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ETHICAL DILEMMAS IN NURSING PRACTICET S A LOG L I D OU A R E T I
A S S I STANT P R O F ES S OR
N U RS I NG D E PA RT ME NT
I N T ER NAT I ONA L H E L L ENI C U N I V ERS I T Y
This work is licensed under aCreative Commons Attribution-Non Commercial 4.0 International (CC BY-NC 4.0)
Ethical Dilemmas
Ethical dilemmas are human dilemmas in which an individual
or a group of professionals can envision ethically justified
reasons for taking or not taking a particular act
Ethical theories, principles, and decision-making frameworks
help health professionals think through these issues and
dilemmas
Stanhope M & Lancaster J., 2015
Ethical Dilemmas
Legally correct Legally incorrect
Morally correct Doing so Ethical Dilemma
Morally incorrect Ethical Dilemma Not doing so
Ethical principles
The ethical behavior of health professionals should be guided by four key principles:
Autonomy
It derives from the Greek words "self" and " law“ (literally “self-rule”).The capacity to live according to one's own reasons and motives
Beneficence
The duty of doing what is in the best interest of the patient throughoutthe process of diagnosis and treatment
Nonmaleficence (“Do no harm”)
The obligation an individual has of not causing harm to anyone includingdamage prevention and removal
Justice
Persons (patients) should be treated fairly and equitably. Respecting therights of individuals but also treating all patients in a given situation thesame, regardless of who they are
https://www.ncbi.nlm.nih.gov/books/NBK538279/
Community health care professionals are in close contact with difficult situations such as:
Nurs Ethics. 2009;16(3):340–362, Nursing Ethics 2017 25:2, 133-152
• pain management
• dealing with impending death
• physical disorders – complications
• emotional disorders (despair, anxiety, fear, loneliness) simultaneously with expectations fortreatment of the disease
Ethical problems at the end of lifeEthical dilemmas are related to:
patients' quality of life
diversity of values
euthanasia
cost - effectiveness of treatment
the continuation or discontinuation of therapy
disagreements in decision making
difficulty in accepting the death process from the patient's family
the autonomy- self-disposition of the patient
palliative careDoolen J, York NL, 2007;Høye S & Severinsson E, 2008; Steinberg SM, 2011; Kalafati M &Paikopoulou D, 2011; Menaka, A, et al, 2012;
Karlsson, M., Kasén, A & Wärån-Furu, C, 2017; Van den Bulcke B et al, 2018
In the US the most common ethical dilemmas encountered when providing palliative care are:
truth telling
concern about morphine use due to possiblerespiratory depression in an advanced stagepatient
issues related to parenteral or enteralnutrition and difficulty meeting the needs ofdemented patients
Nilsson et al, 2009; Jones BJ. 2010;Volkert D et al, 2015; Low JA& Ho E, 2017; Watt AD et al 2019
In the UK the most difficult ethical decisions encountered when providing end-of-life care are:
treatment of hypercalcemia
uremia
hypoglycaemia / hyperglycaemia
abnormal liver function
hydration and nutritional care
the use of antibiotics, steroids and analgesics
the care site
the strategies used in emergencies
maintenance or withdrawal of life-sustaining procedures
Taylor H, 2018; Taylor H 2019
Facilitating ethical and legal practice
The Four Box Method
Patient Preferences
Quality of Life Contextual Features
Jonsen et al, 2015
Clinical Indications
Decision making in ethical dilemmas
Patient participation
• Patient ability to participate in decision making (capacity / competency)
• Communication with the environment
• Understanding information
• Situation perception
• Selection documentation
Decision making in ethical dilemmas
Advance directives
Living will: it describes what kind of care the patient wants or does not
want to be offered in specific medical conditions
Durable power of attorney: the patient authorizes a representative to
take decisions on his/her behalf
ARCHIVES OF HELLENIC MEDICINE 2010, 27 (1): 18-36; Can Fam Physician. 2015 Apr; 61(4): 353–356
Patients' autonomy and self-determination
The concepts of "patient autonomy and self-determination" as well as "patient rights andresponsibilities" are derived from Western cultural values
People who are mentally competent have the right to decide on the care they wish toreceive at the end of their life, recording it in official legal documents.
In cultures where the emphasis is on destiny, approaching a dying patient to completethese end-of-life legal documents is considered inappropriate or inhumane.
Giger JN, Davidhizar RE, 2006; Doolen J, York NL, 2007; Chih, A.-H, 2016
Decision making in ethical dilemmas
The ethical decision-making process should include:
regular meetings where ethical issues will be discussed
meetings related to palliative care
regular family meetings
protocol on discontinuation of treatment
Decision making at the end of life
Krakaues et al, 2002; Position Statement. Palliative Care Australia, 2015
Differences in beliefs, values and traditional healthcare practices are particularly important at the end of life
Culture, even for people who do not usually followtraditional practices, is particularly important for shapingattitudes about the dying process, death, and preferencefor end-of-life care
Palliative Care
WHO, 2019
«Palliative care is an approach that improves the quality of life ofpatients (adults and children) and their families who are facingproblems associated with life-threatening illness. It prevents andrelieves suffering through the early identification, correct assessmentand treatment of pain and other problems, whether physical,psychosocial or spiritual»
The palliative care approach is a universally accepted care philosophy aimed at :
confirming the approach of life and death as more normalthan a biomedical procedure
relieving pain and other symptoms
helping people to be able to accept their death as bestthey can
neither hastening nor postponing death
providing a support system to help people live as activelyand creatively they can until death
providing a support system for the family and friendsduring illness and mourning period
Palliative care / End-of-life care
Health professionals maintain strong culturallydefined beliefs about the process of dying and death.These beliefs determine their practice of caring forpeople who are dying
The core values, principles and philosophy of Westernsocieties may be foreign to patients with different culturalbackgrounds
Krawley et al, 2005; Position Statement. Palliative Care Australia, 2015
Recommendations for Health Professionals
•Teaching medical and nursing staff of general ethical principles
•Development of practical skills for dealing with ethical issuesthrough undergraduate and postgraduate courses
•Participation in conferences and lectures to acquirespecialized knowledge on dealing with ethical issues both inhospital and in the community
•Update - continuous training
•Support from the most experienced colleagues to the youngerones in order to face the ethical dilemmas presented ineveryday practice
•Discussion, good communication and cooperation amongcolleagues
Conclusions
The ethical decision making process requires:
good knowledge of the code of conduct
the development of an expanded rationale on the ethical aspects of an issue (ethical imagination) that will enable health professionals:
- to go beyond formal thinking
- to look for comprehensive solutions to ethical dilemmas that arise
Conclusions
In the care of the terminal patients, nurses have to face:
differences of opinion with other healthgroups
role conflict
making critical decisions
conditions that favor the development ofstress and anxiety about their actions
Conclusions
Nursing is a field where stressful dilemmas arise
Health professionals should be aware that in all cases there are limits
* Treatment should not be worse than the disease*
Indicative Reference List
• Chater K et al. Palliative care in a multicultural society: a challenge for western ethics. Australian Journal of Advanced Nursing, The, 2008, 26.2: 95
• Crawley LM. Racial, cultural, and ethnic factors influencing end-of-life care. Journal of Palliative Medicine, 2005, 8.supplement 1: s-58-s-69
• Douglas M.K. et al. Guidelines for implementing culturally competent nursing care. Journal of Transcultural Nursing, 2014, 25.2: 109-121
• Krakauer E, Crenner, C, Fox, K. Barriers to Optimum End‐of‐life Care for Minority Patients. Journal of the American Geriatrics Society, 2002, 50.1: 182-190
• Nilsson ME, Maciejewski PK, Zhang B, Wright AA, Trice ED. Mental health, treatment preferences, advance care planning, location, and quality ofdeath in advanced cancer patients with dependent children. Cancer , 2009,115: 399-409
• O'Sullivan R, Mailo K, Angeles R, Agarwal G. Advance directives: survey of primary care patients. Can Fam Physician. 2015, 61(4):353-356
• Rainer J, Scheneider KJ, Lorenz RA. Ethical dilemmas in nursing: An integrative review, J of Clinical Nursing, 2018, 27(19-20):3446-3461
• Sharma G, Freeman J, Zhang D, Goodwin JS. Continuity of care and intensive care unit use at the end of life. Arch Intern Med 2009, 169: 81-86
• Taylor H (2018) Legal issues in end-of-life care 1: the adult patient. Nursing Times [online], 2018, 114: 11, 25-28
• Taylor H (2019) Legal issues in end-of-life care 3: difficult decisions. Nursing Times [online], 2019,115: 1, 36-39
• Vaartio H, Leino-Kilpi H, Suominen T, Puukka P. Nursing Advocacy in Procedural Pain Care. Nurs Ethics.,2009,16(3):340–362
• Watt AD, Jenkins NL, McColl G, Collins S, Desmond PM. Ethical issues in the treatment of late‐stage Alzheimer’s disease. Journal of Alzheimer'sDisease 2019, 68(4):1311‐6
• Wiegand, D. L., MacMillan, J., dos Santos, M. R., & Bousso, R. S. Palliative and End-of-Life Ethical Dilemmas in the Intensive Care Unit. AACN AdvancedCritical Care, 2015, 6(2), 142–150