Ethical vs Moral Reasoning
Ethical – collective determination of acceptable and unacceptable conduct in accordance with professional standards that reflect criteria for practice and community expectations – e.g. ‘RNs must act with…’
Moral – individual determination of ‘right’ and ‘wrong’ in accordance with personal standards, beliefs and values – e.g. ‘I believe it is wrong to…
8 Ethical Principles
- Autonomy
- Beneficence
- Non-Maleficence
- Accountability
- Veracity
- Fidelity
- Justice
- Confidentiality
Autonomy (define)
Respecting patients’ right to self-determination, including:
- Consent (or refusal) – voluntary, fully-informed and with capacity.
- Information – sufficient, timely and unbiased
- Communication
- Planning – e.g. EOL/ACP.
Veracity (define)
Providing complete, honest and unbiased information to patients, including:
- Diagnosis and prognosis
- Treatment – purpose, alternatives, side-effects.
- Rights – consent, refuse treatment, second opinions.
Fidelity (define)
Fulfilling obligations and not making promises that cannot be kept.
- Professional standards and codes
- Trusting relationships
Beneficence (define)
Acting in the patient’s best interests by:
- Adopting holistic view of person
- Providing person-centred care
- Balancing benefits against risks/harms
Non-Maleficence (define)
Avoiding causing un/intentional harm to patients by:
- Delivering evidence-based practice
- Implementing safety and quality measures
- Maintaining fitness and competence for practice
- Reporting notifiable conduct
Justice (define)
Fair and equitable distribution of care for patients, involving:
- Avoiding discrimination (bias/stereotyping)
- Protecting vulnerable patients
- Prioritising patients according to urgency
- Allocating resources appropriately
Accountability (define)
Accepting responsibility for actions and outcomes of nursing care, by:
- Reporting errors/incidents
- Promoting open disclosure
- Delegating and supervising care
- Maintaining accurate/timely documentation
Confidentiality (define)
Respecting privacy and protecting personal information
- Explaining req. for info and seeking informed consent to share
- Proper collection, access, use and disclosure of information
- Appropriate information protection measures
8 Steps for Ethical Reasoning
- Identify the ethical issues based on perspectives of main stakeholders (i.e. patient, families and caregivers)
- Clarify personal values and effect on ability to participate in decision-making.
- Allocate roles in decision-making process
- Determine possible courses of action and alternatives
- Rank each option according to which provides the greatest balance of benefits over possible harms.
- Develop a plan of action with stakeholders
- Implement plan, evaluate responses and modify as required.
4 Fundamental Responsibilities (ICN Code of Ethics)
- To promote health
- To prevent illness
- To restore health
- To alleviate suffering and promote a dignified death
Benefits of Ethical Frameworks
A. Diverse – accounts for predicaments outside our own experiences and complex issues.
B. Multi-faceted – promotes consideration of multiple perspectives in complex scenarios.
C. Structured – not susceptible to fracturing/paralysis during illness/trauma (cf. patient’s moral frameworks).
D. Objective – allows health professionals to support decision-making without pushing their own values/beliefs.
E. Directive – provides guidance for behaviour of patients, families and colleagues.
RN Standards for Practice
1.5 Uses ethical frameworks to make decisions.
2 – Engages in therapeutic and professional relationships
3 – Maintains capability for practice
6 – Provides safe, appropriate and responsive quality nursing
Medical Futility (define)
Medical futility refers to situations where the proposed therapy should not be performed because available data show that it will not improve the patient’s medical condition. Concept is used to justify decisions not to pursue treatment options requested by patients.
Withdrawing vs Withholding treatment (explain)
Withdrawing – the removal of a therapy that has been started in an attempt to sustain life but is not (still) effective - e.g. mechanical ventilation, vasoactive agents.
Withholding – the decision not to make further therapeutic interventions or escalations - e.g. DNR/DNI.
ACD vs DNR
A DNR order states that the patient must not receive resuscitation attempts if they undergo cardiac/respiratory arrest.
An ACD is a more comprehensive legal document that outlines the patients preferences for treatment in a variety of situations where the patient no longer has decision-making capacity - e.g. organ donation, proxy health decision-maker.
4 Actions for ethical decision-making (ACPA)
- Promote patient autonomy through a case-based approach to ethical decisions - clarify relevant factual considerations, encourage ACDs, ACDs should be explicit.
- Promote congruence between individuals and substitute decision-makers - promote substitute decision-maker appointments, educate SDMs on roles/responsibilities, monitor capabilities of SDM.
- Promote supported decision-making - provide information and resources, promote involvement of support people, enable decision-making wherever possible.
- Promote a coordinated care environment - ACDs in consultation with MDT.
Advanced care plan (define)
An advance care plan is created by someone else on behalf of a the patient (with diminished or no capacity). Include an individual’s beliefs, values and preferences in relation to future care decisions. These help guide healthcare professionals and SDMs but are not necessarily legally binding.
Quality of life (define)
An individual’s perception of their level of health, comfort and wellbeing in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.
Advanced care directive (define)
A legally binding document containing a person’s preferences for future care in the event that they lose decision-making capacity. Includes values, goals, preferred outcomes and directions about care and treatment. May also appoint a SDM.
Benefits of ACP
- Ensures patients receive care that is consistent with their values and preferences.
- Improves ongoing and EOL care and patient/family satisfaction
- Reduces anxiety, stress and depression for patient and family members
- Reduces unnecessary treatments and episodes of care for healthcare workers
Barriers to ACP
- Patient unwilling or unable to communicate EOL issues
- Lack of awareness among patients and caregivers/families of ACP process
- Lack of knowledge/familiarity among healthcare professionals
- Lack of coordination of services
- Insufficient time
