Chapter 20: Ethical/Legal Principles and Issues

Learning Objectives Define key ethical constructs as they relate to the care of geriatric patients. Relate concepts of ethics to their implications in the care of geriatric patients. Recognize the influence of personal values, attitudes, and expectations about aging on care of older adults and their families/extended families.

Learning Objectives (cont’d) Analyze the impact of fiscal, sociocultural, and medico-legal factors on decision making in the care of geriatric patients. Identify strategies for facilitating appropriate levels of autonomy and supporting the right to self-determination decisions in the care of geriatric patients.

Case study: ethical or moral dilemma An 80 year old patient in the nurse’s care just emphatically told her during the admission process that he does not wish any life prolonging procedures to be done if he should “code”. The nurse leaves the room to begin the appropriate referrals and paperwork for advance directives. When she returns, the patient is not breathing and has no pulse.

Case study questions What should the nurse do? What is the nurse bound legally to do? What ethical principles are in conflict in the given situation? What other options does the nurse have to uphold the patient’s autonomy? Are there any foreseeable problems in this situation?

Moral vs Ethic Used inter changeably. Moral is principles with respect to right or wrong conduct and is from personal principles. Ethics is the rules of conduct and is from social system Ex1) Nurses have to follow an ethical code laid down their profession, regardless of their own feelings or preferences. Ex2) A doctor or nurse may not euthanize a pt. even at the pt’s request as per ethical standards for health professional. However, the same doctor or nurse may personally believe in a pt’s right to die, as per the nurse’s own morality.

Ethical/Legal Principles and Issues Ethics of care in the geriatric population is complex and challenging Nursing Practice requires mindfulness of a person’s autonomy within changing capacity Ethical/Moral Principles Advocacy Autonomy Beneficence/ nonmaleficence Confidentiality Fidelity Fiduciary responsibility Justice Quality of life Reciprocity Sanctity of life Veracity

Conflict and Dilemma Ethical conflict occurs when a choice must be made between 2 equal possibilities. 3 types of moral conflict: moral distress, moral uncertainty, and moral dilemma. Moral distress When someone wants to do the right thing but is limited by constraints of organization or society.

Conflict and Dilemma (cont’d) Moral uncertainty Confusion in situations when a person is uncertain what the moral problem is or which moral principles or values apply to it. Moral dilemma When two or more moral principles apply that support mutually inconsistent actions.

Moral Principles Incorporated into professional code of ethics Advocacy: Loyalty and a championing of the needs and interests of others. Nurses advocate for patients by supporting them in their efforts to retain as much autonomy as their abilities allow. - Protecting the health and safety of clients by communicating needs, promoting safe environments, and helping with assertion of legal rights.

Autonomy: Beneficence: Nonmaleficence Person’s right to make independent decisions Respect for personal liberty, values, beliefs, and choices Ex) advance directive, consent form Beneficence: To do good To prevent or remove harm More proactive than nonmaleficence Ex) palliative care, pain management Nonmaleficence Not to inflict harm or evil, ex) assessing contraindication, stopping meds that is shown to be harmful, Refusing Tx that has not been effective,..

Duty to honor commitments Keeping promises or being true to another Confidentiality Duty not to disclose information shared in a trusted manner or relationship Privacy: duty to respect limited access to a person Health Insurance Portability and Accountability Act (HIPPA) Exceptions) if clients may indicate harm to themselves or others, if the client gives permission for the information to be shared. Fidelity Duty to honor commitments Keeping promises or being true to another Trust is earned, and fidelity is demonstrated in daily work Ex) not giving false assurance

Fiduciary Responsibility Health care professionals have an ethical obligation to good stewardship of both the patient’s and the organization’s fund Justice Providing equal care for all patients Fairness of an act or situation Ex) matter of who gets what (organ donation) Veracity Truthfulness Not misleading patients or their families Duty to be honest, tell the truth, not deceive others

Reciprocity: Golden rule. A feature of integrity concerned with the ability to be true to one’s self while respecting and supporting the values and views of another. Passive resistance does not support reciprocity. If a nurse cannot demonstrate reciprocity, another should take his or her place in the care of the patient.

Moral Principles Informed consent Elements to include in discussion The specific condition requiring treatment The purpose and distinct nature of the procedure or treatment Potential complications or risks associated with the procedure or treatment Reasonable alternatives with a discussion of their relative risks and benefits Discussion of the option of taking no action The probability of success of the recommended treatment or procedure

Patient Rights Patient rights direct actions on ethical issues in the care of geriatric populations The Patient Self-Determination Act of 1990: patients are provided the opportunity to express their preferences regarding life-saving or life-sustaining care on entering any healthcare service, including hospitals, long term care centers, and home care agencies. -Terri Shiavo case

Patient Rights Advance directives and living wills Advance directive: describe actions to be taken if the patient is no longer able to provide informed consent Living will: direct preferences for end-of-life care issues, providing an “if I am terminally ill and not expected to recover, then ...” plan Durable power of attorney Legal document designating alternative decision maker in the event the person is incapacitated: health & financial issue

Patient Rights Competence Assisted suicide (p.727) Mental clarity and appropriateness for decision making based on a mental status exam Required for persons to exercise autonomy and right to decide Assisted suicide (p.727) Violation of the Code of Ethics for Nurses Oregon: Death with Dignity Act (1997) California: the End of Life Option Act took effect on June 9, 2016 Oregon, Vermont, Washington, Montana, CA allow death with dignity.

Ethics in Practice Medical errors Considerable effort has been put into reducing mistakes and improving patient safety. Average hospital patient can expect to be subjected to at least one medication error per day QSEN (Quality and Safety Education for Nurses)

Summary Nurses respect the worth, dignity, and rights of the elderly as they provide care that meets their patients’ comprehensive needs across the life span continuum. Scope and Standards of Practice (ANA) Framework for ethical decision making provides a foundation for discussion when dilemmas arise, smoothing the way for integrity-saving compromise.