1. Rural Bioethical Situations: Resources for Informing Public Health Providers and Students Angeline Bushy, PhD, RN, FAAN, PHCNS-BC University of Central Florida College of Nursing Angeline.bushy@ucf.edu

2. OBJECTIVES The participant will be able to: Articulate feature of the rural context and its impact on ethical situations. Articulate feature of the rural context and its impact on ethical situations. Identify the impact of ethics conflicts on rural health care organizations. Identify the impact of ethics conflicts on rural health care organizations. Discuss approaches for anticipating and decreasing ethics conflicts. Discuss approaches for anticipating and decreasing ethics conflicts. List at least two resources to address ethics conflicts in the rural context. List at least two resources to address ethics conflicts in the rural context.

3. What is Bioethics? Branch of applied philosophy that deals with moral issues in the health professions Branch of applied philosophy that deals with moral issues in the health professions Attempts to answer the question; “What is right” with regard to human behaviors in matters of life and death Attempts to answer the question; “What is right” with regard to human behaviors in matters of life and death Implies that a judgment should be made about rightness/ wrongness or goodness/badness of a given medical or scientific practice Implies that a judgment should be made about rightness/ wrongness or goodness/badness of a given medical or scientific practice

4. What is Rural Health Care Bioethics? Focuses on how the unique rural context influences the: presentation of ethical challenges response to those challenges. Reflects on ethical issues encountered in the unique environment of rural settings

5. Common(Bio)Ethical Situations Informed consent Informed consent Proxy Proxy Withholding & with drawl of life support Withholding & with drawl of life support Confidentiality Confidentiality Justice in the distribution of healthcare resources Justice in the distribution of healthcare resources Advances in medical technologies/therapies Advances in medical technologies/therapies Advanced directives (individual versus family versus provider preferences/understanding) Advanced directives (individual versus family versus provider preferences/understanding) Costs versus benefits of services/care Costs versus benefits of services/care Intra/inter professional competence issues Intra/inter professional competence issues Other relative to PH and rural practice/context ? Other relative to PH and rural practice/context ?

6. Characteristics of Rural Compared to more populated areas rural has: Small/low population density Small/low population density Few personnel in local health department Few personnel in local health department Overlapping personal & professional relationships Overlapping personal & professional relationships Isolation; great distances between resources; professionals Isolation; great distances between resources; professionals Few specialists Few specialists Small hospitals (many 25 beds or less) Small hospitals (many 25 beds or less) Close-knit relationships; interdependence; self-reliance Close-knit relationships; interdependence; self-reliance Economic climate; higher rates of uninsured; lower per person/family income; OSHA defined hazardous occupations Economic climate; higher rates of uninsured; lower per person/family income; OSHA defined hazardous occupations Poor(er) health status Poor(er) health status Limited ethics resources ( rural-focused literature, ethicists, education, ethics/IRB committees) Limited ethics resources ( rural-focused literature, ethicists, education, ethics/IRB committees)

7. Features Rural Context(s) Diversity Diversity Overlapping relationships Overlapping relationships Disease stigma Disease stigma Values and preferences Values and preferences Diffuse role boundaries Diffuse role boundaries Privacy and confidentiality Privacy and confidentiality Local versus outside preference for support Local versus outside preference for support

8. Moving Ethics Upstream... Promoting ethical awareness among staff/community Promoting ethical awareness among staff/community Facilitating ethical discussions (intra/inter professional) Facilitating ethical discussions (intra/inter professional) Examining actual and potential ethical cases Examining actual and potential ethical cases Identifying relevant ethical resources Establishing ethical practice guidelines Directing activities to enhance the quality of care and the organization’s overall culture Monitoring effects of bioethical educational initiatives Monitoring effects of bioethical educational initiatives

9. (Bio)Ethics Resources Web-based resources Web-based resources Growing number of publications on rural bioethics Growing number of publications on rural bioethics Little written relative to ethics in rural Public Health practice settings Little written relative to ethics in rural Public Health practice settings Needed case studies and best practice rural ethics awareness, education and decision models Needed case studies and best practice rural ethics awareness, education and decision models

10. http://dms.dartmouth.edu/cfm/resources/rhc/

11. http://dms.dartmouth.edu/cfm/resources/manual/manual.pdf

13. Implications for Rural Public Health Professionals Integrate rural ethics content in PH professional education Integrate rural ethics content in PH professional education Implement Ethics & IRB Committees in rural communities Implement Ethics & IRB Committees in rural communities Facilitate ethics awareness among rural residents Facilitate ethics awareness among rural residents Disseminate information on rural PH ethics initiatives Disseminate information on rural PH ethics initiatives Publish rural PH bioethical case scenarios to inform educators Publish rural PH bioethical case scenarios to inform educators

14. Summary Potential and actual ethics ethics issues frequently encountered in rural and urban PH settings Potential and actual ethics ethics issues frequently encountered in rural and urban PH settings Ethics issues are influenced by the rural context Ethics issues are influenced by the rural context Ethical issues have an impact on allocating resources & quality of care Ethical issues have an impact on allocating resources & quality of care Go beyond reacting to Go beyond reacting to ethics conflicts; PH professionals/students must move upstream to decrease ethics conflicts

15. References Bushy A. (2011). ANA-CE Program- Rural nursing: Practice and issues. Accessed on June 7, 2011 at: http://nursingworld.org/mods/mod700/rurlfull.htmhttp://www.nursingworld.org/ mods/mod700/rurlfull.htm Bushy A. (2011). ANA-CE Program- Rural nursing: Practice and issues. Accessed on June 7, 2011 at: http://nursingworld.org/mods/mod700/rurlfull.htmhttp://www.nursingworld.org/ mods/mod700/rurlfull.htm Cook A & Hoas H. (2008). Ethics and rural healthcare: What really happens, what might help? American Journal of Bioethics, 8(4), 52-56. Cook A & Hoas H. (2008). Ethics and rural healthcare: What really happens, what might help? American Journal of Bioethics, 8(4), 52-56. Cook A & Hoas H. (2008). Revisiting ethics and rural healthcare: What really happens, what might help? American Journal of Bioethics. In Focus. Accessed on June 3, 2011 at: http://www.informaworld.com/smpp/section?content=a794419479&fulltext=713 240928 Cook A & Hoas H. (2008). Revisiting ethics and rural healthcare: What really happens, what might help? American Journal of Bioethics. In Focus. Accessed on June 3, 2011 at: http://www.informaworld.com/smpp/section?content=a794419479&fulltext=713 240928 Bushy A. (2006). Nursing in rural and frontier areas: Issues, challenges and opportunities. Harvard Health Policy Review, 9(1), 17-27. Bushy A. (2006). Nursing in rural and frontier areas: Issues, challenges and opportunities. Harvard Health Policy Review, 9(1), 17-27. Grady C, Danis M, Farrar A, O'Donnell P, Soeken K, et al. (2008). Does ethics education influence the moral action of practicing nurses and social workers? American Journal of Bioethics, 8(4), 4-11. Grady C, Danis M, Farrar A, O'Donnell P, Soeken K, et al. (2008). Does ethics education influence the moral action of practicing nurses and social workers? American Journal of Bioethics, 8(4), 4-11.

16. Nelson B, Pomerantz A, Howard K & Bushy A. (2007). A proposed rural health care ethics agenda. Journal of Medical Ethics, 33, 136-139. Nelson B, Pomerantz A, Howard K & Bushy A. (2007). A proposed rural health care ethics agenda. Journal of Medical Ethics, 33, 136-139. Nelson, W (Ed). (2009). Handbook for rural health care ethics: A practical guide for professional. Accessed on line June 7, 201 at: http://dms.dartmouth.edu/cfm/resources/ethics/chapter-00.pdf Nelson, W (Ed). (2009). Handbook for rural health care ethics: A practical guide for professional. Accessed on line June 7, 201 at: http://dms.dartmouth.edu/cfm/resources/ethics/chapter-00.pdf http://dms.dartmouth.edu/cfm/resources/ethics/chapter-00.pdf Nelson, W. & Schifferdecker K (2009). Rural health care ethics: A manual for trainers. Accessed on line June 7, 2011 at: http://dms.dartmouth.edu/cfm/resources/manual/manual.pdf Nelson, W. & Schifferdecker K (2009). Rural health care ethics: A manual for trainers. Accessed on line June 7, 2011 at: http://dms.dartmouth.edu/cfm/resources/manual/manual.pdf http://dms.dartmouth.edu/cfm/resources/manual/manual.pdf Nelson W, Greene M & West A. (2010). Rural Health Care Ethics: No Longer the Forgotten Quarter of Medical Ethics. Cambridge Quarterly for Healthcare Ethics, 19(4), 510-517. Nelson W, Greene M & West A. (2010). Rural Health Care Ethics: No Longer the Forgotten Quarter of Medical Ethics. Cambridge Quarterly for Healthcare Ethics, 19(4), 510-517. Pavlish C, Brown-Saltzman K, Hersh M, et al. (2011). Early indicators and risk factors for ethical issues in clinical practice. Journal of Nursing Scholarship, 43(1), 13-21. Pavlish C, Brown-Saltzman K, Hersh M, et al. (2011). Early indicators and risk factors for ethical issues in clinical practice. Journal of Nursing Scholarship, 43(1), 13-21. Larson K & Elliot R. (2010). The emotional impact of malpractice. Nephrology Nursing Journal, 37(2), 153-155. Larson K & Elliot R. (2010). The emotional impact of malpractice. Nephrology Nursing Journal, 37(2), 153-155. Schlairet M. (2009). Bioethics mediation: The role and importance of nurse advocacy. Nursing Outlook. 77, 185-193. Schlairet M. (2009). Bioethics mediation: The role and importance of nurse advocacy. Nursing Outlook. 77, 185-193.

17. Questions???

18. Presenter Disclosures Angeline Bushy No relationships to disclose