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HISTORICAL DEVELOPMENT OF MEDICAL SURGICAL
NURSING IN INDIA
In the history of Indian medicine begins from 3000 BC. In the Indus valley civilizations we can see the
drainage and we will understand that they have given importance to health and hygiene.
In 2000 BC the RIGVEDA marks the beginning of Indian system of medicine. The conditions like
fever, cough, constipation, diarrhea, dropsy abscesses, seizures, skin diseases including leprosy were
treated from that time. The herbs were used for the treatment.
In 272 BC king Ashoka built number of hospitals. He had given his emphasis on the prevention of the
diseases. Doctors, Nurses and the Midwifes were also available in that time. Nalanda and Thaxaxila
were the two famous medical schools.
In 100 B C, the surgical field was the well known by surgeons Sushruta and Charaka. Especially two
types of operation at those times were outstanding, Removal of the gall bladder stone and the plastic
surgery of the nose.
Nursing in India:
In the beginning the nursing was hindered by many difficulties like the cast system among the Hindus,
the Pardha system among the Muslims and the low status of the women. In the beginning period the
nurse has a servant image so no one was ready for nursing. The military nursing was the earliest type
of the nursing in 1664 the British east India company helped to start a hospital for soldiers in madras
(St. George HOSPITAL). The company appointed staff was served in the hospital. In 1854 the
government sanctioned training school for the midwives. 1864 Miss Florence Nightingale starts the
efforts to reform the hospitals. St. Stephens Hospital Delhi – 1864 - First to train Indian girls as nurses.
. In 1871 the government, general hospital of madras took a plan to train the nurses. The nurses from
the England were the in charge of the training and the students were those who previously received
there diploma in midwifery. 1905 – T.N.A.I established. 1926 – Madras state formed the first
registration council .1946 – First four year Basic Bachelor degree program established in R.A.K
(Rajkumari Amrit Kaur College of Nursing) Delhi and C.M.C Vellore. After 1947 the many changes
begin to take place. The attitude towards the nursing begins to change and the nursing begin to see as a
profession. The Indian Nursing Council was passed by ordinance on December 31, 1947. The council
was constituted in 1949. The development of Nursing in India was greatly influenced by the Christian
missionaries, World War, British rule and by the International agencies such as the World Health
Organization UNICEF, the Red Cross, UNSAID etc.
11960 – First Masters Degree program was started in R.A.K College of Nursing Delhi. . In 1970 the
WHO recognized nursing as a profession.
Nursing today provides an ever widening scope of opportunity for service. Today nurses enjoy many
rights and privileges, but the desired standards by the complete dedication for the profession.
ETHICS
Ethics are distinction between right and wrong based on body on a body of knowledge, not based on
opinions. Ethics in nursing is a set of moral codes of professional behaviors towards holistic care.
ETHICAL ISSUES IN MEDICAL SURGICAL NURSING ARE-
1. INFORMED CONSENT
Informed consent is a process for getting permission before conducting a healthcare intervention on a
person. A health care provider may ask a patient to consent to receive therapy before providing it, or a clinical
researcher may ask a research participant before enrolling that person into a clinical trial. Informed consent is
collected according to guidelines from the fields of medical ethics and research ethics . This is a principle of
autonomy. It requires accurate communication with patients regarding what the health team proposes or intends
to do with the patient and his or her body and psyche. The basic assumption is that no one is in a better position
to make decisions about therapeutic or research procedures than the person who will be directly affected. When
every effort is made to provide patients with adequate information, the humanity of the person is protected and
his or her status as an autonomous individual confirmed, this preserving important ethical standards.
In cases where an individual is provided insufficient information to form a reasoned decision, serious ethical
issues arise. Such cases in a clinical trial in medical research are anticipated and prevented by an ethics
committee or Institutional Review Board.
An important question is whether nurses stand in the process of providing informed consent? It is not
always easy to determine, but perhaps the best response is that it is clear that where nurses should stand. They
should guarantee that the patients have the information that they need to make informed decisions. If the
patients have the right to be informed, every nurse has an obligation to see that they are informed. Nurses
should be clear about this, since in practice nurses often spend previous time trying to determine what [patients
know instead of what they need to know to make a sound decision. When nurses make a choice to contribute
actively to the process of informed consent, ethical obligations to patients are much more likely to be met.
2. WITHHOLDING AND WITHDRAWING LIFE- SUSTAINING TREATMENT
On the medicine wards,we will have patients who are receiving treatments or interventions that keep them
alive, and we will face the decision to discontinue these treatments. Examples include dialysis for acute or
chronic renal failure and mechanical ventilation for respiratory failure. In some circumstances,these treatments
are no longer of benefit, while in others the patient or family no longer wants them. At the heart of any
disagreement associated with end of life care is determining what is beneficial for the patient. Increasingly it is
recognized that the best person to decide is the patient. Today it is well accepted that the competent patients
have a right to accept or reject intervention .A problem occurs when a patient needs members of the health care
team to assist the patient to carry out his or her wishes and those wishes will bring about the end of life care.
3. THE PRINCIPLE OF JUSTICE AND THE RIGHT TO HEALTH CARE ACCESS
A theory of justice for health and health care should help us answer three central questions. First, is health
care special? Is it morally important in ways that justify (and explain) the fact that many societies distribute
health care more equally than many other social goods? Second, when are health inequalities unjust? After all,
many socially controllable factors besides access to health care affect the levels of population health and the
degree of health inequalities in a population. Third, how can we meet competing health care needs fairly under
reasonable resource constraints? During the last twenty years, a major literature has emerged exploring the
social determinants of health. We have long known that the richer people are, the longer and healthier their
lives. The powerful findings of the last couple of decades, however, have deepened our understanding of the
factors at work producing these effects on population health and the distribution of health within populations. It
is less tenable to think that it is simply poverty and true deprivation that diminishes the health of some people,
for there is growing evidence that race and class effects operate across a broad range of inequalities
The question that is usually asked is how much health care access the principle of justice requires. At present
the debate continues.
4. ABORTION
Abortion is highly a publicized issue about which many people feel very strongly. Debate continues, pitting the
principle of sanctity of life against the principle of autonomy and the women’s right to control her own body.
This is especially a volatile issue because no public consensus has yet been reached. Nurses have no right to
impose their values on a client. Nursing code of ethics supports clients’ right to information and counselling in
making decisions.
According to the research conducted by Connie M. Ulrich, and Carol Taylor they found that Younger nurses
and those with fewer years of experience encountered ethical issues more frequently and reported higher levels
of stress. Nurses from different regions also experienced specific types of ethical problems more commonly.
5. ORGAN TRANSPLANTATION
Organs for transplantation may come from living donors or from donors who have just died. Many living
people choose to become donors by giving consent. Ethical issues related to organ transplantation include
allocation of potential donors, consent, clear definition of death, and conflicts of interest between potential
donors and recipients. In some situations, a person’s religious belief may also present conflict. For example,
certain religions forbid the mutilation of the body, even for the benefit of another person.
6. END-OF LIFE ISSUES
The increase in technological advances and the growing number of elderly people have expanded the ethical
dilemmas faced by elders and health care professions. Providing them with the information and professional
assistance, as well as the highest quality of care and caring, is of the utmost importance during these times.
Some of the most frequent disturbing ethical problems for nurses involve issues that arise around death and
dying. These include euthanasia, assisted suicide, termination of life sustaining treatment, and withdrawing or
withholding of foods and fluids.
Advanced Directives – Written instruction recognized under state law relating to the provision of healthcare
when an individual is incapacitated. Advance Directives may take two forms:
• Health Care Proxy – a written directive designating a person to make health care decisions on behalf of
an individual when he/she becomes unable to make such decisions. The person designated is the “agent.”
• Living Will – a written advance directive in which an individual specifies choices for medical treatment.
Euthanasia and Assisted suicide- ‘Euthanasia’ a Greek word meaning ‘good death’ is popularly known as
‘mercy killing’. Active euthanasia involves actions to directly bring about the client’s death, with or without the
clients consent. An example of this would be the administration of a lethal medication to end the client’s
suffering. Regardless of the care giver’s intent, active euthanasia is forbidden by law and can result in criminal
charges of murder.
Active euthanasia includes assisted suicide, or giving clients the means to kill themselves if they
request it (e.g. providing pills or a weapon). In any case the nurse should recall that legality and morality are not
one and the same. Determining whether an action is legal is only one aspect of deciding whether it is ethical.
The questions of suicide and assisted suicide are still controversial in our society. The ANA’s position
statement on assisted suicide (ANA, 1995) states that active euthanasia and assisted suicide are in violation of
the Code for Nurses.
Passive euthanasia involves the withdrawal of extraordinary means of life support, such as
removing a ventilator or withholding special attempts to revive a client ( e.g. giving a client’ no code’ status).
Termination of life sustaining treatment – Antibiotics, organ transplant, and technological advances (e.g.
ventilators) help to prolong life, but not necessarily to restore health. Clients may specify that they wish to have
life sustaining measures withdrawn, they may have advanced directives on this matter, or they may appoint a
surrogate decision maker. However it is usually more troubling for health care professionals on to withdraw a
treatment than to decide initially not to begin it. Nurses must understand that a decision to withdraw a treatment
is not a decision to withdraw care. As the primary care givers, nurses must ensure that sensitive care and the
comfort are given as the client’s illness progresses. Keeping clients and families well informed is an ongoing
process, allowing them time to ask questions and discuss the situation. It is also essential that they understand
that they can re-evaluate and change their decision if they wish.
Withdrawing or withholding of foods and fluids- It is generally accepted that providing foods and
fluids is a part of ordinary nursing practice and, therefore, a moral duty. However, when foods and fluids are
administered by tube to a dying client, or are given over a long period of time to an unconscious client who is
not expected to improve, then some consider it to be an extraordinary, or heroic, measure. A nurse is morally
obligated to withhold foods and fluids (or any treatment) if it is determined to be more harmful to administer
them than to withhold them. The nurse must also honor competent patients’ refusal of foods and fluids.
COMMON ETHICAL DILEMMAS IN NURSING
While a career in nursing is immensely fulfilling, it’s not without its share of challenges. Regardless
of their area of practice or accreditation, nurses face a multitude of ethical dilemmas every day. While
there’s no clear-cut right or wrong answer to the often life and death ethical issues encountered by
nurses, there is a set of principles upon which ethical decision making is based.
Ethical dilemma occurs when there is conflict between two or more ethical principles. No correct
decision exists. The nurse must make a choice between two alternatives that are equally unsatisfactory.
 Patient freedom versus nurse control
Nurses are highly educated and therefore aware of the best clinical course of action when one exists.
But what happens when a patient rejects medical advice and makes a decision that may result in less
optimal outcomes? From deciding whether or not a labor and delivery patient would benefit from pain
medication, to encouraging a patient to eat when they are refusing food, nurses walk a fine line every
day.While nurses do not sign the Hippocratic Oath, they are s till bound by the promise to devote
themselves to the welfare of the patients committed to the care, as well as to live up to the standards of
the profession.
 Reproductive Rights
The pro-choice vs. pro-life argument is an intensely personal one based on an individual's core set of
values and beliefs. If you are pro-life, can you support a patient’s right to an abortion? If you are pro-
choice, can you respect a patient’s choice to continue a pregnancy even if it threatens her own life?
With more than 208 million pregnancies occurring worldwide every year, nurses can expect to be
confronted with this ethical dilemma on any given shift.
 Honesty vs. Information
Families will often choose to withhold truthful information to “protect” a patient from emotional
distress. For nurses, this poses another common ethical dilemma: does a patient have the right to know
everything about their condition, even if sharing the information will cause harm? Is honesty always
best? What if sparing a patient this information can promote happier, less stressful final days?
Deciding what information will be shared – along with how and when to share it – can be a difficult
part of a nurse’s responsibilities
.
 The Minor Dilemma
Working with children presents a unique set of ethical challenges. Not only must nurses consider the
best interests of the patient, but they must balance this against the wishes, beliefs and values of a
family. While patients, families and physicians may be aligned in the ideal world, in the real world
ethical issues do arise. While parents are tasked with difficult decisions too, the nurse’s ultimate
responsibility is to the patient.
Ethical issues related to privacy can also arise with minors. While they do have some basic rights to
privacy, the law requires disclosure of certain information to parents. In many cases, this is
information that minors do not want disclosed. In this instance, nurses benefit from an understanding
of law, as well as hospital policy.
 The Battle of Beliefs
What is science-based, empirical knowledge to a nurse might be completely subjective to a patient
with a particular set of religious or personal beliefs. Certain religions forbid medical procedures which
can mean the difference between life and death. For example, in some cultures and religions, blood
transfusions – even lifesaving ones – are unacceptable. A nurse’s attempts to explain the benefits of
the procedure weighed against the risks of opting out can overstep the line. Is it the nurse’s job to
support the patient’s right to the decision, or is it their responsibility to do everything in their power to
urge them toward a preventable action?
As science continues its onward march, questions related to ethics and human rights are only expected
to grow, pertaining to everything from stem cell research to genetic testing.
 Resource Management
If a patient is in a medically futile, vegetative state, the cost of maintenance is high. At what point do
you draw the line and redirect these resources to patients for whom they could be truly life -saving?
How do you balance what may be perceived as a financial decision against what is an entirely personal
decision to a grieving family? After all, when it comes to clinging to hope for the survival of a loved
one, no resource is poorly spent.
Nurses are charged with maintaining a “big picture” perspective while simultaneously dealing with
intensely personal situations on a day to day basis.
CULTURAL ISSUES IN NURSING
Culture refers to the cumulative deposit of knowledge, experience, beliefs, values, attitudes, meanings,
hierarchies, religion, notions of time, roles, spatial relations, concepts of the universe, and material objects and
possessions acquired by a group of people in the course of generations through individual and group striving.
In many cultures, health decisions are not made by an individual but by a group: family, community and/or
society. Socialized medicine or government sponsored health care for all residents is reflective of the value
placed on collectivism
DOS AND DON’S RELATING TO VARIOUS CULTURES
Name
 Don’t judge a person’s religion by his name.
 Don’t use western titles such as Mr,Mrs,Miss,Ms in some cultures.
 Do ask for a family name for those who don’t have as specific name
 Do avoid repetitions in clinical notes. Find the correct name first rather than misuse several different names
Language
 Don’t assume that all ethnic minority groups speak English.
 Do avoid making assumptions using accurate assessment procedures.
 Don’t use the family to interpret intimate questions.
 Don’t use a family member to break a bad news. He or she may avoid the issue if it is
believed to be too stressful for the client.
 Do use an interpreter who understands medical terminology, which will avoid stress for the
interpreter and the client and also avoid misinterpretations.
 Don’t use the language which is strange for the patients.
Religion
 Don’t judge about a clients religion
 Do avoid incorrect assumptions: find out the different beliefs and approaches.
 Do record clearly and make notes of the client’s wishes to see or have present a representative
from his religion.
 Do ask family who you should contact if the client is not able to rely this to you do remember
that many Eastern religions fast on certain days: pray at certain times: wear religious objects or symbols.
 Don’t mistake religious objects or symbols for jewellery.
 Do check to see if any nursing interventions will compromise any religious beliefs.
 Do inform the client and /or family of any nursing interventions before commencing, to
check religious beliefs.
Diet
 Don’t give Jews or Muslims pork or pork products
 Do remember that not all Muslims eat halal meat.
 Do consult client regarding any diet preferences.
 Do remember that being taken out of a family environment can be frightening and cause loneliness,
which may cause loss of appetite.
Personal hygiene
 Do supply the client with a jug of water and a bowl and /or a running tap and empty washbasin
to allow hand, face and body washing.
 Do make exemptions when the client is dependent
 Do remember that all people will not cut their hairs or during special occations.
Modesty
 Don’t compromise the client’s dignity and modesty.
 Do remember that exposure of the female body to the male will cause distress to certain cultures, especially
if the client is in purdah.
 Do offer separate bays in mixed-bedded wards,or if possible a single room, especially for those in purdah.
 Do remember that hospital gowns often exposé more than they cover, and are therefore unacceptable.
 Do avoid exposure of arms or legs, for example: in the case of fractured limb .do additional; covering to
protect modesty.
Hospital procedures
 Do give careful thought to hospital procedures and routines before commencing them.
 Do remember that discussing elimination or other intimate health issues may be culturally offensive .
 Do approach all patients sensitively, ensure privacy and maintain the individual right to self-respect.
 Do remember that some medications and treatments may be taboo for some religious groups.
 Don’t give Muslims, Jews and vegetarians iron injections derived from pigs.
 Don’t give insulin of porcine origin to Jews or Muslims.
Visiting
 Do remember that limiting visiting to two people may cause distress in extended family cultures.
 Do remember that the family may include children, uncles, aunts, grandchildren, parents, and grandparents.
 Do remember that open visiting is more accommodating.
 Do allow the family to participate in the client’s care.
Death and bereavement
 Do involve client and family in the care.
 `Do remember that Eastern cultures like to take an active part in the care of dying relatives,
especially last offices.
 Do remember that in certain cultures, custom and practices will need to be followed if the client is
to proceed along the continuum of life following her earthly death.
 Do ensure that you are conversant with specific cultural requirements for death, bereavement and
last offices.
CURRENT CONCEPTOF HEALTH
Health is individually defined by each person.On a personal level, individuals define health according to – how
they feel – absence or presence of symptoms of illness – and ability to carry out activities
WHO refers health as situation that may exist in some individuals but not in everyone all the time, it is not
usually observed in a groups of human beings and in communities. Nobody is qualified as completely healthy,
i.e., perfect biological, psychological and social functioning all the time. That is, if we accept the WHO
definition, we are all sick.
Health is world-wide social goal. Health and its maintenance is major social investment. Health involves
individuals, state and international responsibility. Health is central to quality of life and health is integral part of
development. Health is inter- sectoral and which is essence of productive life. Modern society says that health
is a fundamental human right.
1. Health as a human right.
 Citizens have the right to health insurance, guaranteeing them accessible medical care and
free use of medical services under conditions and order.
 Health care for citizens is funded by the state budget, employers, personal and collective
insurance payments and other sources under conditions and order, stipulated by law.
 The state promotes citizens health and encourages the development of sport and tourism.
 No single person can be subjected unwillingly to treatment and sanitary measures,except
for the cases foreseen in law
 The state exercises control over all treatment facilities, as well as the production of
medications, bioactive substances and medical equipment and over trade with them.”
2. Social dimension of health includes the level of social skills one possesses, social functioning and the
ability to see oneself as a member of a larger society. It states that harmony and integration within and between
each individuals and other members of the society. It also refers to the ability to make and maintain
relationships with other people or communities.
3 Spiritual dimension ofhealth includes integrity, principle and ethics, the purpose of life, commitment to
some higher being, belief in the concepts that are not subject to “state of art” explanation. It is intangible
“something” that transcends physiology and psychology. Spiritual health is connected with religious beliefs and
practices. It also deals with personal creeds,principles of behavior and ways of achieving peace of mind and
with oneself.being at peace
4 Concept ofdisease The oxford English Dictionary defines disease as “ a condition of the body or some
part or organ of the body in which its functions are disturbed or deranged”. Webster defines disease as “a
condition in which body health is impaired, a departure from a state of health, an alteration of the human body
interrupting the performance of vital functions”.
The simplest definition is that disease is just the opposite of health: i.e. any deviation from normal functioning
or state of complete physical or mental well-being. 39 From ecological point of view, disease is defined as “a
maladjustment of the human organism to the environment.”
Sickness is a state of social dysfunction i.e. a role that the individual assumes when ill (sickness role). Illness is
a subjective state of the person who feels aware of not being well. Disease is a physiological/psychological
dysfunction.
.
5 Standard of living Income and occupation, standards of housing, sanitation and nutrition, the level of
provision of health, educational, recreational and other services all be used individually as measures of
socioeconomic status,and collectively as an index of the standard of living.
6 Level ofliving Health is affected by and is affecting the level of living. It consists of certain objective
components : food consumption, education, occupation and working conditions, housing, social security,
clothing, recreation and leisure human rights.
7 Quality of life A composite subjective measure of physical, mental and social wellbeing as perceived by
each individual or by group .Quality of life of individuals e.g. happiness, satisfaction and gratification as it is
expressed in such life concerns as health, marriage, family work, financial situation, educational opportunities,
self-esteem,creativity, belongingness, and trust in others.
8 Responsibility for health
International responsibility, national responsibility, State responsibility: constitutional rights. Community
responsibility: health care for the people to the health care by the people. Individual responsibility: self care for
maintaining his own health, adoption of healthy life style

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Development of med surg in india, current concept of health, ethical issues in nsg

  • 1. HISTORICAL DEVELOPMENT OF MEDICAL SURGICAL NURSING IN INDIA In the history of Indian medicine begins from 3000 BC. In the Indus valley civilizations we can see the drainage and we will understand that they have given importance to health and hygiene. In 2000 BC the RIGVEDA marks the beginning of Indian system of medicine. The conditions like fever, cough, constipation, diarrhea, dropsy abscesses, seizures, skin diseases including leprosy were treated from that time. The herbs were used for the treatment. In 272 BC king Ashoka built number of hospitals. He had given his emphasis on the prevention of the diseases. Doctors, Nurses and the Midwifes were also available in that time. Nalanda and Thaxaxila were the two famous medical schools. In 100 B C, the surgical field was the well known by surgeons Sushruta and Charaka. Especially two types of operation at those times were outstanding, Removal of the gall bladder stone and the plastic surgery of the nose. Nursing in India: In the beginning the nursing was hindered by many difficulties like the cast system among the Hindus, the Pardha system among the Muslims and the low status of the women. In the beginning period the nurse has a servant image so no one was ready for nursing. The military nursing was the earliest type of the nursing in 1664 the British east India company helped to start a hospital for soldiers in madras (St. George HOSPITAL). The company appointed staff was served in the hospital. In 1854 the government sanctioned training school for the midwives. 1864 Miss Florence Nightingale starts the efforts to reform the hospitals. St. Stephens Hospital Delhi – 1864 - First to train Indian girls as nurses. . In 1871 the government, general hospital of madras took a plan to train the nurses. The nurses from the England were the in charge of the training and the students were those who previously received there diploma in midwifery. 1905 – T.N.A.I established. 1926 – Madras state formed the first registration council .1946 – First four year Basic Bachelor degree program established in R.A.K (Rajkumari Amrit Kaur College of Nursing) Delhi and C.M.C Vellore. After 1947 the many changes begin to take place. The attitude towards the nursing begins to change and the nursing begin to see as a profession. The Indian Nursing Council was passed by ordinance on December 31, 1947. The council was constituted in 1949. The development of Nursing in India was greatly influenced by the Christian missionaries, World War, British rule and by the International agencies such as the World Health Organization UNICEF, the Red Cross, UNSAID etc. 11960 – First Masters Degree program was started in R.A.K College of Nursing Delhi. . In 1970 the WHO recognized nursing as a profession. Nursing today provides an ever widening scope of opportunity for service. Today nurses enjoy many rights and privileges, but the desired standards by the complete dedication for the profession.
  • 2. ETHICS Ethics are distinction between right and wrong based on body on a body of knowledge, not based on opinions. Ethics in nursing is a set of moral codes of professional behaviors towards holistic care. ETHICAL ISSUES IN MEDICAL SURGICAL NURSING ARE- 1. INFORMED CONSENT Informed consent is a process for getting permission before conducting a healthcare intervention on a person. A health care provider may ask a patient to consent to receive therapy before providing it, or a clinical researcher may ask a research participant before enrolling that person into a clinical trial. Informed consent is collected according to guidelines from the fields of medical ethics and research ethics . This is a principle of autonomy. It requires accurate communication with patients regarding what the health team proposes or intends to do with the patient and his or her body and psyche. The basic assumption is that no one is in a better position to make decisions about therapeutic or research procedures than the person who will be directly affected. When every effort is made to provide patients with adequate information, the humanity of the person is protected and his or her status as an autonomous individual confirmed, this preserving important ethical standards. In cases where an individual is provided insufficient information to form a reasoned decision, serious ethical issues arise. Such cases in a clinical trial in medical research are anticipated and prevented by an ethics committee or Institutional Review Board. An important question is whether nurses stand in the process of providing informed consent? It is not always easy to determine, but perhaps the best response is that it is clear that where nurses should stand. They should guarantee that the patients have the information that they need to make informed decisions. If the patients have the right to be informed, every nurse has an obligation to see that they are informed. Nurses should be clear about this, since in practice nurses often spend previous time trying to determine what [patients know instead of what they need to know to make a sound decision. When nurses make a choice to contribute actively to the process of informed consent, ethical obligations to patients are much more likely to be met. 2. WITHHOLDING AND WITHDRAWING LIFE- SUSTAINING TREATMENT On the medicine wards,we will have patients who are receiving treatments or interventions that keep them alive, and we will face the decision to discontinue these treatments. Examples include dialysis for acute or chronic renal failure and mechanical ventilation for respiratory failure. In some circumstances,these treatments are no longer of benefit, while in others the patient or family no longer wants them. At the heart of any disagreement associated with end of life care is determining what is beneficial for the patient. Increasingly it is recognized that the best person to decide is the patient. Today it is well accepted that the competent patients have a right to accept or reject intervention .A problem occurs when a patient needs members of the health care team to assist the patient to carry out his or her wishes and those wishes will bring about the end of life care.
  • 3. 3. THE PRINCIPLE OF JUSTICE AND THE RIGHT TO HEALTH CARE ACCESS A theory of justice for health and health care should help us answer three central questions. First, is health care special? Is it morally important in ways that justify (and explain) the fact that many societies distribute health care more equally than many other social goods? Second, when are health inequalities unjust? After all, many socially controllable factors besides access to health care affect the levels of population health and the degree of health inequalities in a population. Third, how can we meet competing health care needs fairly under reasonable resource constraints? During the last twenty years, a major literature has emerged exploring the social determinants of health. We have long known that the richer people are, the longer and healthier their lives. The powerful findings of the last couple of decades, however, have deepened our understanding of the factors at work producing these effects on population health and the distribution of health within populations. It is less tenable to think that it is simply poverty and true deprivation that diminishes the health of some people, for there is growing evidence that race and class effects operate across a broad range of inequalities The question that is usually asked is how much health care access the principle of justice requires. At present the debate continues. 4. ABORTION Abortion is highly a publicized issue about which many people feel very strongly. Debate continues, pitting the principle of sanctity of life against the principle of autonomy and the women’s right to control her own body. This is especially a volatile issue because no public consensus has yet been reached. Nurses have no right to impose their values on a client. Nursing code of ethics supports clients’ right to information and counselling in making decisions. According to the research conducted by Connie M. Ulrich, and Carol Taylor they found that Younger nurses and those with fewer years of experience encountered ethical issues more frequently and reported higher levels of stress. Nurses from different regions also experienced specific types of ethical problems more commonly. 5. ORGAN TRANSPLANTATION Organs for transplantation may come from living donors or from donors who have just died. Many living people choose to become donors by giving consent. Ethical issues related to organ transplantation include allocation of potential donors, consent, clear definition of death, and conflicts of interest between potential donors and recipients. In some situations, a person’s religious belief may also present conflict. For example, certain religions forbid the mutilation of the body, even for the benefit of another person. 6. END-OF LIFE ISSUES The increase in technological advances and the growing number of elderly people have expanded the ethical dilemmas faced by elders and health care professions. Providing them with the information and professional assistance, as well as the highest quality of care and caring, is of the utmost importance during these times. Some of the most frequent disturbing ethical problems for nurses involve issues that arise around death and dying. These include euthanasia, assisted suicide, termination of life sustaining treatment, and withdrawing or withholding of foods and fluids.
  • 4. Advanced Directives – Written instruction recognized under state law relating to the provision of healthcare when an individual is incapacitated. Advance Directives may take two forms: • Health Care Proxy – a written directive designating a person to make health care decisions on behalf of an individual when he/she becomes unable to make such decisions. The person designated is the “agent.” • Living Will – a written advance directive in which an individual specifies choices for medical treatment. Euthanasia and Assisted suicide- ‘Euthanasia’ a Greek word meaning ‘good death’ is popularly known as ‘mercy killing’. Active euthanasia involves actions to directly bring about the client’s death, with or without the clients consent. An example of this would be the administration of a lethal medication to end the client’s suffering. Regardless of the care giver’s intent, active euthanasia is forbidden by law and can result in criminal charges of murder. Active euthanasia includes assisted suicide, or giving clients the means to kill themselves if they request it (e.g. providing pills or a weapon). In any case the nurse should recall that legality and morality are not one and the same. Determining whether an action is legal is only one aspect of deciding whether it is ethical. The questions of suicide and assisted suicide are still controversial in our society. The ANA’s position statement on assisted suicide (ANA, 1995) states that active euthanasia and assisted suicide are in violation of the Code for Nurses. Passive euthanasia involves the withdrawal of extraordinary means of life support, such as removing a ventilator or withholding special attempts to revive a client ( e.g. giving a client’ no code’ status). Termination of life sustaining treatment – Antibiotics, organ transplant, and technological advances (e.g. ventilators) help to prolong life, but not necessarily to restore health. Clients may specify that they wish to have life sustaining measures withdrawn, they may have advanced directives on this matter, or they may appoint a surrogate decision maker. However it is usually more troubling for health care professionals on to withdraw a treatment than to decide initially not to begin it. Nurses must understand that a decision to withdraw a treatment is not a decision to withdraw care. As the primary care givers, nurses must ensure that sensitive care and the comfort are given as the client’s illness progresses. Keeping clients and families well informed is an ongoing process, allowing them time to ask questions and discuss the situation. It is also essential that they understand that they can re-evaluate and change their decision if they wish. Withdrawing or withholding of foods and fluids- It is generally accepted that providing foods and fluids is a part of ordinary nursing practice and, therefore, a moral duty. However, when foods and fluids are administered by tube to a dying client, or are given over a long period of time to an unconscious client who is not expected to improve, then some consider it to be an extraordinary, or heroic, measure. A nurse is morally obligated to withhold foods and fluids (or any treatment) if it is determined to be more harmful to administer them than to withhold them. The nurse must also honor competent patients’ refusal of foods and fluids.
  • 5. COMMON ETHICAL DILEMMAS IN NURSING While a career in nursing is immensely fulfilling, it’s not without its share of challenges. Regardless of their area of practice or accreditation, nurses face a multitude of ethical dilemmas every day. While there’s no clear-cut right or wrong answer to the often life and death ethical issues encountered by nurses, there is a set of principles upon which ethical decision making is based. Ethical dilemma occurs when there is conflict between two or more ethical principles. No correct decision exists. The nurse must make a choice between two alternatives that are equally unsatisfactory.  Patient freedom versus nurse control Nurses are highly educated and therefore aware of the best clinical course of action when one exists. But what happens when a patient rejects medical advice and makes a decision that may result in less optimal outcomes? From deciding whether or not a labor and delivery patient would benefit from pain medication, to encouraging a patient to eat when they are refusing food, nurses walk a fine line every day.While nurses do not sign the Hippocratic Oath, they are s till bound by the promise to devote themselves to the welfare of the patients committed to the care, as well as to live up to the standards of the profession.  Reproductive Rights The pro-choice vs. pro-life argument is an intensely personal one based on an individual's core set of values and beliefs. If you are pro-life, can you support a patient’s right to an abortion? If you are pro- choice, can you respect a patient’s choice to continue a pregnancy even if it threatens her own life? With more than 208 million pregnancies occurring worldwide every year, nurses can expect to be confronted with this ethical dilemma on any given shift.  Honesty vs. Information Families will often choose to withhold truthful information to “protect” a patient from emotional distress. For nurses, this poses another common ethical dilemma: does a patient have the right to know everything about their condition, even if sharing the information will cause harm? Is honesty always best? What if sparing a patient this information can promote happier, less stressful final days? Deciding what information will be shared – along with how and when to share it – can be a difficult part of a nurse’s responsibilities .  The Minor Dilemma Working with children presents a unique set of ethical challenges. Not only must nurses consider the best interests of the patient, but they must balance this against the wishes, beliefs and values of a family. While patients, families and physicians may be aligned in the ideal world, in the real world ethical issues do arise. While parents are tasked with difficult decisions too, the nurse’s ultimate responsibility is to the patient. Ethical issues related to privacy can also arise with minors. While they do have some basic rights to privacy, the law requires disclosure of certain information to parents. In many cases, this is information that minors do not want disclosed. In this instance, nurses benefit from an understanding of law, as well as hospital policy.
  • 6.  The Battle of Beliefs What is science-based, empirical knowledge to a nurse might be completely subjective to a patient with a particular set of religious or personal beliefs. Certain religions forbid medical procedures which can mean the difference between life and death. For example, in some cultures and religions, blood transfusions – even lifesaving ones – are unacceptable. A nurse’s attempts to explain the benefits of the procedure weighed against the risks of opting out can overstep the line. Is it the nurse’s job to support the patient’s right to the decision, or is it their responsibility to do everything in their power to urge them toward a preventable action? As science continues its onward march, questions related to ethics and human rights are only expected to grow, pertaining to everything from stem cell research to genetic testing.  Resource Management If a patient is in a medically futile, vegetative state, the cost of maintenance is high. At what point do you draw the line and redirect these resources to patients for whom they could be truly life -saving? How do you balance what may be perceived as a financial decision against what is an entirely personal decision to a grieving family? After all, when it comes to clinging to hope for the survival of a loved one, no resource is poorly spent. Nurses are charged with maintaining a “big picture” perspective while simultaneously dealing with intensely personal situations on a day to day basis. CULTURAL ISSUES IN NURSING Culture refers to the cumulative deposit of knowledge, experience, beliefs, values, attitudes, meanings, hierarchies, religion, notions of time, roles, spatial relations, concepts of the universe, and material objects and possessions acquired by a group of people in the course of generations through individual and group striving. In many cultures, health decisions are not made by an individual but by a group: family, community and/or society. Socialized medicine or government sponsored health care for all residents is reflective of the value placed on collectivism DOS AND DON’S RELATING TO VARIOUS CULTURES Name  Don’t judge a person’s religion by his name.  Don’t use western titles such as Mr,Mrs,Miss,Ms in some cultures.  Do ask for a family name for those who don’t have as specific name  Do avoid repetitions in clinical notes. Find the correct name first rather than misuse several different names Language  Don’t assume that all ethnic minority groups speak English.  Do avoid making assumptions using accurate assessment procedures.  Don’t use the family to interpret intimate questions.
  • 7.  Don’t use a family member to break a bad news. He or she may avoid the issue if it is believed to be too stressful for the client.  Do use an interpreter who understands medical terminology, which will avoid stress for the interpreter and the client and also avoid misinterpretations.  Don’t use the language which is strange for the patients. Religion  Don’t judge about a clients religion  Do avoid incorrect assumptions: find out the different beliefs and approaches.  Do record clearly and make notes of the client’s wishes to see or have present a representative from his religion.  Do ask family who you should contact if the client is not able to rely this to you do remember that many Eastern religions fast on certain days: pray at certain times: wear religious objects or symbols.  Don’t mistake religious objects or symbols for jewellery.  Do check to see if any nursing interventions will compromise any religious beliefs.  Do inform the client and /or family of any nursing interventions before commencing, to check religious beliefs. Diet  Don’t give Jews or Muslims pork or pork products  Do remember that not all Muslims eat halal meat.  Do consult client regarding any diet preferences.  Do remember that being taken out of a family environment can be frightening and cause loneliness, which may cause loss of appetite. Personal hygiene  Do supply the client with a jug of water and a bowl and /or a running tap and empty washbasin to allow hand, face and body washing.  Do make exemptions when the client is dependent  Do remember that all people will not cut their hairs or during special occations. Modesty  Don’t compromise the client’s dignity and modesty.  Do remember that exposure of the female body to the male will cause distress to certain cultures, especially if the client is in purdah.  Do offer separate bays in mixed-bedded wards,or if possible a single room, especially for those in purdah.  Do remember that hospital gowns often exposé more than they cover, and are therefore unacceptable.  Do avoid exposure of arms or legs, for example: in the case of fractured limb .do additional; covering to protect modesty. Hospital procedures  Do give careful thought to hospital procedures and routines before commencing them.  Do remember that discussing elimination or other intimate health issues may be culturally offensive .  Do approach all patients sensitively, ensure privacy and maintain the individual right to self-respect.  Do remember that some medications and treatments may be taboo for some religious groups.
  • 8.  Don’t give Muslims, Jews and vegetarians iron injections derived from pigs.  Don’t give insulin of porcine origin to Jews or Muslims. Visiting  Do remember that limiting visiting to two people may cause distress in extended family cultures.  Do remember that the family may include children, uncles, aunts, grandchildren, parents, and grandparents.  Do remember that open visiting is more accommodating.  Do allow the family to participate in the client’s care. Death and bereavement  Do involve client and family in the care.  `Do remember that Eastern cultures like to take an active part in the care of dying relatives, especially last offices.  Do remember that in certain cultures, custom and practices will need to be followed if the client is to proceed along the continuum of life following her earthly death.  Do ensure that you are conversant with specific cultural requirements for death, bereavement and last offices. CURRENT CONCEPTOF HEALTH Health is individually defined by each person.On a personal level, individuals define health according to – how they feel – absence or presence of symptoms of illness – and ability to carry out activities WHO refers health as situation that may exist in some individuals but not in everyone all the time, it is not usually observed in a groups of human beings and in communities. Nobody is qualified as completely healthy, i.e., perfect biological, psychological and social functioning all the time. That is, if we accept the WHO definition, we are all sick. Health is world-wide social goal. Health and its maintenance is major social investment. Health involves individuals, state and international responsibility. Health is central to quality of life and health is integral part of development. Health is inter- sectoral and which is essence of productive life. Modern society says that health is a fundamental human right. 1. Health as a human right.  Citizens have the right to health insurance, guaranteeing them accessible medical care and free use of medical services under conditions and order.  Health care for citizens is funded by the state budget, employers, personal and collective insurance payments and other sources under conditions and order, stipulated by law.  The state promotes citizens health and encourages the development of sport and tourism.  No single person can be subjected unwillingly to treatment and sanitary measures,except for the cases foreseen in law  The state exercises control over all treatment facilities, as well as the production of medications, bioactive substances and medical equipment and over trade with them.”
  • 9. 2. Social dimension of health includes the level of social skills one possesses, social functioning and the ability to see oneself as a member of a larger society. It states that harmony and integration within and between each individuals and other members of the society. It also refers to the ability to make and maintain relationships with other people or communities. 3 Spiritual dimension ofhealth includes integrity, principle and ethics, the purpose of life, commitment to some higher being, belief in the concepts that are not subject to “state of art” explanation. It is intangible “something” that transcends physiology and psychology. Spiritual health is connected with religious beliefs and practices. It also deals with personal creeds,principles of behavior and ways of achieving peace of mind and with oneself.being at peace 4 Concept ofdisease The oxford English Dictionary defines disease as “ a condition of the body or some part or organ of the body in which its functions are disturbed or deranged”. Webster defines disease as “a condition in which body health is impaired, a departure from a state of health, an alteration of the human body interrupting the performance of vital functions”. The simplest definition is that disease is just the opposite of health: i.e. any deviation from normal functioning or state of complete physical or mental well-being. 39 From ecological point of view, disease is defined as “a maladjustment of the human organism to the environment.” Sickness is a state of social dysfunction i.e. a role that the individual assumes when ill (sickness role). Illness is a subjective state of the person who feels aware of not being well. Disease is a physiological/psychological dysfunction. . 5 Standard of living Income and occupation, standards of housing, sanitation and nutrition, the level of provision of health, educational, recreational and other services all be used individually as measures of socioeconomic status,and collectively as an index of the standard of living. 6 Level ofliving Health is affected by and is affecting the level of living. It consists of certain objective components : food consumption, education, occupation and working conditions, housing, social security, clothing, recreation and leisure human rights. 7 Quality of life A composite subjective measure of physical, mental and social wellbeing as perceived by each individual or by group .Quality of life of individuals e.g. happiness, satisfaction and gratification as it is expressed in such life concerns as health, marriage, family work, financial situation, educational opportunities, self-esteem,creativity, belongingness, and trust in others. 8 Responsibility for health International responsibility, national responsibility, State responsibility: constitutional rights. Community responsibility: health care for the people to the health care by the people. Individual responsibility: self care for maintaining his own health, adoption of healthy life style