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Patients’ rights are a subcategory of human rights. However, the code cannot and does not give direction in all situations nurses encounter in practice. Consent may relate to healthcare treatment, participation in human research and/or use and disclosure of personal health information. This person would usually be a spouse, close relative or unpaid carer of the incompetent individual. Acts such as the. In an emergency, healthcare treatment may be provided without the consent of any person, although ‘emergency’ has not routinely been formally defined. Much of this research arises out of transnational collaborations made up of sponsors in high income countries (pharmaceutical industries, aid agencies, charitable trusts) and researchers and research subjects in low- to middle-income ones. The patient relies on the professional’s expertise, knowledge and advice, but it is up to the patient to decide whether he/she will accept or reject treatment, or in some circumstances request that the professional make the decision. The best interests principle is a guiding principle for decision making in health care, and is defined as acting in a way that best promotes the good of the individual. administering an injection), and should be wary of relying on ‘implied’ consent. Nurses in all settings and roles are bound by the ANA’s nursing code of ethics, which deals with various areas of patient care and provides guidance in handling the top ethical issues in nursing today, such as the five discussed below. in relation to individual autonomy and informed consent, needs to take account of cultural values, while respecting absolutely the ethical standards. In situations where there is not enough of a resource to be equally distributed, often guidelines or policies (e.g. • describe the ethical conduct of human research, in particular issues of patient risk, protection and privacy, and how to apply ethical principles within research practice. Ethical implications of brain death and organ donation that particularly relate to nursing practice are also reviewed. How to Write Care Plans; Nursing Diagnoses; Students. Conditions of scarcity and competition result in the predominant problems associated with distributive justice. Terms such as ‘medical agent’, ‘medical power of attorney’ and ‘enduring guardian’ are relatively common in relation to patient advocacy. (1978) ‘A contrary view of the nurse as patient advocate’, Adshead, G. and Dickenson, D. (1993) ‘Why do doctors and nurses disagree?’, in Dickensen, D. and Johnson, M. (eds). Paediatric Considerations in Critical Care, Essential Nursing Care of the Critically Ill Patient. Dilemmas are different from problems, because problems have potential solutions.5. Quickly memorize the terms, phrases and much more. New Zealand and most states of Australia have an Act that allows for the appointment of a person to hold enduring power of attorney.52 It is found in the literature that most individuals do not want to write advanced directives and are hesitant to document their end of life care desires. To show lack of respect for an autonomous agent, or to withhold information necessary to make a considered judgement, when there are no compelling reasons to do so, is to repudiate that person’s judgements. (1994) ‘Ethical decision-making in intensive care: a nurse’s perspective’. One example of a combination document is the Five Wishes advance directive in the US, created by the non-profit organisation Aging with Dignity. Ethical Issues - Consent Introduction. Decision making in the critical care setting is conducted within, and is shaped by, a particular sociological context. 31(4):236-240, July/August 2012. Each of these types of consent has differing requirements. The incidence of withholding and withdrawal of life support from critically ill patients has increased to the extent that these practices now precede over half the deaths in many ICUs. If the courts have appointed a person to be a guardian for an incompetent individual, then the guardian can provide consent on behalf of that individual. In Australia, when active treatment is withdrawn or withheld, legally the same principles apply. infection, pneumothorax on insertion). Hence, decisions regarding withdrawal and withholding of life support treatment(s) are not made without substantial consideration by the critical care team. In a UK study that attempted to draft cessation of treatment guidelines, nursing staff were concerned over legality, morality, ethics and their own professional accountability. With the introduction in the UK of the Human Rights Act21 there is increasing public awareness of individual rights, and in the medical setting people are encouraged to participate actively in decisions regarding their care. A healthcare practitioner must not assume that a patient provides a valid consent on the basis that the individual has been admitted to a hospital.16 All treating staff (nurses, doctors, allied health etc) are required to facilitate discussions about diagnosis, treatment options and care with the patient, to enable the patient to provide informed consent.17 When specific treatment is to be undertaken by a medical practitioner, the responsibility for obtaining consent rests with the medical practitioner; this responsibility may not be delegated to a nurse.16, Patients have the right, as autonomous individuals, to discuss any concerns or raise questions, at any time, with staff. Rather, the role of proxy tends to be assumed on the basis of an existing relationship between proxy and patient. The majority of the community and doctors favour active life-ending procedures for terminally-ill patients. Nurses require more assistance to meet the ethic … Ethics in critical care in nursing Crit Care Nurs Clin North Am. c. patient before hospitalization. Penn, K. (1994) ‘Patient advocacy in palliative care’. Drought, T.S. The Australian and New Zealand Intensive Care Society (ANZICS) recommends an ‘alternative care plan’ (comfort care) be implemented with a focus on dignity and comfort. To deny a competent individual autonomy is to treat that person paternalistically. 1. Some of these principles and how they relate specifically to critical care nursing practice are discussed individually in this chapter. While it is essential that all members of the critical care team be able to contribute and be heard, the final decision (and ultimately legal accountability in Australia and New Zealand for the act of withdrawal of therapy) rests with the treating medical officer. Despite the importance placed on quality of life in terms of its influence in the decision-making process, it is difficult to articulate a common understanding of the concept. Capacity fluctuates with both time and the complexity of the decision being made; thus, sound decisions require careful assessment of individual patients. Another form authorises a specific type of power of attorney or health care proxy, where someone is appointed by the individual to make decisions on their behalf when they are incapacitated. These are useful records to provide clarity when treatment options require full and frank discussion and consideration, particularly regarding complex, critically ill patients (see Palliative care below). Because of the vulnerable nature of the critically ill individual, direct informed consent is often difficult, and surrogate consent may be the only option, particularly in an emergency. These statements also emphasise to healthcare professionals that their relationships with patients are constrained ethically and are bound by certain associated duties.4 In addition, the World Federation of Critical Care Nurses has published a Position Statement on the rights of the critically ill patient (see Appendix A3). BioethicsLine: 1972-1999 In addition, the Nursing Council of New Zealand has published a Code of Conduct for Nursing that incorporates ethical principles (2004) (Box 5.2).15 These codes outline the generic obligation of nurses to accept the rights of individuals, and to respect individuals’ needs, values, culture and vulnerability in the provision of nursing care. However, the decision-making process certainly must involve broad, detailed and documented consultation with family and team members. A general distinction can be made between civil law jurisdictions, which codify their laws, and common law systems, where judge-made law is not consolidated. Fenton, M. (1988) ‘Moral distress in clinical practice: implications for the nurse administrator’, Hunt, G. (1991) ‘The concept of moral responsibility’, Paper presented at the Inaugural Conference of the National Centre for Nursing and Midwifery Ethics, Queen Charlotte College, Thames Valley University, cited in: Tschudin, V. and Marks-Maran, D. (eds) 1993). With advances in technology in health care, it is possible more than ever before to restore, sustain and prolong life with the use of complex technology and associated therapies, such as mechanical ventilation, extracorporeal oxygenation, intra-aortic balloon counterpulsation devices, haemodialysis and organ transplantation. Comparisons between the experience of critical care nurses in Sweden and the United Kingdom will be made for the simple reason that these are the only two European countries that have, to date, published research papers related to the way that nurses deal with, or feel about, the moral dimensions of critical care practice. The New Zealand Bill of Rights and the Health Act 1956 are currently under revision in New Zealand.12,13 These documents can be accessed via the New Zealand Ministry of Health (www.hon.govt.nz). Mass critical care planning has occurred at the regional (2), state/provincial (3, 4), national (5–7), and international (8) levels. Although some nurses draw a distinction between ethics and morality, there is no philosophical difference between the two terms, and attempting to make a distinction can cause confusion.4 Difficulties arise in ethical decision making where no consensus has developed or where all the alternatives in a given situation have specific drawbacks. Ethical issues in critical care: a nursing model. New Zealand and most states of Australia have an Act that allows for the appointment of a person to hold enduring power of attorney. Nurses are expected to practise in an ethical manner, through the demonstration of a range of ethical competencies articulated by registering bodies and the relevant codes of ethics (see. Nurses appear at times unable to influence the decision-making process.46, Some international literature reflects the different ethical reasoning and decision-making frameworks extant between medical staff and nurses. This situation particularly arises when the patient is incompetent and is therefore unable to participate in the decision-making process. A competent individual has the right to decline or accept healthcare treatment. Many of these guidance documents emphasize the need to protect the public and minimize harm. (2)University of Barcelona, Spain. An explanation of whom to contact for answers to pertinent questions about the research and research subjects’ rights, and whom to contact in the event of a research-related injury to the subject. As the provision of care to the critically ill becomes more complex due to technological advancement, and the profession of nursing more )34, In the Ethicus study of 4248 patients who died or had limitations of treatments in 37 ICUs in 17 European countries, life support was limited in 73% of patients. © 2020 Springer Nature Switzerland AG. Consent to conduct research involving unconscious individuals (incompetent adults) in critical care is one of the situations not comprehensively covered in most legislation (see also Ethics in research later in this chapter). a living will) or proxy (the appointment of a person(s) with enduring power of attorney to act as surrogate decision maker), or some combination of both. When science travels, so does its ethics. If a person is assessed as not being competent, consent must be sought from someone who has lawful authority to consent on his or her behalf. Common ethical principles that relate to critical care nursing practice are outlined in this chapter, with a description of how they may be applied to practical situations such as clinical decision making, obtaining informed consent and applied research. The medical agent should be someone not involved in a professional capacity in the delivery of the related health care. Use the quiz and worksheet to check your knowledge of these issues as well as some medical terms. A living will is one form of advance directive, leaving instructions for treatment. To avoid the accusation of battery, clinicians need to make clear what they are proposing to do and why ‘in broad terms’. Consent provides assurance that patients and others are neither deceived nor coerced. Some states have legislated to allow this authority to be delegated to a ‘person responsible’ or ‘statutory health authority’ without prior formal appointment. A common ethical dilemma found in critical care is related to the opposing positions of ‘maintaining life at all costs’ and ‘relieving suffering associated with prolonging life ineffectively’. The ‘group think’ approach of ‘That’s how we’ve always done it’ requires critical reflection on what is the ethical or ‘right thing to do’.28 Clinical audits and other dedicated review systems and processes are useful platforms for ethical discussion and debate between critical care colleagues. Acts of Parliament); Statute law has particular relevance to ethics in the critical care context. ‘Statements of patients’ rights’ relate to particular moral interests that a person might have in healthcare contexts, and hence require special protection when a person assumes the role of a patient.4 Institutional ‘position statements’ or ‘policies’ are useful to remind patients, laypersons and health professionals that patients do have entitlements and special interests that need to be respected. (1995) ‘Ethical practice in a technological age’. Observational studies demonstrate that North American health care workers consult families more often than do European workers,39,41 and some seriously ill patients wish to participate in end of life decisions whilst others do not.42, In most cases where there is doubt about the efficacy and appropriateness of a life-sustaining treatment, it may be considered preferable to commence treatment, with an option to review and cease treatment in particular circumstances after broad consultation. This service is more advanced with JavaScript available, Ethical Issues in Nursing and Midwifery Practice be able to comprehend and retain information, believe it (i.e. However, even for formally-appointed guardians, certain procedures are not allowed and the consent of a guardianship authority is required. The nurse justifies public trust and confidence. Related to this issue is that of the human rights of research subjects, as well as of health professionals as researchers in a variety of sociocultural contexts, and the contribution that international human rights instruments can make in the application of the general principles of ethics to research involving human subjects. A statement that participation is voluntary, refusal to participate will involve no penalty or loss of benefits to which the subject is otherwise entitled, and the subject may discontinue participation at any time without penalty or loss of benefits, to which the subject is otherwise entitled. The issue concerns largely, though not exclusively, two principles: respect for autonomy and protection of dependent or vulnerable persons and populations. Withholding/withdrawal of life support are processes by which healthcare therapy or interventions either are not given or are forgone, with the understanding that the patient will most probably die from the underlying disease.33. Making a substituted judgement is relatively informal, in the sense that the patient usually has not formally appointed the proxy decision maker. Kendrick, K. (1993) ‘Understanding ethics in nursing practice’. People may also have a combination of both. (eds), UKCC (United Kingdom Central Council for Nursing, Midwifery and Health Visiting) (1992), Tinker, J., Browne, D.R.G. Personal ethics may be described as a personal set of moral values that an individual chooses to live by, whereas professional ethics refer to agreed standards and behaviours expected of members of a particular professional group. In an emergency, healthcare treatment may be provided without the consent of any person, although ‘emergency’ has not routinely been formally defined. Critical care nurses need to be aware of the relevant policies and procedures to have an understanding of their individual obligations and responsibilities. Critical care staff need to be trained in assessing the most critical cases and providing sufficient medical care for patients who may recover. Enduring guardians can potentially make a wider range of decisions than a medical agent, but an enduring guardian can make decisions only once a person is considered to be unable to make his/her own decisions. The nurse justifies public trust and confidence. and Sibbald, W.J. Consent in human research is guided by a variety of different documents. These types of situations are referred to as ‘ethical dilemmas’. Many clinical scenarios invite ethical reflection and raise questions about health professionals’ decision making and behaviour, as distinct from specific diagnostic or technical questions. In that event, it is likely that withdrawal of treatment will not occur until concordance is reached. If there is stated objection from a family member, especially if the person has medical power of attorney (or equivalent), the doctor must take this into consideration and respect the rights of any patient’s legal representative. An autonomous person is an individual capable of deliberation and action about personal goals. Better communication skills among clinicians and more effective educational resources are required to solve these problems. In any given decision-making situation, the participants hold different presumptions about their roles in the process, different frames of reference based on different levels of knowledge, and different amounts of relevant experience. However, some persons are in need of extensive protection, depending on the risk of harm and likely benefit of protecting them, and in these cases paternalism may be considered justifiable.6,7, According to the principle of autonomy, critical care patients are entitled to be treated as self-determining. Individuals should be treated as autonomous agents; and individuals with diminished autonomy are entitled to protection. Author information: (1)University of Barcelona, Spain annafalco@ub.edu. Nurses hold in confidence any information obtained in a professional capacity, use professional judgement where there is a need to share information for the therapeutic benefit and safety of a person, and ensure that privacy is safeguarded. This study was supported with funds made available through the Center for Research in Critical Care Nursing, funded by the National Center for Research in Critical Care Nursing, funded by the National Center for Nursing Research (#1 P20 NR02334), J Dunbar‐Jacob PhD RN FAAN, Principal Investigator. The role of critical care nurses in relation to ethical issues has become increasingly complex. In that event, it is likely that withdrawal of treatment will not occur until concordance is reached. When asked where they would rather be if they had a terminal illness with only a short time to live, more doctors and nurses preferred being home or in a hospice and more patients and families preferred being in an ICU. 2. An advance health care directive, also known as a living will, personal directive, advance directive or advance decision, are instructions given by individuals specifying what actions should be taken for their health in the event that they are no longer able to make decisions due to illness or incapacity, and appoints a person to make such decisions on their behalf. Legal systems elaborate rights and responsibilities in a variety of ways. DOI:10.3912/OJIN.Vol23No01Man01 Key Words:ethical awareness, nursing ethics, ethical sensitivity, moral sensitivity, critical care Ethical awareness involves recognizing the ethical implications of all nursing actions, and is the first step in moral action. To establish that trust you must respect patients’ autonomy – their right to decide whether or not to undergo any medical intervention … [They] must be given sufficient information, in a way that they can understand, in order to enable them to make informed decisions about their care.24, In many countries, if patients believe that clinicians have abused their right to make informed choices about their care, they can pursue a remedy in the civil courts for having been deliberately touched without their consent (battery) or for having received insufficient information about risks (negligence). Another ethical issue in some health care facilities is the population's access to critical care. (See Chapter 8 for further details on cultural aspects of care.) The fair, equitable and appropriate distribution of health care, determined by justified rules or ‘norms’, is termed distributive justice. Enduring guardians can potentially make a wider range of decisions than a medical agent, but an enduring guardian can make decisions only once a person is considered to be unable to make his/her own decisions. In many countries, if patients believe that clinicians have abused their right to make informed choices about their care, they can pursue a remedy in the civil courts for having been deliberately touched without their consent (battery) or for having received insufficient information about risks (negligence). Care in nursing practice are also reviewed frameworks facilitates the delivery of appropriate skilled nursing care. ) deceived. These are: • statute law has particular relevance to ethics in critical care nurses should welcome a wider of... Material risks it entails ) something ’ to a patient that he has 4... Conduct for nurses requires ethical behavior from all practitioners of nursing to discuss any concerns raise! 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From unethical nurses philosophical, legal and ethical issues in handling and reporting [ to whom ] impaired care! Zealand and most states of Australia have an understanding of patient ’ s needs, values culture. Substantive and procedural norms ( 9, 10 ) in the critical care need! The quiz and worksheet to check your knowledge of these levels, practice. 2013 ; 14: 1 – 8 is described in this study nursing ethics reflects the different reasoning... Fact that the patient and the level to which basic needs are,. Physician leaves, the patient would have wanted in his/her present circumstances ’ their. Symptom of something larger needs to take account of cultural values, culture vulnerability! With diminished autonomy are entitled to protection, K. ( 1993 ) ‘ the case of an relationship! V. ( 1994 ) ‘ nurses should maintain awareness of the ethical conflict in critical care, egalitarian generally! 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