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Patient Rights and Ethical Decisions
The purpose of this paper is to discuss nursing ethics. The paper will discuss: the history of ethics, definition, doctor/nurse being education about ethics in college, code of ethics, futile care and the confusion with DNR orders. Ethics needs to be recognized on all levels of healthcare such as doctors, nurses, patients and families. CINAHAL and PubMed search engines were utilized for . Many articles were presented with the initial search, expansion on keywords assisted in generating more specific articles.
Nursing ethics has a vast spectrum of subjects. The history of ethics was around way longer then the declaration of specific ethical issues. According to Fox, Myers and Pearlman (2007), the field of ethics consultation has been developing over the last three decades, (Kosnick 1974; Rosner 1985). Ethics has become an organized and accepted division of healthcare services. Gallagher (2010), discussed the purpose of nursing ethics is to help us think, speak and perform better in our practice. The Nursing Code of Ethics was addressed by Lachman (2009). “Futile care” is discussed by Sibbald, Downar, Hawryluck (2007). Ball (2009) addressed the need for clarification of DNR orders in surgery patients.
Ethical issues arise daily in the healthcare world. The manor in which issues are addressed vary. “There are, it might be said, as many histories of nursing ethics as there are individual ethicists and professional or cultural contexts” (Guildford 2010, p.1). “A code of ethics is a fundamental document for any profession. It provides a social contract with the society served, as well as ethical and legal guidance to all members of the profession” (Lachman 2009, p.55). According to Lachman, since the original ANA Code from 1950, the significance of service to others has been consistent. Two changes in the code have occurred since the original. First, not only the patient is being treated, but the family and community where they live are also considered.
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Teaching should be implemented as part of the curriculum for physicians and nurses. According to Hanson(?), the thought that this teaching should occur is contrary to some modern thoughts in the ethical field. Recent literature was recognized that the different disciplines should have different levels of teaching about ethics and different ethical responsibilities and codes. Some say the difference between nursing and physicians is the difference between caring and curing. In teaching different professional students together could have a more direct benefit especially for nursing students. Ethics courses can promote valuable outcomes such as better communication. To study ethics, the learner must have or achieve good communication skills. They must be able to collaborate with the team. In order for mutual respect to be achieved between doctors and nurses there must be improved collaboration between them. In order to obtain respect there must be a level of understanding of the other participant’s roles and thoughts. Shared planning is crucial along with decision making to resolve ethical issues. There must be a plan developed to address the results of the action, treatment, care after a treatment and possibly care after discharge. This should be addressed and resolved with careful consideration of each member’s role. Problems do exist in bringing the disciplines together to teach ethics. Issues arise such as conflicting class schedules, books and professors to teach the two different professions. It is in fact worth noting that even with all the difficulties several schools have attempted interdisciplinary ethical education and have been pleased with the results. By teaching ethics together to the different professions it can make for a better professional, ethical and healthcare environment for all.
Patients have the right to make their own decisions in regards to their medical care. That does include the right to refuse care at any point throughout their treatment. Providers must comply with the wishes of the patient. Do not resuscitate orders are part of the patients right to make their own decisions without penalty. Ball's (2009) article discusses the automatic suspension or continuing DNR orders for patients having surgery. “In 1991, Congress passed the Patient Self-Determination Act to protect the right of United States citizens. This law mandates patients' rights to make decisions regarding their own medical care. Patients can accept or refuse treatment and also have the right to issue a do-not-resuscitate order as part of an advanced directive. The law requires Medicare and Medicaid providers, such as hospital, nursing homes, health agencies, to ask a patient whether he or she has an advance directive when the patient enters the heath care system. This information must then be documented in the patient's medical record. Patients also must be given information about advance health care directives if they request it. When a patient who has a do-not-resuscitate order is scheduled for surgery, confusion on the part of the surgical team may prompt the need for further questions to determine the patient's true wishes” (Ball 2009, p.140) In 1970 the first do-not-resuscitate orders by a doctor was legalized.
In the mid 70's, DNR orders were automatically suspended when a patient went to surgery. It was assumed that if a patient wanted surgery they wanted the DNR orders on hold. It was quickly realized that the status of the DNR orders needed to focus on location, timing, and circumstances regarding the orders. It was noted in Ball's article that an automatic suspension of DNR orders was not appropriate nor could it be justified for a patient going to surgery. Several issues also need to be addressed regarding the DNR orders: when was the DNR order written, who wrote the order, what reason was DNR ordered, what was the patient’s condition at the time of the orders, versus the patients condition at this time, were diagnostics done to verify the patient was terminal and how much influence did the previous physician writing the order have over the patient’s decision? According to Ball (2009) patients may reconsider what they originally wanted in the DNR orders, such as a witnessed “shockable” arrest, cardiac arrest due to certain therapies or witnessed arrest in an operating room.
There are many reasons a patient with DNR orders may want to go through surgery: insertion of a device, repair of a chronic problem, pain relieving procedures, removal of an organ and /or insertion of ports. To be considered: “When a patient consents to having a surgical procedure performed, the patient essentially is stating that he or she expects to survive the procedure. When a patient arrives in the surgical suite with a do-not-resuscitate order, surgical team members often have concerns because cardiac or respiratory arrests in the OR are different from cardiac or respiratory arrests that occur outside of the perioperative department. When a patient's arrest is witnessed, as in surgery, the survival rate is much higher. So the decision to strictly abide by the do-not-resuscitate order often is confusing to surgical teams” (Ball 2009, p.143).
Futile care is a term often thrown around loosely but is it understood what that actually means? According to Sibbald, Downar and Hawryluck, ICU physicians, nurses and respiratory therapists all seem to have similar and well-formed opinions about how futile care is defined and how it should be resolved. They also have opinions about where to focus efforts so future futile care is not performed in the ICU. One of the studies the group looked at was a “European survey found that 73% of respondents “frequently” admitted patients to the ICU with “no hope of survival for more than a few weeks” even though only 33% felt that they should admit such patients. Another recent study found that 87% of physicians and 95% of nurses surveyed in Canadian ICUs felt that they had provided futile care at least once in the year before being surveyed” (Sibbald, Downar and Hawryluck 2007, p.1201).
Futile care is defined in many ways. There are many perceptions of what futile care means. Respondents in this particular study expressed what their perception of futile care means. “Common factors identified when describing a care of perceived inappropriate care: intubation, comorbidities, poor quality of life, bleak prognosis, pain and suffering, brain death or persistent vegetative state and prolonged stay in ICU. Reasons given for why care was considered inappropriate or excessive: patient in dying process, patient had no meaningful quality of like, use of considerable resources to no benefit, pain and suffering. Reasons given for why inappropriate or excessive care is provided: demands of family or substitute decision maker, lack of skilled and timely communication and lack of consensus among treating team. Reasons given why families usually pursue inappropriate or excessive care against the advice of clinicians: cultural or religious reasons, lack of education or knowledge about critical care. Current strategies to avoid or limit medically futile care: communication, wait-and-see, paternalism and legal action. Suggestions for new strategies to avoid or limit medically futile care: education, early discussion of resuscitation orders, guidelines for admission to intensive care units and assistance of a clinical ethicist” ( Sibbald, Downar, Hawryluck 2007, p.1202). Some of the participants in these studies made comments such as: “Sometimes the discussion is: Do you want everything done? The alternative to doing everything is often left blank.” People in our community who should have end-of-life discussions with their caregivers and families often do not. Therefore you are having these discussions in a crisis situtaion. Many of the participants in the study felt that resuscitation status should be addressed every time a patient is admitted to the hospital. It was also found that nurses in general are less satisfied with end-of-life decisions that have been made then physicians were. This study conveys that a standard of care to help guide decision making would be a great tool.
There is a huge amount of controversy surrounding what ethical decisions need to be made and who and when the decisions should be made. With continued research in the field answers may become more evident, such as instituting standards and guidelines. As long as there are patients, doctors and nursing there will be controversy about the ethical decisions in healthcare. The most important issue is to provide the best care to patients and families.