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

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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