Chapter 20: Ethical/Legal Principles

and Issues

Learning Objectives

• Define key ethical constructs as they relate to the care of geriatric patients.

• Relate concepts of ethics to their implications in the care of geriatric patients.

• Recognize the influence of personal values, attitudes, and expectations about aging on care of older adults and their families/extended families.

Learning Objectives (cont’d)

• Analyze the impact of fiscal, sociocultural, and medico-legal factors on decision making in the care of geriatric patients.

• Identify strategies for facilitating appropriate levels of autonomy and supporting the right to self-determination decisions in the care of geriatric patients.

Case study: ethical or moral dilemma

• An 80 year old patient in the nurse’s care just emphatically told her during the admission process that he does not wish any life prolonging procedures to be done if he should “code”. The nurse leaves the room to begin the appropriate referrals and paperwork for advance directives. When she returns, the patient is not breathing and has no pulse.

Case study questions• What should the nurse do?• What is the nurse bound legally to do?• What ethical principles are in conflict in

the given situation?• What other options does the nurse have

to uphold the patient’s autonomy?• Are there any foreseeable problems in

this situation?

Ethical/Legal Principles and Issues• Ethics of care in the geriatric population is

complex and challenging• Nursing Practice requires mindfulness of a

person’s autonomy within changing capacity

Ethical/Moral Principles

AdvocacyAutonomyBeneficence/ nonmaleficenceConfidentialityFidelity

Fiduciary responsibilityJusticeQuality of lifeReciprocitySanctity of lifeVeracity

Conflict and Dilemma• Ethical conflict occurs when a choice must

be made between 2 equal possibilities.• 3 types of moral conflict: moral distress,

moral uncertainty, and moral dilemma.• Moral distress

– When someone wants to do the right thing but is limited by constraints of organization or society.

Conflict and Dilemma (cont’d)

• Moral uncertainty– Confusion in situations when a person is

uncertain what the moral problem is or which moral principles or values apply to it.

• Moral dilemma– When two or more moral principles apply that

support mutually inconsistent actions.

Moral Principles• Incorporated into professional code of

ethics• Advocacy:

– Loyalty and a championing of the needs and interests of others.

– Nurses advocate for patients by supporting them in their efforts to retain as much autonomy as their abilities allow.

- Protecting the health and safety of clients by communicating needs, promoting safe environments, and helping with assertion of legla rights.

• Autonomy:– Person’s right to make independent decisions– Respect for personal liberty, values, beliefs, and

choices

• Beneficence: – To do good – To prevent or remove harm– More proactive than nonmaleficence

• Nonmaleficence– Not to inflict harm or evil

• Confidentiality– Duty not to disclose information shared in a

trusted manner or relationship– Privacy: duty to respect limited access to a

person– Health Insurance Portability and Accountability

Act (HIPPA)

• Fidelity– Duty to honor commitments– Keeping promises or being true to another– Trust is earned, and fidelity is demonstrated in

daily work

• Fiduciary Responsibility– Health care professionals have an ethical

obligation to good stewardship of both the patient’s and the organization’s fund

• Justice– Treat equals equally and treat those who are

unequal according to their needs– Fairness of an act or situation

• Veracity– Truthfulness– Not misleading patients or their families– Duty to be honest, tell the truth, not deceive

others

• Reciprocity:

Golden rule. A feature of integrity concerned with the ability to be true to one’s self while respecting and supporting the values and views of another.

Question

When a nurse tells a patient the truth about his terminal condition, she is engaging in:

a. beneficence

b. autonomy

c. veracity

d. fidelity

Moral Principles• Informed consent

– Elements to include in discussion• The specific condition requiring treatment• The purpose and distinct nature of the procedure or

treatment• Potential complications or risks associated with

the procedure or treatment• Reasonable alternatives with a discussion of their

relative risks and benefits• Discussion of the option of taking no action• The probability of success of the recommended

treatment or procedure

Patient Rights• Patient rights direct actions on ethical

issues in the care of geriatric populations• The Patient Self-Determination Act of

1990: patients are provided the opportunity to express their preferences regarding life-saving or life-sustaining care on entering any healthcare service, including hospitals, long term care centers, and home care agencies.

Patient Rights• Advance directives and living wills

– Advance directive: describe actions to be taken if the patient is no longer able to provide informed consent

– Living will: direct preferences for end-of-life care issues, providing an “if I am terminally ill and not expected to recover, then ...” plan

• Durable power of attorney– Legal document designating alternative

decision maker in the event the person is incapacitated

Patient Rights

• Competence– Mental clarity and appropriateness for decision

making based on a mental status exam– Required for persons to exercise autonomy

and right to decide

• Assisted suicide– Violation of the Code of Ethics for Nurses– Oregon: Death with Dignity Act (1997)

Ethics in Practice• Medical errors

– Considerable effort has been put into reducing mistakes and improving patient safety.

– Average hospital patient can expect to be subjected to at least one medication error per day

Summary• Nurses respect the worth, dignity, and

rights of the elderly as they provide care that meets their patients’ comprehensive needs across the life span continuum.

• Scope and Standards of Practice (ANA)

• Framework for ethical decision making provides a foundation for discussion when dilemmas arise, smoothing the way for integrity-saving compromise.

QuestionA family member asks the nurse to witness the signing of a Living Will at the bedside of a mentally competent, alert, adult patient. In signing as a witness, the nurse is stating:

a) the signature of this person was valid and not coerced

b) the person was mentally competent to sign

c) the person is terminally ill at the time

d) a and b only