The Patient Self-Determination Act does not specify who should discuss treatment decisions or advance directives with clients. Because directives are often implemented on nursing units, however, nurses need to be knowledge- able about living wills and healthcare surro- gates and be prepared to answer questions that clients may have about directives and the forms used by the healthcare institution.
As client advocates, the responsibility for creating an awareness of individual rights often falls on nurses. It is the responsibility of the healthcare institution to educate personnel about the policies of the institution so that nurses and others involved in client care can inform healthcare consumers of their choices.
Nurses who are unsure of the policies in their healthcare institution should contact the appropriate department.
CONCLUSION
Nurses need to understand the legalities involved in the delivery of safe health care. It is important to know the standards of care estab- lished within your institution, because these will be the standards to which you will be held accountable. Healthcare consumers have a right to quality care, and nurses have an obli- gation to deliver it. Caring for clients safely and avoiding legal difficulties require nurses to adhere to the expected standards of care and carefully document changes in client status.
172 ❖ Essentials of Nursing Leadership and Management
S T U D Y Q U E S T I O N S
1. How do federal laws, court decisions, and state boards of nursing affect nurs- ing practice? Give an example of each.
2. The next time you are on your clinical unit, look at the nursing documentation done by several different staff members. Do you believe it is adequate? Explain your rationale.
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R E F E R E N C E S
American Nurses Association. (1992). Position Statement on Nursing Care and Do Not Resuscitate Decisions.
Washington, D.C.: American Nurses Association.
American Nurses Association (1998). Legal Aspects of Standards and Guidelines for Clinical Nursing Practice.
Washington, D.C.: American Nurses Association.
Badzek, L. (1992). What you need to know about advance directives. Nursing92, 22(6), 57–60.
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C R I T I C A L T H I N K I N G E X E R C I S E
Mr. Evans, 40 years old, was admitted to the medical-surgical unit from the emergency department with a diagnosis of acute abdomen. He had a 20-year his- tory of Crohn’s disease and had been on prednisone, 20 mg, every day for the last year. Because he was allowed nothing by mouth (NPO), total parenteral nutrition was started through a triple-lumen central venous catheter line, and his steroids were changed to Solu-medrol, 60 mg by IV push q6h. He was also receiving several intravenous antibiotics, as well as medication for pain and nau- sea. Over the next several days, his condition worsened. He was in severe pain and needed more analgesics. One evening at 9 P.M., it was discovered that his central venous catheter line was out. The registered nurse notified the physician, who stated that a surgeon would come in the morning to replace it. The nurse failed to ask the physician what to do about the intravenous steroids, antibiotics, and fluid replacement because the patient was still NPO. At 7 A.M., the night nurse noted that the client had had no urinary output since 11 P.M. the night before. She failed to report this information to the day shift.
The client’s physician made rounds at 9 A.M. The nurse for Mr. Evans did not discuss the fact that the client had not voided since 11 P.M. the previous night, nor did she request orders for alternative delivery of the steroids and antibiotics. At 5 P.M. that evening, while Mr. Evans was having a computed tomography (CT) scan, his blood pressure dropped to 70 mm Hg, and because no one was in the scan room with him, he coded. He was transported to the intensive care unit and intubated. He developed sepsis and acute respiratory dis- tress syndrome.
1. List all the problems you can find with the nursing care in this case.
2. What were the nursing responsibilities in reporting information?
3. What do you think was the possible cause of the drop in Mr. Evans’s blood pressure and his subsequent code?
4. If you worked in risk management, how would you discuss this situation with the nurse manager and the staff?
3. How does your institution handle medication errors?
4. If a nurse is found to be less than proficient in the delivery of safe care, how should the nurse manager remedy the situation?
5. Describe the areas that should be accessed in determining standards of care.
Explain whether each is an example of an internal or external standard of care.
6. Explain the importance of federal agencies in setting standards of care in healthcare institutions.
7. Look at the forms for advance directives and DNR policies in your institution.
Do they follow the guidelines of the Patient Self-Determination Act?
8. What should a practicing nurse do to stay out of court? What should a nurse not do?
Beckman, J.P. (1995). Nursing Malpractice: Implications for Clinical Practice and Nursing Education. Seattle:
Washington University Press.
Bernzweig, E.P. (1994). The Nurse’s Liability for Mal- practice. New York: McGraw-Hill.
Black, H.C. (1957). Black’s Law Dictionary. St. Paul, Minn.: West Publishing.
Catalano, J.T. (1996). Contemporary Professional Nursing. Philadelphia, Pa.: F.A. Davis Co.
Cushing, M. (1988). Nursing Jurisprudence. Norwalk, Conn.: Appleton & Lange.
Flarey, D. (1991). Advanced directives: In search of self- determination. J Nurs Adm, 21(11), 17.
Kozier, B., Erb, G., Blais, K., & Wilkinson, J.M. (1995).
Fundamentals of Nursing: Concepts, Process and Practice (15th ed.). Menlo Park, Calif.: Addison-Wesley.
Marshall, S.B., Marshall, L.F., Vos, H.R., & Chestnut, R.M. (1990). Neuroscience Critical Care: Patho- physiology and Patient Management. Philadelphia, Pa.:
W.B. Saunders.
Northrop, C.E., & Kelly, M.E. (1987). State of New Jersey v. Winter. In Legal Issues in Nursing. St. Louis, Mo.: C.V. Mosby.
Patient Self-Care Determination Act. (1989). S.R. 13566, Congressional Record.
Prosser, W.L., & Keeton, D. (1984). The Law of Torts (5th ed.). St. Paul, Minn.: West Publishing.
Reigle, J. (1992). Preserving patient self-determination through advance directives. Heart Lung, 21(2), 196–198.
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175
Questions of Values and Ethics
O U T L I N E Values
Value Systems
How Values Are Developed Values Clarification Belief Systems Ethics and Morals Morals
Ethical Principles Ethical Codes Ethical Dilemmas
Resolving Ethical Dilemmas Faced by Nurses
Assessment Planning Implementation Evaluation
Practice Issues Related to Technology Current Ethical Issues
Conclusion
O B J E C T I V E S
After reading this chapter, the student should be able to:
• Discuss the way values are formed.
• Differentiate between personal ethics and professional ethics.
• List the seven basic ethical principles and give an example of each.
• Identify an ethical dilemma in the clinical setting.
• Discuss current ethical issues in health care and possible solutions.
C H A P T E R 1 3
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It is 1961. In a large metropolitan hospital, 10 healthcare professionals are meeting to consider the cases of three different individuals. Ironically, the cases have something in common. Larry Jones, age 66, Irma Kolnick, age 31, and Nancy Roberts, age 10, are all suffering from chronic renal failure and are in need of hemodialysis. Equipment is scarce, the cost of the treatment is prohibitive, and it is doubtful that treatment will be covered by health insur- ance. The hospital is able to provide this treatment to only one of these individuals.
Who shall live, and who shall die? In a novel of the same name, Noah Gordon called this decision-making group “the Death Com- mittee’’ (Gordon, 1965). Today, such groups are referred to as ethics committees.
Not so long ago, we had neither the knowl- edge nor the technology to prolong life. The main role of nurses and physicians was to sup- port patients through the time of illness, help- ing them toward recovery or keeping them comfortable until death. There were few “who shall live, and who shall die?’’ decisions.
In the late 1960s, technological advances made the intensive care unit possible. Health care can now keep alive people who would die without intervention. The development of new drugs and advances in biomechanical technology permit physicians and nurses to challenge nature. This progress also brings new, perplexing questions. The ability to pro- long life has created some heartbreaking situ- ations for families and terrible ethical dilemmas for healthcare professionals. How is the decision made about when it is time to turn off the life support machines that are keeping alive someone’s beloved son or daughter after, for example, an auto accident?
Families and professionals alike are faced with some of the most difficult ethical deci- sions at times like this. How do we define death? How do we know when it has occurred? Perhaps we also need to ask, “What is life? Is there ever a time when life is no longer worth living?’’
Healthcare professionals have looked to philosophy, especially the branch that deals with human behavior, for resolution of these issues. The field of biomedical ethics (or sim- ply bioethics), a subdiscipline of the area known as ethics—or the philosophical study of morality, has evolved. In essence, bioethics is the study of medical morality, the moral and social implications of health care and sci-
ence in human life (Mappes & Zembaty, 1991).
To understand biomedical ethics, we need to first consider the basic concepts of values, belief systems, and morality. We will then discuss the resolution of ethical dilemmas in health care.