1. Chapter 20: Ethical/Legal Principles and Issues

2. 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.

3. 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.

4. 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.

5. 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?

6. 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

7. 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.

8. 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.

9. 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 legla rights.

10. Autonomy: Beneficence: Nonmaleficence
Person’s right to make independent decisions
Respect for personal liberty, values, beliefs, and choices
Beneficence:
To do good
To prevent or remove harm
More proactive than nonmaleficence
Nonmaleficence
Not to inflict harm or evil

11. Confidentiality Fidelity
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)
Fidelity
Duty to honor commitments
Keeping promises or being true to another
Trust is earned, and fidelity is demonstrated in daily work

12. Fiduciary Responsibility
Health care professionals have an ethical obligation to good stewardship of both the patient’s and the organization’s fund
Justice
Treat equals equally and treat those who are unequal according to their needs
Fairness of an act or situation
Veracity
Truthfulness
Not misleading patients or their families
Duty to be honest, tell the truth, not deceive others

13. 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.

14. Question
When a nurse tells a patient the truth about his terminal condition, she is engaging in:
a. beneficence
b. autonomy
c. veracity
d. fidelity

15. 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

16. 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.

17. 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

18. Patient Rights Competence Assisted suicide
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
Violation of the Code of Ethics for Nurses
Oregon: Death with Dignity Act (1997)

19. 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

20. 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.

21. Question
A family member asks the nurse to witness the signing of a Living Will at the bedside of a mentally competent, alert, adult patient. In signing as a witness, the nurse is stating:
the signature of this person was valid and not coerced
the person was mentally competent to sign
the person is terminally ill at the time
a and b only