Chapter 22 Ethics and Values •This chapter describes tools for you to use to embrace the role of ethics in your professional life and to participate and promote resolution when ethical dilemmas develop. •This chapter also shows that clarifying values—your own, your patients’, your coworkers’—is an important and effective part of ethical discourse.

Ethics and Values Defined The study of conduct and character. It is concerned with determining what is good or valuable for individuals and society at large. Values Personal beliefs about the worth of a given idea, attitude, custom, or object that set standards that influence behavior. Ethics •Acts that are ethical reflect a commitment to standards beyond personal preferences (i.e., standards that individuals, professions, and societies strive to meet). •Using a standard process to think through ethical dilemmas helps nurses deal with ethical issues. •A code of ethics provides a foundation for professional nurses. In this chapter, we will learn about and discuss the code of ethics established by the American Nurses Association (ANA). Values •The values that an individual holds reflect cultural and social influences; not only do these values vary among people, they develop and change over time. Value formation begins in childhood and is shaped by experiences. •Inevitably you will work with patients and colleagues whose values differ from yours. •To negotiate differences of opinion and values, it is important to be clear about your own values: what you value, why, and how you respect your own values, even as you try to respect those of others whose values differ from yours. •The process of values clarification helps you to explore values and feelings and decide how to act on personal beliefs and respect the values of others, even if they differ from your own.

Basic Terms in Health Ethics Autonomy Commitment to include patients in decisions Beneficence Taking positive actions to help others Nonmaleficence Avoidance of harm or hurt Justice Being fair Fidelity Agreement to keep promises •Ethics describes right and wrong behaviors. •Ethical issues differ from legal issues. Legal issues will be discussed in Chapter 23. •Standards of ethics in health care include autonomy, beneficence, nonmaleficence, justice, and fidelity. •Respect for autonomy refers to the commitment to include patients in decisions about all aspects of care as a way of acknowledging and protecting a patient’s independence. •The principle of beneficence is fundamental to the practice of nursing and medicine. •Maleficence refers to harm or hurt; thus nonmaleficence is the avoidance of harm or hurt. In health care, ethical practice involves not only the will to do good, but an equal commitment to do no harm. •Justice refers to fairness. It is used most often in discussions about access to health care resources, including the just distribution of resources. •As a nurse, you keep promises by following through on your actions and interventions.

Professional Nursing Code of Ethics A set of guiding principles that all members of a profession accept Helps professional groups settle questions about practice or behavior Includes advocacy, responsibility, accountability, and confidentiality •The American Nurses Association (ANA) code of ethics provides a foundation for professional nursing. •A code of ethics can be defined as a collective statement about the group’s expectations and standards of behavior. •The ANA established the first code of nursing ethics decades ago. •The ANA reviews and revises the code regularly to reflect changes in practice. However, basic principles of responsibility, accountability, advocacy, and confidentiality remain constant. [The ANA Code of ethics, from Box 22-1 (on text p. 287), is covered on the next slide.] •Advocacy refers to the support of a particular cause. Responsibility refers to willingness to respect obligations and to follow through on promises. •Accountability refers to the ability to answer for one’s own actions. Standards are set by The Joint Commission and the ANA. Health care facilities have compliance officers who are responsible for making sure that the institution remains in compliance with standards and regulations. •The concept of confidentiality is well established. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandates protection of the patient’s personal health information.

The ANA Code of Ethics 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. 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. [Box 22-1 (on text p. 287) covers the entire ANA Code of Ethics (the first and summary paragraphs are shown on the slide)]. [Have one of the nursing students read the first paragraph. Then review the specific points below before covering the summary paragraph (second bullet on the slide) after a student reads the paragraph.] •Following are the specific points of the code: •The nurse’s primary commitment is to the patient, whether an individual, family, group, or community. •The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient. •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. •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. •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. •The nurse participates in advancement of the profession through contributions to practice, education, administration, and knowledge development. •The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs. (Copyright © 2001 Code of Ethics for Nurses with Interpretive Statements. By American Nurses Association. Reprinted with permission. All rights reserved.)

Case Study Anna Moreno is an 82-year-old African American widow and retired schoolteacher. She lives with her 55-year-old daughter and three teenage grandchildren. Her daughter Lucille is a single mother and a full-time nurse. Anna assists with the care of her grandchildren when her daughter is at work. She also volunteers at the library and at her church. She has diabetes and high blood pressure, both controlled with diet and medication. [This case study will be presented in several sections throughout this presentation. Encourage discussion with nursing students of each section of the case study. After the entire case study has been presented, the slide presentation will include a summary of the case study as it relates to nursing philosophies and perspectives on ethics and values.] •What have we learned so far? •Who in this case study is likely to need further health care in the near future?

Quick Quiz! 1. Your patient is about to undergo a controversial orthopedic procedure. The procedure may cause periods of pain. Although nurses agree to do no harm, this procedure may be the patient’s only treatment choice. This example describes the ethical principle of A. Autonomy. B. Fidelity. C. Justice. D. Nonmaleficence. Answer: D [Discuss.]

Ethics and Philosophy Deontology Defines actions as right or wrong Utilitarianism Proposes that the value of something is determined by its usefulness Feminist Ethics Focuses on the inequality between people Ethics of Care Emphasizes the importance of understanding relationships, especially as they are revealed in personal narratives •Historically, health care ethics constituted a search for fixed standards that would determine right action. Ethics has grown into a complex field of study, more flexible than fixed, filled with differences of opinion and deeply meaningful efforts to understand human interaction. •These philosophies, or theories on ethics, provide a foundation for developing strategies to use when an ethical dilemma occurs: •Deontology: proposes a system of ethics that is perhaps most familiar to health care practitioners. Deontology defines actions as right or wrong based on their “right-making characteristics,” such as fidelity to promises, truthfulness, and justice. •Utilitarianism: A utilitarian system of ethics proposes that the value of something is determined by its usefulness. This philosophy is also known as consequentialism because its main emphasis is on the outcome or consequence of an action. A third term associated with this philosophy is teleology, from the Greek word telos, meaning “end,” or the study of ends or final causes. The greatest good for the greatest number of people is the guiding principle for determining right action in this system. •Feminist Ethics: Feminist ethics critiques conventional ethics such as deontology and utilitarianism. It looks to the nature of relationships to guide participants in making difficult decisions, especially relationships in which power is unequal, or in which a point of view has become ignored or invisible. Writers with a feminist perspective tend to concentrate more on practical solutions than on theory. Feminist ethicists propose that the natural human urge to be influenced by relationships is a positive value. •Ethics of Care: The ethics of care and feminist ethics are closely related. Both promote a philosophy that focuses on understanding relationships, especially personal narratives. An early proponent of the ethics of care used the term the one-caring to identify the individual who provides care, and the cared-for to refer to the patient or patients. In adopting this language, the author hoped to emphasize the role of feelings.

Case Study (cont’d) Lucille accompanies her mother to the physician’s office for a routine visit. When her mother steps out to have some lab work done, Lucille asks to speak privately to the nurse, Mary Ann, and reveals some serious concerns. Lucille had received a call from the manager of the library where her mother volunteers. The manager described finding Ms. Moreno in the janitor's closet one day, confused and tearful.  [Ask the class: What is your initial reaction to this situation? Discuss.]

Nursing and Values Ethical dilemmas almost always occur in the presence of conflicting values. To resolve ethical dilemmas, one needs to distinguish among values, facts, and opinion. Sometimes people have such strong values that they consider them to be facts, not just opinions. Sometimes people are so passionate about their values that they provoke judgmental attitudes during conflict. •Ethical problems arise in the presence of differences in values, changing professional roles, technological advances, and social issues that influence quality of life. •Nursing practice requires you to be in contact with patients physically, emotionally, psychologically, and spiritually. •In most other intimate relationships, you choose to enter the relationship precisely because you anticipate that your values will be shared with the other person. •But as a nurse, you agree to provide care to your patients solely on the basis of their need for your services. •As a nurse, you will need to respect your own values even as you try to respect those of others whose values differ from yours.

Values Clarification Statement Rank Preparing for the future is an important activity and reflects maturity. 1 2 3 4 Life has a predestined course. The individual should follow that course. Vague answers are dishonest and confusing. Vague answers are sometimes preferred because they avoid embarrassment and confrontation. Punctuality and efficiency are characteristics of a person who is both intelligent and concerned. Punctuality is not as important as maintaining a relaxed atmosphere, enjoying the moment, and being with family and friends. When in severe pain, it is important to remain strong and not to complain too much. When in severe pain, it is better to talk about the discomfort and express frustration. Statement Rank Preparing for the future is an important activity and reflects maturity. 1 2 3 4 Life has a predestined course. The individual should follow that course. Vague answers are dishonest and confusing. Vague answers are sometimes preferred because they avoid embarrassment and confrontation. Punctuality and efficiency are characteristics of a person who is both intelligent and concerned. Punctuality is not as important as maintaining a relaxed atmosphere, enjoying the moment, and being with family and friends. When in severe pain, it is important to remain strong and not to complain too much. When in severe pain, it is better to talk about the discomfort and express frustration. •The process of values clarification helps you to explore values and feelings and decide how to act on personal beliefs and respect the values of others, even if they differ from yours. •Ethical problems arise in the presence of differences in values, changing professional roles, technological advances, and social issues that influence quality of life. •We have discussed that ethical dilemmas almost always occur in the presence of conflicting values. To resolve ethical dilemmas, one needs to distinguish among values, facts, and opinions. •Clarifying values is an important and effective part of ethical discourse. •In the process of values clarification, you learn to tolerate differences in a way that often (although not always) becomes the key to resolution of ethical dilemmas. [These points are from the cultural values exercise in Box 22-3 on text p. 289. The statements on the right are opinions. The statements on the left reflect the opposite opinion.] [Ask students to read each statement and reflect on their own values and opinions. Choose 1 if you strongly agree with the statement on the left, 2 if you moderately agree. Choose 4 if you strongly agree with the statement on the right and 3 if you moderately agree. You might ask them to reveal their ratings and discuss them with the class. The remainder of the statements in this exercise are on the next slide.]

Values Clarification (cont’d) Statement Rank Addressing someone by his or her first name shows friendliness. 1 2 3 4 Addressing someone by his or her first name is disrespectful. Direct questions are usually the best way to gain information. Direct questioning is rude and could cause embarrassment. Direct eye contact shows interest. Direct eye contact is intrusive. Ultimately the independence of the individual must come before the needs of the family. The needs of the individual are always less important than the needs of the family. [Remind the class: Each statement is an opinion. Each statement directly across from it reflects the opposite opinion. Choose 1 if you strongly agree with the statement on the left, 2 if you moderately agree. Choose 4 if you strongly agreement with the statement on the right and 3 if you moderately agree. Continue to have students consider the bulleted points on the slide. You might ask them to reveal their ratings and discuss them with the class.] •The values in this exercise conflict are in neutral terms, so you can appreciate how differing values need not indicate “right” or “wrong.” For example, for some people, it is important to remain silent and stoic in the presence of great pain; for others, it is important to talk about it to understand and control it. •Identifying values as something separate from facts can help you find tolerance for others, even when differences among you make you seem worlds apart.

Case Study (cont’d) The manager expressed growing concern about Ms. Moreno’s ability to finish tasks, such as reshelving books and taking phone messages. She recommended that Lucille get an evaluation of her mother’s mental status. Lucille tells the nurse that she is not at all convinced that her mother is having mental problems.  [Ask the class: Why do you think Lucille is convinced that her mother is not having mental problems? Who do you think is in the best position to know whether Ms. Moreno is having problems with her mental health? Discuss.]

How to Process an Ethical Dilemma Step 1: Ask if this is an ethical dilemma. Step 2: Gather all relevant information. Step 3: Clarify values. Step 4: Verbalize the problem. Step 5: Identify possible courses of action. Step 6: Negotiate a plan. Step 7: Evaluate the plan. •Ethical dilemmas cause distress for patients and caregivers. •Resolving an ethical dilemma is in many ways similar to the nursing process, in that it requires a deliberate and systematic plan. •A process for resolving ethical dilemmas that respects differences of opinion and all participants equally helps health care providers resolve conflict about right actions. •These seven steps will guide you through assessment, planning, implementation, and evaluation of an ethical dilemma. [See also Box 22-4 on text p. 291, which presents guidelines on how to process an ethical dilemma. Discuss these steps with students.]

Institutional Resources Ethics committees are usually multidisciplinary and serve several purposes: education, policy recommendation, and case consultation. Any person involved in an ethical dilemma, including nurses, physicians, health care providers, patients, and family members, can request access to an ethics committee. Health care institutions establish ethics committees to process ethical dilemmas. Nurses provide insight about ethical problems at family conferences, at staff meetings, and even in one-on-one meetings. Many ethical problems begin when people feel misled or are not aware of their options and do not know when to speak up about their concerns. Ethics committees serve to complement relationships within the workplace and the community and offer a valuable resource for strengthening these relationships. •A process for resolving ethical dilemmas that respects differences of opinion and all participants equally helps health care providers resolve conflict about right actions.

Issues in Health Care Ethics Quality of life: central to discussions about end-of-life care, cancer therapy, physician-assisted suicide, and DNR Genetic screening: What are the risks and benefits to individuals and to society of learning about the presence of a disease that has not yet caused symptoms, or for which a cure is not yet available? Care at the end of life: interventions unlikely to produce benefit for the patient Access to care: As a nurse, you will certainly deal with ethical issues related to access to care. •These four professional ethical/bioethical issues will influence your and the care you give your patients: quality of life, genetic screening, care at the end of life, and access to care. [Discuss the first three issues with the students. Access to care is discussed further on the next slide.]

Ethics and Access to Care The number of uninsured in the United States grew from 39 million people in 2000 to more than 46.3 million people by 2008—more than 15% of the total population. Many of the uninsured are women and children. Although two thirds of the uninsured are poor, nearly 80% come from working families. •Access to care and health care reform may seem distantly related to your daily job or to a specific patient care assignment. But as a nurse, you will certainly deal with ethical issues related to access to care. Another way to frame this problem is how to allocate scarce resources. •You may care for a patient about to be discharged from the hospital when you find that he or she cannot afford to fill a prescription. •Do you advocate for a delay in discharge? •Do you have time to find financial resources to subsidize the prescription costs? •Your involvement with issues such as these and others requires dedication to your professional ethics, a personal commitment to continuing education, and continuing engagement. •The courage and intelligence to act as both an advocate for patients and a professional member of the health care community come from a committed effort to learn and understand ethical principles. •As a professional nurse, you provide a unique point of view regarding patients, the systems that support patients, and the institutions that make up the health care system. •You have a duty and a privilege to articulate that point of view. •Learning the language of ethical discourse is part of the skill necessary to exercise this privilege. •Review and consideration of various ethical principles helps you form personal points of view—a necessary factor in the negotiation of difficult ethical situations.

Quick Quiz! 2. If a nurse decides to withhold a medication because it might further lower the patient’s blood pressure, the nurse will be practicing the principle of A. Responsibility. B. Accountability. C. Competency. D. Moral behavior. Answer: B [Discuss.] 22 - 18

Nurses Collaborate With Other Professionals Consensus building: an act of discovery in which “collective wisdom” guides a group to the best possible decision A nurse’s point of view offers a unique voice in the resolution of ethical dilemmas. •Nurses collaborate with other professionals in making ethical decisions. The nurse’s point of view offers a unique voice in the resolution of ethical dilemmas. •When nurses are faced with ethical decisions, it is important to realize that these decisions most often are made by collaborating with others. •We have discussed that patients spend more time with nurses than with any other health care providers, and that patients and their families may feel safer or more comfortable in revealing information not always shared with physicians, health care providers, or others, and that this is one of the reasons why a nurse’s point of view is so valuable. However, it is important to remember that care of any patient involves many disciplines. •Managers and administrators from many different professional backgrounds contribute to ethical discourse with their knowledge of systems, distribution of resources, financial possibilities, and limits. •Bringing different points of view to agreement and harmony, or consensus, requires skill and patience. •Building consensus encourages respect for unusual points of view while striving for agreement among all participants. •As a strategy for solving dilemmas, consensus building promotes respect and agreement rather than a particular philosophy or moral system itself. [Shown is Figure 22-1 from text p. 290 (Copyright 2007 Jupiter Images Corporation).]

Culturally Competent Care: End-of-Life Decisions Acknowledgment of and respect for cultural differences Willingness to negotiate and compromise when world views differ Being aware of one’s own values and biases Using communication skills that enhance empathy Knowing cultural practices of patient groups regularly seen Understanding that all patients are individuals who may not share the same views as others within their own ethnic group [This information is taken from Box 22-2 on text p. 288.] •These are the ground rules for culturally competent care, as proposed by the American College of Physicians. •Culturally competent care requires respect and patience. •Research about end-of-life care shows that the standard of autonomous decision making is not necessarily universal. •Some older-adult patients may defer to their children to make decisions for them as a sign of respect. •Some patients defer to a group elder to make decisions, even when the patient is competent to make them. •Although respect for autonomy has a strong presence in Western philosophy, especially in health care ethics, other cultures may express a preference for group process in making important decisions. [Discuss cultural differences in making end-of-life decisions.]

Case Study (cont’d) From Mary Ann’s perspective, Lucille seems angry and defensive about the manager’s report. She even accuses the manager of discrimination against older adults. She adamantly refuses offers of a physical or mental evaluation for her mother, or even to discuss the issues with her mother. Instead, she requests that the nurse write a letter that validates her mother’s good health. •What do you think about Lucille’s reaction? Do you agree with Mary Ann? •What do you think Mary Ann will do? [Discuss.]

Moral Distress Moral distress describes the anguish experienced when a person feels unable to act according to closely held core values. Because moral distress is a shared experience, efforts to alleviate distress are most successful when they are also shared. [Box 22-5 on text p. 292 covers Moral Distress.] •In this study, the PICO question was as follows: Which actions serve to diminish distress and promote compassionate care for nurses experiencing moral distress when caring for dying patients? •Fully 45% of nurses interviewed for this study considered leaving their positions to alleviate the burden of moral distress (Hamric, 2007). •Evidence from interviews with nurses and physicians in 14 intensive care units (ICUs) revealed that physicians are as capable of experiencing moral distress as are nurses. •For both nurses and physicians, the highest levels of distress were experienced when caregivers felt pressured to continue unwarranted aggressive treatments for patients in the ICU. •To alleviate moral distress, the authors of this study recommend the following: •Interdisciplinary ethics education, in which nurses and physicians learn together about ethical discourse •Sharing stories about professional perspectives regarding difficult clinical decisions •Increasing opportunities for collegial practice such as routine multidisciplinary rounds •Recurrent situations of moral distress indicate underlying systemic problems of poor communication, inadequate collaboration, and perceived powerlessness and must be addressed if nurses and physicians are to minimize this phenomenon in clinical settings (Ulrich, Hamric, and Grady, 2010). •Willingness to speak up if you experience moral distress takes courage, but engaging in constructive conversation is key to the management of moral distress in the workplace.

Ethical Issues on Aging Older people usually are not as familiar with the concept of autonomy as are people from younger generations. As people age, they develop clinical conditions that affect the communication process. Some patients become incapacitated by stroke or disease. Most older adults take multiple medications, some of which affect cognitive skills in subtle ways. Consensus about medical goals for the older adult is hard to achieve. [This slide reviews ethical issues on aging from Box 22-6 on text p. 293.] •When an aging patient is at the end of life, issues may be complicated by his or her ability to make competent decisions because of dementia, Alzheimer’s disease, or stroke. •How and when to respect the wishes of older patients whose cognitive capacities are in doubt or dispute can complicate clinical decisions and necessitate ethical discourse. •Because older people usually are not as familiar with the concept of autonomy as are people from younger generations, older adults are sometimes uncomfortable disagreeing with physicians, health care providers, or nurses. They view assertiveness as a violation of trust. It is important to evaluate the competence of a patient to make decisions and to provide assistance when necessary, especially when treatment choices conflict or ethical issues arise. When is a person so diminished by old age that a treatment plan not only prolongs life but also prolongs suffering? Working to ensure dignity and comfort is as important as achieving medical success (Burke and Laramie, 2003).

Quick Quiz! 3. A nurse is working with a terminally ill adult patient. The nurse decides to tell the adult children that they need to decide how to advise their father about taking analgesics during the terminal phase of his illness. This step of processing an ethical dilemma is A. Articulation of the problem. B. Evaluation of the action. C. Negotiation of the outcome. D. Determination of values surrounding the problem. Answer: C [Discuss.]

Case Study (cont’d) After all, Lucille argues, her mother’s blood pressure is normal, and her blood glucose levels are within normal limits. Mary Ann realizes that this situation is complex. She will need to get the help of others to sort out the best response to Lucille’s request. Is this an ethical dilemma for Mary Ann? •Let’s consider the situation that this case presents to the nurse, Mary Ann, in terms of how to process an ethical dilemma. [The steps for processing an ethical dilemma are on Slide 9. You might choose to review them now with students, then return to examine them individually as they relate to this case study, in the following slides. Step 1 is discussed here, Steps 2 and 3 on the next slide, and Steps 4 through 7 and the conclusion on the following slide.] •Step 1: Is this an ethical dilemma? •If a review of scientific data does not resolve the question, if the question is perplexing, and if the answer will have profound relevance for several areas of human concern, then an ethical dilemma exists. •In this case study, Mary Ann is perplexed by her options. She cannot write a letter about Ms. Moreno’s state of health without knowing more, but Ms. Moreno’s daughter refuses to seek more information. •For Mary Ann, an ethical dilemma exists.

Case Study (cont’d) Mary Anne has determined that the situation is an ethical dilemma. Now she must: Step 2: Gather all information relevant to the case. Step 3: Examine and determine her own values and opinions about the issues. •We have seen in Step 1 that Mary Ann has concluded that an ethical dilemma exists. Let’s continue to apply the steps of this process now. •Step 2: Gather all information relevant to the case. •Complete assessment of the facts of the case is critical to an effective decision. An overlooked fact sometimes provides quick resolution, or deeply affects the options available. •Patient, family, institutional, and social perspectives are important sources of relevant information. •In the case of Ms. Moreno, the medical record would provide important information. Other sources might include psychosocial information about Ms. Moreno’s daughter and her children. •Step 3: Examine and determine your own values and opinions about the issues. •Values clarification provides a foundation for clarity and confidence during discussions that are necessary for resolution of a dilemma. Taking this step ensures that you are able to distinguish between your personal values and those of the other participants and allows you to become a more open listener. •If you were the clinic nurse in the case study, how would you feel about elder care, child care, working mothers? [Steps 4 through 7 are covered on the following slide.]

Case Study (cont’d) Step 4: State the problem clearly. Step 5: Consider possible courses of action. Step 6: Negotiate the outcome. Step 7: Evaluate the action. •Step 4: State the problem clearly. •A clear, simple statement of the dilemma is not always easy, but it is essential for the next step to take place. •The immediate dilemma involves the request to validate Ms. Moreno’s competence, without enough information to make an honest assessment. •Step 5: Consider possible courses of action. •To respect all sides of an issue, it is helpful to list potential actions, especially when the list will reflect opinions that conflict. •Actions might include consulting with a social worker and a gerontologist. •Eventually, the course of action will likely involve decisions about Anna Moreno’s ability to continue her work at the library. •Step 6: Negotiate the outcome. •Sometimes courses of action that seem unlikely at the beginning of the process take on new possibility as they are put to rational and respectful consideration. •Negotiation requires a confidence in your own point of view and a deep respect for the opinions of others. •For Anna Moreno and her family, effective negotiation with Anna’s daughter is critical to a positive outcome. •Step 7: Evaluate the action. •The last step in resolving an ethical dilemma involves evaluating the outcomes. Do the interventions provide for a compromise that is acceptable to all? Have the actions taken helped to answer the questions that you identified at the beginning of the process? •An ethical dilemma is often emotionally complicated, so it will be helpful to review the original issues to ensure that the process has worked. •For Anna Moreno, even though the dilemma arose around the request for a letter, other issues were identified and addressed during the process: Ms. Moreno’s possible mental decline, child care issues for Ms. Moreno’s grandchildren, and the fact that her daughter Lucille was refusing outside help. •Mary Ann gathers all the facts and includes others in the process. She collaborates with a social worker and a gerontologist. Together, the three professionals meet with Lucille. When they present their concerns to Lucille in a clear, professional manner, Lucille is able to look at the situation realistically, rather than letting her emotions and fears get in the way. Lucille realizes that her mother does need to undergo testing. •Mary Ann helps Lucille to make the appointments and arrangements for all of the tests that Lucille’s mother needs. Lucille realizes that just pretending that nothing is wrong, or being angry about the situation, is not a solution. The resolution to the ethical dilemma in this case study presented is effective and satisfying. [Discuss.]