ethics

1. Ethics
Shumaila Yasir
Sr. Lecturer
ION, POF

2. Objectives
 By the end of the session students will be
ale to;
1. Differentiate between, morals, value and
belief
2. Define ethics and ethical principles
3. Discuss ethical principles in clinical
context
4. Identify different code of ethics in nursing
profession
5. Apply concepts of ethics in clinical
situations

3. Values
 Values
◦ Personal beliefs about truth and worth of
behaviors, thought, objects
 Beliefs
◦ Interpretations or conclusion that one
accepts as true

4. Values
 Personal values develop from
◦ Individual social traditions
◦ Cultural, ethnic religious norms
 Professional values develop from
◦ Socialization into nursing profession
◦ Established code of ethics
◦ Faculty and other nurses
◦ Clinical and life experiences
 Values clarification

5. Professional Values
 Altruism
 Autonomy
 Human dignity
 Integrity
 Social justice

7. Morals
 An individual’s own code for acceptable
behavior
 They arise from an individual’s
conscience
 They act as a guide for individual
behavior
 They are Learned

8. Ethics
 Ethics deals with the
“rightness” or
“wrongness” of human
behavior
 Concerned with the
motivation behind the
behavior
 Bioethics is the
application of these
principles to life-and-
death issues

9. Ethical Principles
 Autonomy
 Nonmaleficence
 Beneficence
 Justice
 Fidelity
 Confidentiality
 Veracity
 Accountability

10. Autonomy
 The freedom to make decisions about oneself
 The right to self-determination
 Healthcare providers need to respect patient’s
rights to make choices about healthcare, even if the
healthcare providers do not agree with the patient’s
decision.

11. Nonmaleficence
 Requires that no harm be caused to an
individual, either unintentionally or
deliberately
 This principle requires nurses to protect
individuals who are unable to protect
themselves

12. Beneficence
 This principle means
“doing good” for others
 Nurses need to assist
clients in meeting all their
needs
◦ Biological
◦ Psychological
◦ Social

13. Justice
 Every individual must be treated
equally
 This requires nurses to be
nonjudgmental

14. Fidelity
 Loyalty
 The promise to fulfill all
commitments
 The basis of accountability
 Includes the professionals
faithfulness or loyalty to
agreements &
responsibilities accepted as
part of the practice of the
profession

15. Confidentiality
 Anything stated to nurses or health-
care providers by patients must
remain confidential
 The only times this principle may
be violated are:
◦ If patients may indicate harm to
themselves or others
◦ If the patient gives permission for the
information to be shared

16. Veracity
 This principle implies
“truthfulness”
 Nurses need to be truthful
to their clients
 Veracity is an important
component of building
trusting relationships

17. Accountability
 Individuals need to be
responsible for their own
actions
 Nurses are accountable
to themselves and to
their colleagues

18. Ethical Dilemmas
 Occur when a problem
exists between ethical
principles
 Deciding in favor of one
principle usually violates
another
 Both sides have
“goodness” and
“badness” associated with
them

19. Nursing Codes of Ethics
 General codes of ethics
 American Nurses Association (ANA)
Code of Ethics for Nurses
 International Council of Nurses Code
of Ethics

21. Why call an Ethics Consult?
 Ethics Consult can help:
◦ Discover and understand the issues
◦ Serves as a forum for sharing of concerns and
questions
◦ Identifies possible treatment alternatives
◦ Provides guidance to the staff, patient, and
family members
◦ Resolves conflicts

22. Using the Nursing Process
 Assessment
 Planning
 Implementation
 Evaluation

23. Approach to Ethical Dilemma
What Values are in conflict
Collect
the facts
Am I involved
Assessment
List and
Rank the options
Identify
Decision-Makers
Determine goals
of treatment
Planning
Use of
discussion and
negotiation
Work towards
a mutually
acceptable decision
Implementation
Re-evaluate as necessary
Determine
whether desired
outcomes have been
reached
Evaluation
Approach

24. Ethical Decision Making Process
 Describe the problem
 Gather the facts
 Clarify values
 Note reactions
 Identify ethical Principles
 Clarify legal rules
 Explore options and alternatives
 Decide on a recommendation
 Develop an action plan
 Evaluate the plan

25. GROUP WORK

26. Case #1
Patient is an 89 year old male admitted with
Hyperkalemia, ESRD, HTN, and Bladder Cancer.
Patient’s past medical history includes recurrent
bladder carcinoma, CVA, hernia repair and
hemodyalisis. Patient was admitted due to weakness
and 2 weeks of diarrhea for which he had refused to
be dialyzed for 7 days.
Patient lives at home with wife and daughter who
are both his healthcare surrogates. Based on
patient’s poor prognosis, oncologist had
recommended on previous admissions that patient
be made Hospice Care with comfort measures.

27. Case #1 Cont.
Daughter and wife have refused Hospice care and
want patient to be dialyzed and continue
aggressive treatment to include full
resuscitation if cardiopulmonary arrest.
Daughter and wife have requested all
physicians to refrain from speaking to patient
about his prognosis.
At this time all physicians have followed
daughter and wife’s request not let patient know
that his cancer has returned, except for the
“new” attending physician.

28. • Autonomy?
• Nonmaleficence?
• Beneficence?
• Justice?
• Fidelity?
• Confidentiality?
• Veracity?
• Accountability?
Is there an Ethical dilemma?

29. What would you do?
 Tell “new” physician to get on board with
the rest of the healthcare providers in
following the wife and daughter’s request…
 Tell the patient that his wife and daughter
are keeping information from him…
 Do nothing…
 Call for an ethics consult?

30. Ethical Decision Making Process
 Describe the problem
 Gather the facts
 Clarify values
 Note reactions
 Identify ethical Principles
 Clarify legal rules
 Explore options and alternatives
 Decide on a recommendation
 Develop an action plan
 Evaluate the plan

31. Resolution
 Ethics spoke with Attending physician and plan
was to speak first with daughter and wife
regarding their role as health care surrogates.
 Attending physician, healthcare team, and
ethics would then meet with patient and inquire
if he wanted information regarding his prognosis
and/or medical care.
 After speaking with daughter, wife, and patient
individually and obtaining a clearer
understanding of the patient’s wishes, and the
clarification of the healthcare surrogates role, a
family conference would be scheduled with
health care team and family to summarize the
findings…

32. Resolution
 Things never go as you plan them…
 Daughter refused to have wife speak with
the team
 Daughter wanted to be part of the
conversation when attending spoke to her
father to inquire if he wanted information or
not…
 Attending agreed to let daughter be present
during the conversation (mistake)

33. Case # 2
88 year old male with extensive medical history including end stage
Parkinson's disease. He was admitted due to pneumonia and was
intubated and now is in Intensive care unit. Patient’s wife was
identified as proxy since patient had never completed an Advance
Directive or had a Living Will.
2 weeks have passed and patient has been unable to be weaned from
ventilator.
Wife continues to indicate she wants to take patient home on the
ventilator…
Attending physician did not feel that wife’s request to take patient
home were realistic nor did he feel patient would have “a good
quality of life.”
His recommendations were Comfort Measure/Withdraw of life
support.

34. Case # 2 Continued
Palliative Care is involved and many family
conferences have been held. Wife refuses to
make patient a Do Not Resuscitate, or sign any
type of withdrawal papers. She wants “full care”
She continues to verbalize she wants to take patient
home.
Wife had full time 24 hour care team at home
taking care of patient and she wants to take him
home.
Ethics consult is called by attending physician….

35. What would you do?
 Try to convince wife that a DNR would
be the best for the patient in his
condition…
 Speak to physician to find out what he
plans to do next…
 Call for an ethics consult

36. Ethical Decision Making Process
 Describe the problem
 Gather the facts
 Clarify values
 Note reactions
 Identify ethical Principles
 Clarify legal rules
 Explore options and alternatives
 Decide on a recommendation
 Develop an action plan
 Evaluate the plan

37. Resolution
Palliative Care and ethics consultant met with wife and
she understood that if he went home, he would have to
have a tracheotomy. Recommendations from team
was to arrange Respiratory department to show
caregivers and wife how to take care of patient once
he was at home with tracheotomy.
Wife agrees to tracheotomy and a consult is requested.
Wife was also informed of him having to go to a skilled
nursing facility first and then after he was stronger
would be able to go home.
Patient was trached and discharge to skilled nursing
facility for rehab.

38. Case #3
54 year old male - history of previous subdural hematoma, HTN,
and atrial fibrillation. Patient aspirated and coded. He is in
intensive care unit on ventilator and Dopamine for
hemodynamic stability.
Attempts at weaning have been unsuccessful…wife (healthcare
surrogate) signed consent for tracheotomy in order for patient to
be weaned off ventilator as recommended by pulmonologist…
On the same day wife signed consent for tracheotomy, Primary
Care Physicians during rounds feels that his prognosis is poor,
and his recommendation for plan of care is to have patient made
CMO and eventually withdrawal of life support should be
initiated, he did not agree with pulmonologist
recommendations…
Pulmonologist does not agree with current plan to make patient
CMO and withdrawal and wants to continue therapy…”he can
improve, give him time”.

39. Case #3 Cont.
Pulmonologist contacts wife regarding the scheduling of
the tracheotomy, and is surprised to find out that she
has signed papers for Comfort Measures Only &
withdrawal of ventilator…
Family is now confused with conflicting goals of
care…wife has agreed to CMO and withdrawal of
vent after speaking with attending but is still not sure
she is doing the right thing…she would like to give
time but “how long?”
Staff is torn between wife’s decision and her
verbalization of “confusion” and physician’s
recommendations and conflicting opinions by
pulmonologist and attending physician…
Pulmonologists calls for ethics consult…patient is not
withdrawn awaiting ethics recommendations…

40. What would you do?
 Tell wife attending is right and she should
sign the CMO papers…
 Tell wife she should get a pulmonologists
second opinion…
 Call Risk Management because of the
conflict between the attending and
pulmonary doctor…
 Call attending and tell him wife is
confused…
 Do NOTHING!
** Ethics Consult was requested by
pulmonologist…

41. Ethical Decision Making Process
 Describe the problem
 Gather the facts
 Clarify values
 Note reactions
 Identify ethical Principles
 Clarify legal rules
 Explore options and alternatives
 Decide on a recommendation
 Develop an action plan
 Evaluate the plan

42. Reference
 Kozier, M. C. Erbs(2009).
Fundamentals of Nursing Concepts,
Process and Practice(9th.ed).
Pearson: Chennai.