping one’s promises or commitments.. Cite examples? 5. Veracity—concerns always telling the truth. Cite how this is done. Ref. Guido, 2010, Ch. 1 Nonmaleficience—need to tell patient injection will hurt briefly—outcome is less pain Fidelity—nurses should not promise patients what they cannot fulfill: if a patient requests to know the time when he can have his next pain medication and the nurse says she will go check and come right back—the nurse needs to do this or send someone else to fulfill the promise made to the patient—trust is lost if not fulfilled. Veracity--truth—when one completely answers patient’s questions to the best of the nurse’s ability. Difficult when nurses are not allowed to talk with patients about certain information because it is “restricted by healthcare provider/family orders.” For example--Cannot discuss lab results indicating patient has HIV—patient wants to know lab results….nurse needs to work through ethical dilemma—talk with MD or supervisor and help get some direction from supervisor

22 Ethical Principles: Nursing Profession cont.
6. Justice—all people should be treated fairly and equally. With hospital cost containment measures does patient equality always occur? 7. Respect for Others—highest principle; incorporates all ethical principles; acknowledges the right of individuals to make their own informed decisions-- to live or die by those decisions Case Study Exercises. Guido, 2010, p. 10. Exercise 1.2 #1-4. Identify what ethical principles you feel should be used by the nursing staff for each case study. Class discussion exercise. Justice—supply and demand issues. Example: Two patients need critical care bed (CCU) and only one is available—what actions might the nurse take? The nurse may call physicians of patients in the CCU and ask the physicians if his patient might be ready to be moved out of CCU to the step-down unit—if yes, that would open up 2 CCU beds. One patient may need to stay in the emergency room with 1-1 observation by critical care nurse if CCU bed does not become available. Possible answers to case studies: many to all ethical principles may be identified for each case study. #1: Autonomy, fidelity, veracity, justice #2: Autonomy, respect for others, veracity #3: Paternalism, veracity, fidelity, respect for others #4: Justice, veracity, respect for others Respect for others—All individuals need to be treated the same—whether they are homeless, rich and famous, VIP…..required to do this in Nursing Code of Ethics (2001) , Provision #1–Human Dignity

23 ANA Code of Ethics With Interpretive Statements
9 Provisions: Provisions 1-3: Discuss Fundamental Values of the Professional Nurse Provisions 4-6: Discuss Duty and Loyalty Provisions 7-9: Discuss Expanded Duties Beyond Direct Patient Care

24 ANA Code of Ethics With Interpretive Statements Cont.
Provision 1—The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems. 1.1 Respect for human dignity 1.2 Relationships to patients 1.3 The nature of health problems 1.4 The right to self-determination 1.5 Relationships with colleagues and others REF. ANA Code of Ethics with Interpretive Statements (2001) Practice of nursing examples: Nurses must treat all patients and colleagues with human dignity without bias. The nurse must respect the patient right of self-determination to say ‘no.”

25 ANA Code of Ethics With Interpretive Statements Cont.
Provision 2. The nurse’s primary commitment is to the patient, whether an individual, family, group, or community 2.1 Primacy of patient’s interests 2.2 Conflict of interest for nurses 2.3 Collaboration 2.4 Professional boundaries Ref. ANA Code of Ethics with Interpretive Statements (2001) Practice of nursing examples: Each nurse has a professional obligation to keep the patient at the core of his or her daily practice.

26 ANA Code of Ethics With Interpretive Statements Cont.
Provision 3. The nurse promotes, advocates for, and thrives to protect the health, safety, and rights of the patient 3.1 Privacy 3.2 Confidentiality 3.3 Protection of participants in research 3.4 Standards and review mechanisms 3.5 Acting on questionable practice 3.6 Addressing impaired practice Ref. ANA Code of Ethics with Interpretive Statements (2001) Practice of nursing examples: Each nurse must protect patient’s rights of privacy and confidentiality.

27 ANA Code of Ethics With Interpretive Statements Cont.
Provision 4. The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimum patient care. 4.1 Acceptance of accountability and responsibility 4.2 Accountability for nursing judgment and action 4.3 Responsibility for nursing judgment and action 4.4 Delegation of nursing activities Ref. ANA Code of Ethics for Nurse with Interpretive Statements (2001) Practice of nursing examples: Each nurse is personally and professionally responsible and accountable for his or her clinical practice actions.

28 ANA Code of Ethics With Interpretive Statements Cont.
Provision 5. The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth. 5.1 Moral self-respect 5.2 Professional growth and maintenance of competence 5.3 Wholeness of character 5.4 Preservation of integrity Ref. ANA Code of Ethics for Nurse with Interpretive Statements (2001) Practice of nursing examples: Each nurse has a duty to look inward to oneself and due a values clarification. The nurse owes this same duty to self as to his or her patients.

29 ANA Code of Ethics With Interpretive Statements Cont.
Provision 6. The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action. 6.1 Influence of the environment on moral virtues and values 6.2 Influence of the environment on ethical obligations 6.3 Responsibility for the health care environment Ref. ANA Code of Ethics for Nurse with Interpretive Statements (2001) Practice of nursing examples: Each nurse should work towards a conducive work environment for all individuals concerned while keeping the focus on patient care.

30 ANA Code of Ethics With Interpretive Statements Cont.
Provision 7. The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development. 7.1 Advancing the profession through active involvement in nursing and in health care policy 7.2 Advancing the profession by developing, maintaining, and implementing professional standards in clinical, administrative, and educational practice 7.3 Advancing the profession through knowledge development, dissemination, and application to practice Ref. ANA Code of Ethics for Nurse with Interpretive Statements (2001) Practice of nursing examples: each nurse has a responsibility to improve his or her practice care environment.

31 ANA Code of Ethics With Interpretive Statements Cont.
Provision 8. The nurse collaborates with other health professionals and public in promoting community, national, and international efforts to meet health needs. 8.1 Health needs and concerns 8.2 Responsibilities to the public Ref. ANA Code of Ethics for Nurse with Interpretive Statements (2001) Practice of nursing examples: Each nurse should collaborate with other health care members to bring about improved change to the practice of nursing.

32 ANA Code of Ethics With Interpretive Statements Cont.
Provision 9. The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy 9.1 Assertion of values 9.2 The profession carries out its collective responsibility through professional associations 9.3 Intra-professional integrity 9.4 Social reform Ref. ANA Code of Ethics for Nurse with Interpretive Statements (2001) Practice of nursing examples: Professional nursing organizations are responsible for providing ethical guidelines for the practice of nursing. Practice care guidelines must remain current to enhance ethical nursing practice.

33 Examples of Professional Nursing Organizations Guiding the Ethical Practice of Nursing
ANA Nursing Code of Ethics With Interpretive Statements (2001) International Council of Nurses (ICN) (2006) National Student Nurses’ Association, (NSNA) Inc. Code of Ethics; Part II. Code of Academic and Clinical Conduct and Interpretive Statements. [Adopted by NSNA Board of Directors, Oct. 27, 2009 in Phoenix, AZ] “As students are involved in clinical and academic environments we believe that ethical principles are a necessary guide to professional development…” (NSNA, 2009, p. 1). …..“6. Actively promote the highest level of moral and ethical principles and accept responsibility for our actions….” (NSNA, 2009, p. 4). Retrieved from:

34 NANDA Approved Nursing Diagnoses
Domains of Nursing Diagnosis for Ethical Issues Domain 10. Domains Life Principles Values Beliefs Values/belief/Action Congruence Nursing Diagnoses: Decisional Conflict Moral Distress Retrieved from: Practice of nursing examples: “A NANDA nursing diagnosis is used to determine the appropriate plan of care for the patient. The Nanda nursing diagnosis list drives interventions and patient outcomes, enabling the nurse to develop the patient care plan.” Retrieved from:

35 Legal and Ethical Comparisons REF. Guido, G. (2010)
Legal and Ethical Comparisons REF.  Guido, G. (2010). Legal and ethical issues in nursing (5th ed.). New Jersey: Pearson Hall. Legal Ethical Concerns conduct and actions Concerns all of society Laws enforced by courts, statutes, and the board of registered nursing Concerns attitudes and motives Concerns the individual Ethics guided by ethical rounds, ethical committees, professional organizations Concerns: legal—conduct what a person did or failed to do; ethical—why one behaved the way he or she did Concerns: legal—all of society—not just individual (how an individual’s actions effect society); ethical—looks at individual within society as whole

36 Legal/Illegal Questions For Ethical Issues
Before one proceeds examining ethical issues, one must ask oneself—IS IT: Ethical/Legal Ethical/Illegal Unethical/Legal Unethical/Illegal Examples: Ethical/Legal—informed consent Ethical/Illegal—euthanasia Unethical/Legal—abortion Unethical/Illegal—involuntary treatment in non-emergency situation

37 Examples of California Laws on Ethical Issues
Assisted Suicide: Ca. Pen. Code Statute 401 Abortion: Health & Safety §§ et seq., Active Euthanasia: Code Section Probate §4653 Advance Directive: Ca. Probate Code Section 4701 Do-Not-Resuscitate: orally to MD by competent patient, surrogate,(family member if patient is terminally ill or unconscious and no advance directive, 2 physicians if CPR determined to be medically futile—check hospital policy on required discussions and conditions); in writing by competent patient in form of living will or advance directive prior to becoming ill (Medical-Malpractice. Medical Futility: Ca. Probate Code Section 4735 Assisted Suicide:—anyone who deliberately aids, advises another to commit suicide is guilty of a felony Abortion: “Statutory Definition of Illegal Abortion Performed by unauthorized person Statutory Definition of Legal Abortion Any medical treatment intended to induce the termination of a pregnancy except for the purpose of producing a live birth Penalty for Unlawful Abortion In case of unemancipated minor: misdemeanor, fine up to $1,000 and/or imprisonment in county jail up to 30 days Consent Requirements In case of unemancipated minor, written consent of minor and one parent or legal guardian, or by order of petition to Juvenile Court or in a medical emergency requiring immediate medical attention Residency Requirements for Patients - Physician Licensing Requirements Approved hospital and unanimous approval of medical committee of hospital (unless the health of mother impaired or rape or incest); certified physician/surgeon” ( Active Euthansia: “Euthanasia Condoned in Statutes? Nothing condones, authorizes, or approves mercy killing or permits an affirmative act or omission to end life other than the withholding of health care pursuant to a durable power of attorney so as to permit the natural process of dying. In making health care decisions under a durable power of attorney, an attempted suicide shall not be construed to indicate a decision of the principal that health care treatment be restricted or inhibited. Effect of Withholding of Life-Sustaining Procedures Death resulting from withholding or withdrawing life-sustaining treatment in accordance with the Natural Death Act does not constitute for any purposes suicide or homicide” ( Do-Not Resuscitate Orders: “Do Not Resuscitate Orders: ( For some medical conditions such as terminal cancer, end-stage renal disease, or severe pneumonia, life saving intervention is not warranted when patients stop breathing or when their hearts stop beating. A valid do not resuscitate order (DNR) tells medical professionals not to perform cardiopulmonary resuscitation (CPR) on a patient. DNR orders prove to be beneficial in preventing unnecessary or unwanted treatment at the end of an individual's life. Patient DNR Requests Competent, adult patients can request a DNR order themselves. Patient requests can be made orally to a physician, or in writing in the form of a living will or advance directive prior to becoming ill Family DNR Requests State laws vary as to whether hospitals are required to comply with advance directives. If a patient has designated a health care proxy, that person can request a DNR order. If a patient is too sick to request a DNR order for him or herself and no advance decisions have been made, the patient's family can request one. A family member's request will be honored if the patient is terminally ill or permanently unconscious or if a physician has determined that CPR would be medically futile or that CPR would impose an unnecessary burden on the patient given the individual's stage in life. If a patient's physician disagrees with the patient's request for a DNR order, the physician should transfer the patient to the care of a physician who agrees with the order. Physician DNR Requests Physicians can also enter DNR orders for their patients when it is determined that there would be no medical benefit to administering CPR. Physicians must discuss the DNR order with the patient or the patient's family as long as there is time to do so. Many hospital policies require that two doctors concur on a decision to enter a DNR if the patient is unable to consent to the order. Other Medical Procedures and Care Other therapeutic interventions, including transferring the patient to an intensive care unit, having blood cultures drawn, undergoing central lines placement, and receiving blood transfusions should not be influenced; DNR orders only preclude resuscitative efforts. Revoking and Revising DNR Orders DNR orders should be reviewed periodically and revised if appropriate. Also, patients can elect to revoke DNR orders. If there is doubt about the status of a patient's DNR order, medical personnel should attempt resuscitation” ( orders) Medical Futility: California Probate Code Section 4735 “A health care provider or health care institution may decline to comply with an individual health care instruction or health care decision that requires medically ineffective health care or health care contrary to generally accepted health care standards applicable to the health care provider or institution” (

38 Ethical Issues in Nursing Practice, Examples
Topics of death and dying, DNR:Do-Not-Resuscitate End-of-life care issues Quality versus quantity of life Palliative care issues Advance directives Compromised standards Medical futility Withdrawal of food/fluid Social justice/injustice Reporting/Not reporting compromised co-workers Religious beliefs These ethical issues commonly form the basis for moral distress in nursing practice.

39 Ethical Issues in Nursing Practice Cont.
Scarcity of resources Downsizing Technological advancements Genetics Abuse: elder, child, physical, financial or emotional Euthanasia Assisted suicide Abortion Drug abuse Organ donation, harvesting, stem-cell

40 Ethical Reflection Ethical decision-making involves reflection on the following questions; “Who should make the choice? What are the possible courses of action? What are the available options or alternatives? What are the consequences, both good and bad, of all possible options? Which rules, obligations, and values should direct choices? What are the desired goals and outcomes? (Guido, 2006, p. 8)” Ref: Guido, 2010, p. 16.

41 Moral Model 1. Massage the dilemma (identify involved parties and define issues) 2. Outline the options (examine all + and – options, pros/cons) 3. Resolve the dilemma (decide best option) 4. Act by applying option (most difficult step) 5. Look back/evaluate the process Class Room Exercise. Exercise 2.1 in Guido, 2010, p. 17. Read scenario and apply moral model. Identify which provisions of the nursing code of ethics with interpretive statements (2001) guide resolving the dilemma? Ethical dilemma— you need to identify who are the participants involved and what are the ethical issues? In this scenario—patient has the right to make her own decision—but family and healthcare physicians each have different ideas for the patient. Nursing Code of Ethics with Interpretive Statements (2001): Provision 1—patient has the right to self-determination, be made aware of what is going on—be talked with—not omitted from conversations—informed decision-making Provision 2—nurses have a primary duty to the patient—collaborate with other health care members to talk with patient—not omit her from realistic treatment suggestions/plans Provision 3—the nurse must promote the patient’s rights. The nurse advocates for the patient. What does patient want-----”to die with dignity” Provision 8—the nurse collaborates with all health care team members—putting patient at core of discussions

42 Ethics and Human Rights Issues
Debate Classroom Session—Pros and Cons—ANA Position; Ethical Principle, California Laws, if applicable. Foregoing Nutrition and Hydration Medical Futility Active Euthanasia, Assisted Suicide Social Justice Abortion Resources: and  Guido, G. (2010). Legal and ethical issues in nursing (5thed.). New ersey: Pearson Hall. Official ANA Position Statements “A position statement is an explanation, a justification or a recommendation for a course of action that reflects ANA’s stance regarding the concern. The development process for position statements initially involves internal deliberation by the Congress on Nursing Practice and Economics. A draft of the proposed position statement is then posted on ANA’s Web site, for public comment. Following public comment, the statement is revised if necessary and approved by the ANA Board of Directors. This process allows each and every nurse to voice their views and opinions on the various dimensions of the issue at hand.  Position statements expire or are retired by the organization when appropriate.” Retrieved from

43 Module Summary Moral development, reasoning, and accountability are on-going processes. …professionals’ ethical practice and ethical decision making remain a highly individualistic intuitive, and common sense process rather than one well-reasoned and well-informed” (Ketefian, 1981, p. 98). ”Nurses are faced daily with ethical dilemmas in which they must make a decision. The decisions they will make will be affected by so many factors including principles learned in school and their own personal beliefs, values and experience. Are these choices “right or wrong?”” Retrieved from:

44 Module Summary Cont. Communication is a strong variable in how nurses’ make ethical decisions Nurses’ duties—oneself, professional (patients and institution), and societal American Nurses’ Association Code of Ethics with Interpretive Statements (2001)—duty to oneself—in Provision 5. American Association Colleges of Nursing (AACN) (2008) Developed the Essentials for Baccalaureate Education document stating the nursing student must learn “…to reflect on one’s own beliefs and values as they relate to professional practice” (p. 5) Guido (2010) summarized duty to oneself by stating “Understanding one’s ethics and values is the first step in understanding the ethics and values of others and in assuring the delivery of appropriate nursing care” (p. 4)

45 Reference List AACN (2008). Public Policy Position Paper on Moral Distress. Retrieved from: AACN (2008). 4 A’s to Rise Above Moral Distress Handbook; 4 A’s to Rise Above Moral Distress Toolkit and Bibliography. Retrieved from: and

46 Reference List Cont. Aiken, T. (2004). Legal, ethical and political issues in nursing (2nd ed.). Philadelphia: F.A. Davis American Nurses Association (ANA). (2001). Code of ethics for nurses with interpretive statements. Washington, DC: American Nurses Publishing.  Bosek, M. & Savage, T. (2007). The ethical component of nursing education: Integrating ethics into clinical experience. Philadelphia: Lippincott Williams & Wilkens  Butts, J. & Rich, K. (2005). Nursing ethics across the curriculum and into practice. Boston: Jones and Bartlett.

47 Reference List Cont. Carmel, S., Werner,p., & Ziedenberg, H. (2007). Physicians’ and nurses’ preferances in using life-sustaining treatments. Nursing Ethics 14(5), Clavreul, G. (2008). A question of nursing ethics. Retrieved from: Crain, W. (1985). Kohlberg’s stages of moral development. Theories of development (19 pages). New Jersey: Prentice-Hall. Decasterie, B., Grypdonck, M., Vuylsteke-Wauters, M., & Janssen, P. (1997). Nursing students’ responses to ethical dilemmas in nursing practice. Nursing Ethics 4(1), 12-28 DeCasterle, B., Izumi, S., Godfrey, N., & Denhaaerynck, K. (2008). Nurses’ responses to ethical dilemmas in nursing practice: meta-analysis. Journal of Advanced Nursing 63 (6), Duckett, l., Rowan, M., Ryden, M., Krichbaum, K. et al. (1997). Progress in the moral reasoning of baccalaureate nursing student between program entry and exit. Nursing Research 46 (4),

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54 Ethical Issues Legal Websites
Abortion: Retrieved from: Advanced Directive: Retrieved from Assisted Suicide: Retrieved from: Elder Abuse Laws: California Elder Abuse Laws Ca Penal Code 368 PC Euthanasia: Retrieved from:

55 Ethical Issues Legal Websites cont.
Do-Not-Resuscitate Orders: Retrieved from: Medical Futility: Retrieved from:

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