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ANCC Cardiac-Nursing Certification Exam:
Ethical and Legal Issues
The systematic study of moral conduct and provides the framework for studying and examining moral dilemmas - Ethics The study of moral conduct within the context of health care - Bioethics Refers to norms about right and wrong human conduct that form a social consensus - Morality Socially valued character traits - Moral Virtues Compassion, discernment, trustworthiness, integrity, conscientiousness - Five moral virtues for health professionals Combines active regard for another's welfare with an emotional response of sympathy, tenderness and discomfort at another's misfortune or suffering - Compassion The ability to make judgments and decisions without being unduly influenced by extraneous conditions
- Discernment Involves ability and strength of character, dependability, and reliability - Trustworthiness Firm adherence to moral and ethical principles - Integrity Results in careful, dependable, competent practice - Conscientiousness means to do good, promote the well-being of the patient, prevent harm - Beneficence Means to refrain from doing harm. Obligates the clinician to avoid inflicting harm directly or intentionally. Balanced with beneficence - maximize benefits while minimizing harm - Nonmaleficence Refers to the human right to make one's own decisions. - Autonomy
Veracity, respect the privacy of others, protect confidential information, obtain consent for interventions with patients, when asked, help others make important decisions - Clinicians show respect for autonomy when they engage in the following behaviors Truth-telling - Veracity The principal of fairness. To treat others equally. To refrain from discrimination - Justice Based on the respect for autonomy. - Informed consent Includes the ability to understand and make decisions. Is specific not global. It depends on the match between the patient's abilities and the specific decision-making task. May vary over time or be intermittent. - Decisional capacity Physiological such as illness or hypoxia or situational factors such as medically naive person admitted to the emergency department - Factors that may affect decisions making capacity It is appropriate to assess his or her understanding deliberative capacity and coherence over time, and to consult with an expert when necessary - If the patient's decisional capacity cannot be established initially Are authorized to make decisions for patients when decisional capacity is impaired. Compelled ethically and legally to act in the patient's best interests - Surrogate decision-makers The surrogate decision-maker is required to make the decision that the incompetent patient would have made if competent. Surrogates may have written evidence of a person's wishes via a living will or letter, oral evidence via conversation or they may make inferences based on the person's history of relevant choices - Substituted judgment standard If the surrogate has no way of knowing what choice a person would have made. The surrogate should choose the option that appears to be in the best interests of the patient. - Best interests standard
- Court-appointed guardian
- Durable power of attorney
- Spouse
- Adult children, usually requires consensus
- Parents, usually requires consensus
- Adult siblings, usually requires consensus - Order of surrogate authority in descending order of priority
Fair distribution of resources with all treated equally. Implies a right to health care; however, this right is not articulated in the Constitution of the United States. - Principle of Justice Obligates the nurse to be truthful with patients and members of the healthcare team. - Veracity The increased emphasis on the need to disclose healthcare errors to colleagues, the institution, the patient, and in some cases to government agencies - Example of Veracity Obligates the clinician to appropriately restrict access to the patient and to the health record. Current issue is the need to restrict clinician's access to the electronic medical record of any patients with whom they are not directly involved in care. Includes hospitalized colleagues, employees, public figures, and family or friends - Privacy Requires clinician to share information about the patient only with the patient and those health professionals who are involved in caring for the patient - Confidentiality Refers to faithfulness in keeping a promise. Requires that the nurse put the patient's interests above other interests, such as financial, personal or other people involve din the patient's care of life - Fidelity Describes a situation in which research and practice would suggest that there is less than a 1% chance that the treatment would have the intended effect. - Quantitative medical futility Describes the situations in which the treatment will have the intended effect but will not achieve a desired benefit - Qualitative medical futility Treatment that can be withheld - Extraordinary treatment Treatment that cannot be withheld without clear advance directives from the patient - Ordinary treatment A single act may have two effects, one beneficial and one harmful. - Double Effect
- Will an alternative treatment provide the intended effect without the unintended effect?
- Is the treatment provided for its intended effect?
- Does the intended effect outweigh the unintended effect? - Questions to Consider
- Clinical data and treatment options
- Relevant law
- Patient preferences and beliefs
- Goal of treatment - Ethical Reasoning: Review facts and assumptions about the case or situation Requires a choice between courses of action that involves fundamental concepts of right and wrong. Usually involve concepts of rights, duties and responsibilities. Is not a difference of opinion about treatment or different appraisals of clinical facts. - Ethical dilemma
- Review facts and assumptions about the case or situation
- Define the ethical dilemma in specific terms.
- List possible courses of action
- Choose a course of action
- Evaluate the choice - Ethical Reasoning
- Patient preferences
- Professional standards
- Relevant law
- Personal values and principals - Consider these factors when choosing a possible course of action in an ethical dilemma
- Consistent with ethical principals?
- Consistent with decisions made in similar cases?
- Consistent with values and principals of those affected?
- Consequences of the decision? - How to evaluate your choice in an ethical dilemma Multidisciplinary groups that review ethical dilemmas and advise clinicians - Ethics committees Provide "on call" assistance to patients, families, and clinicians when confronted by ethical dilemmas - Ethics consultation services Provide clinicians with an understanding and a framework for decision making - Formal educational programs in ethics Guide institutional practice - Policies related to ethical issues Are derived from the ethical theory of Liberal Individualism - Patient's rights Published by the American Hospital Association, replaced the 1990 Bill of Patient Rights. The brochure is available in eight languages and is provided to patients and families on admission to let them know what can be expected during their hospital stay - Patient Care Partnership Document
- High-quality hospital care
A legal recognition that enables one to practice in a profession such as nursing - Licensure Protects the public health, safety and welfare. All states require licensure for nursing practice. - Legal Regulation of Nursing Practice State laws that grant the right to practice nursing to people who meet predetermined standards. - Nurse practice acts Are created under the nurse practice act and govern nursing practice in the state - Regulatory boards
- Determining eligibility for licensing and relicensing
- Approving and supervising educational programs
- Enforcing the statute
- Writing rules and regulations governing the practice of nursing - Responsibilities of the Board of Nursing
- Fraud in obtaining license
- Unprofessional, illegal, dishonorable, or immoral conduct
- Performance of specific actions prohibited by the act
- Conviction of a felony or crime or moral turpitude
- Drug or alcohol addiction rendering the person incapable of performing duties - Basic Grounds for Disciplinary Action
- Revocation of license
- Suspension of license for a specified period of time
- Suspension of license for an unspecified period of time with the opportunity to reapply after a specified program of study or treatment
- Prohibition of work in specified settings - Possible Sanctions if Found Guilty during Disciplinary Action The individual is personally responsible for his or her actions. Person who actually causes the harm has the primary responsibility. - Personal Accountability
- Communicate to the physician change in the patient's condition
- Communicate to the nurse manager or supervisor concern about impaired justice
- Communicate to the appropriate person every time the situation occurs concern about short staffing - Duty to Communicate is the most Important Duty of the Nurse Actions of its employees within their scope of employment. May not be responsible if the employee is acting beyond his or her scope of employment. Does not eliminate personal responsibility. - Liabilities of the Employer Can be liable for harm caused by an incompetent nurse if the supervisor failed to assess the nurse's ability, if the employee has a known problem that can affect performance, or if the supervisor failed to provide adequate supervision. -
Liabilities of the supervisor Obligated to carefully monitor the credentials and competence of employees and independent contractors - Responsibilities of the healthcare facility Responsible for his or her own actions. Healthcare facility or organization may be liable if it failed to act despite having reason to know that the independent contractor was incompetent. - Responsibilities of the independent contractors A civil action for financial damages for injury to a person, property, or reputation. - Tort Failure to adhere to the standard of nursing care results in harm to the patient. Is classified as an unintentional tort, most common cause of cases involving nurses. - Negligence
- Duty
- Breach of duty
- Injury or harm to the patient
- Causation - Four Elements that much be Proved to Establish a claim of negligence Must be proved that the nurse had a responsibility to care for the patient. Scope or limits of that responsibility must be proved. Published standards of care and the actions of a reasonably prudent nurse are used to establish scope of responsbility - Duty It must be proved that the nurse deviated in some manner from the standard of care - Breach of Duty Must result. Harm may be physical, emotional or financial - Injury or harm to the patient Breach of duty must be proved to be the proximate cause of injury - Causation
- Know your practice area and remain current
- Know your abilities and limitations
- Know and follow the standards of care in your area
- Know and follow your facility's policies and procedures
- Know your patients and their families build good relationships - The nurse's way to protect themselves against negligent practice Specifies the time limit within which a suit must be filed. Established under state law. Varies by nature of complaint. - Statute of Limitations
What is not considered an invasion of privacy Disclosure to the general public, media or other interested parties. Clinicians who access information about patients for whom they do not have direct responsibility are invading the privacy of those patients and may be subject to institutional and civil penalty - Examples of Invasion of Privacy False or misleading statements that the patient relies on to his or her detritement - Fraud and misrepresentation The unlawful restriction of the freedom of a person, including physical restraint - False Imprisonment
