Chapter 3

1. Chapter 3 Legal and Ethical Considerations

2. Learning Objectives • Define ethics, bioethics, values, morality, moral uncertainty, moral distress, moral outrage, and moral/ethical dilemma. • Explain the principles of ethics: autonomy, justice, fidelity, beneficence, nonmaleficence. • Explain how values are formed. • Explain how values clarification is useful in nursing practice. • Discuss the relationship between culture and values.

3. Learning Objectives • Describe the following philosophical bases for ethics: deontology, utilitarianism, feminist ethics, ethics of care. • Describe the steps in processing ethical dilemmas. • Describe the role of institutional ethics committees. • Explain the role of the LVN/LPN in relation to informed consent.

4. Ethics Values relevant to human conduct Defines what actions are right and wrong, and whether the motives and outcomes of those actions are good or bad Choices are often shades of gray, not black and white, or a choice must be made between two good or two bad options

5. Ethical Dilemmas Ethics does not prescribe one right answer Defines formal processes to explore what is proper conduct Bioethics Ethical questions that arise in the context of health care

6. Ethical Dilemmas Morality Shared ideas of what is right or good within a society or culture Moral distress Occurs when nurse feels powerless because his/her moral beliefs cannot be followed because of institutional or other barriers One reason that some nurses leave nursing

7. Ethical Dilemmas Moral outrage May occur when another person in the health care setting acts in a way that the nurse believes is immoral and the nurse feels powerless to intervene

8. Principles of Ethics Autonomy Recognition is inherent in the concept of informed consent and in advance directives Respect for the rights of people to make decisions about their own health and health care, such as accepting or refusing blood transfusions or medications

9. Principles of Ethics Beneficence Actions to promote good, prevent harm, or remove the patient from harm Nurse behaves in the patient’s best interest The problem is to define good, recognizing that the definitions of the patient, the family, the nurse, and the physician may differ An example of preventing harm is reporting a co-worker who is impaired or incompetent

10. Principles of Ethics Justice Fairness, equity, appropriateness of treatment Recognition that goods and services are limited Decisions about who will receive limited resources are based on various philosophies and might use the criteria of equal distribution; individual need, merit, social contribution, rights, or effort; or serving the greatest good for the greatest number of individuals

11. Principles of Ethics Nonmaleficence Requires that the nurse “do no harm” Therapeutic interventions can be uncomfortable; benefits must justify the discomfort A patient getting out of bed for the first time after surgery likely will experience some pain, but the benefits of mobilization far outweigh temporary discomfort

12. Principles of Ethics Fidelity A commitment to carry through on promises May be spoken or implied Patients have the right to expect staff is committed to their care and will not abandon them The duty of the nurse to practice within the legal definition of the profession and remain competent

13. Principles of Ethics Confidentiality Patient information must be protected Patients have the right to control who has access to personal information Nurses must guard against the careless, accidental, or deliberate sharing of private information Veracity (truth) Nurses must be honest with patients as well as in documentation and communication with colleagues

14. Values Beliefs and attitudes important to a person that influence daily choices Result of cultural, social, and personal experiences Family is foundation for values formation Values essential for professional nurses: altruism, equality, esthetics, freedom, human dignity, justice, and truth

15. Values Values conflicts Values of individuals and institutions are different Risk that patient’s values may not be recognized or respected As a nurse, you can recognize values conflicts by being aware of your own values and learning about those of your patients Try to understand the other person’s views and find common ground

16. Philosophical Basis of Ethics Deontology Defines right and wrong on the basis of whether an action meets the criteria of fidelity, veracity, autonomy, beneficence, and justice Consequences of the action are not considered A limitation of deontology is apparent when an action represents conflicting values

17. Philosophical Basis of Ethics Utilitarian “Right” action produces the greatest good for the greatest number of people Challenge is to agree on the “greatest good” Bound to be differences in opinion as to what constitutes a good outcome

18. Philosophical Basis of Ethics Feminist ethics Inequalities between people on the basis of gender; also places value on relationships Ethics of care Care is a “central activity of human behavior and one that deserves special attention in health care”

19. Steps in Processing Ethical Dilemmas Determine that it is an ethical problem Ethical problems have all of the following characteristics Scientific information does not provide the answer The problem is perplexing, i.e., the answer is not simple The solution is profoundly relevant to several areas of human concern

20. Steps in Processing Ethical Dilemmas Problem must be stated clearly so that all can agree on it Courses of action and consequences outlined Action is taken Outcome evaluated

21. Institutional Ethics Committees Most institutions have committees to process ethical dilemmas Multidisciplinary membership seeks input from patients, families, professionals, administrators Functions of the ethics committee: education, policy recommendation, oversight of policy implementation, consultation on specific cases

22. Legal Implications for Nursing Practice Law defines the boundaries of nursing practice Nurses must know their functions and limitations in order to protect their patients and themselves A nursing license is granted only to those who have met specific educational standards and demonstrated the minimal required level of knowledge as assessed by an examination The state board of nursing can revoke or suspend the license of a nurse who violates the provisions of the licensing statutes

23. Types of Law: Statutory Laws Created by elected legislative bodies, including nurse practice acts Classified as either civil or criminal Criminal laws are concerned with preventing harm to society or punishing violators Civil laws protect individual rights

24. Types of Law: Regulatory Laws Created by administrative bodies, such as state boards of nursing Rules and regulations that address the conduct of nurses Common law Result of judicial decisions made when individual cases are decided in the courts

25. Types of Law: Tort A tort is acivil wrong against a person or property

26. Types of Law: Intentional Tort Assault Contact without the patient’s consent Battery Touching in an offensive or harmful manner without consent Invasion of privacy Unwanted intrusion into the patient’s private affairs Defamation of character Releasing information that could damage a person’s reputation

27. Types of Law: Unintentional Tort Negligence Conduct that falls below the standard of care Malpractice Professional negligence To be found liable, it must be shown that the nurse owed a duty to the patient, the nurse did not carry out that duty, the patient was injured, and the injury was caused by the nurse’s failure to carry out the duty

28. Types of Law: Unintentional Tort Nurse’s best protection against charges of negligence and malpractice Adhere to standards of care; provide competent care; communicate with other members of the health care team; fully document assessments, interventions, and evaluations; and establish good relations with patients Student nurses are held to the same standards of care as are licensed nurses Students should never perform care for which they have not been prepared

29. Malpractice Insurance Health care institutions commonly provide malpractice insurance for nurses they employ Covers legal fees and awards if nurse is sued for professional negligence or medical malpractice If the act in question occurs outside place of employment, the agency insurance does not cover the nurse Nurses need to decide whether to carry personal liability insurance as well

30. Malpractice Insurance At times nurses assist at accident scenes. As long as actions are within accepted standards, Good Samaritan laws protect them from liability State laws vary; nurses should acquaint themselves with the laws in their states of residence

31. Confidentiality Every patient’s right: medical diagnoses and treatment must be kept confidential Protect the privacy of patient records and avoid public discussion of patient information Never copy/remove any part of a patient’s record HIPAA laws of 2003 made health care providers acutely aware of the actions needed to protect patient confidentiality

32. Consent Patients have the right to make decisions about their own care; caregivers may not impose care against a patient’s wishes Informed consent Provide sufficient information for the patient to make an informed decision Elements of informed consent: patient decision-making capacity, sufficient information, and voluntary agreement

33. Consent State law defines who can give consent for minors and people incapable of making their own decisions A confused or sedated person cannot give consent even if usually capable of making decisions Signatures on consent forms must be obtained before administering preoperative medications Consent must be voluntary There can be no real or implied coercion

34. Consent Required for hospital admission, surgery, some treatments, and research participation Physician is responsible for obtaining informed consent Nurses may obtain patient signatures and serve as witnesses to the signature per agency policy If the nurse suspects the patient lacks decision-making capacity or does not fully understand the implications of the consent form, the physician should be contacted and the supervisor notified

35. Physician Orders Legal, appropriate orders should be carried out If nurse believes an order is inappropriate, physician should be contacted for confirmation or correction If physician confirms order and LVN/LPN still believes it is inappropriate, the nurse should contact the supervisor to intervene Nurse may share responsibility for harm that follows implementation of an inappropriate order Verbal orders increase the risk for error; follow agency policy

36. DNR (Do Not Resuscitate) Orders Resuscitation will not be initiated if a patient ceases to breathe or the heart stops Orders should be written and reviewed regularly in case patient’s status changes In many states in the absence of a written order, it is assumed that resuscitation is appropriate

37. Short Staffing Staffing inadequate for competent care The supervisor should be notified Written protest submitted when required to accept an assignment without adequate staffing Nurses should know their state regulations and agency policies for such situations

38. Short Staffing: Patient Abandonment Walking out or refusing an assignment could be viewed as patient abandonment Includes sleeping on the job, leaving in the middle of a shift without notifying anyone, failing to show up or complete an agreed assignment in a home setting, and leaving the patient care area and remaining unavailable such that patient safety may be compromised

39. Short Staffing: Safe Harbor A nurse may be able to invoke “safe harbor” if given an assignment that the nurse believes violates his or her duty to the patient • Protects nurses from actions against their license when they notify the supervisor at the time the assignment is made

40. Floating Nurses are obligated to inform supervisors if they lack the skill to care for particular patients Nurses who float to new units must be oriented to the setting and trained for the new area

41. Right to Refuse Treatment Patients have the right to refuse medical treatment, including life-sustaining care When a patient is incompetent to make his or her own decisions, an effort is made to determine what the person would have wanted Advance directives help define the patient’s wishes