Strategies for Promoting Ethical Decision Making in Health Care Organizations - Essay Example

Strategies for Promoting Ethical Decision Making in Health Care Organizations Introduction: Ethical decision making is the process of clinical decision making considering the ethical principles of professional practice. This indicates that there would be some conflicts between the ethical principles and practical application of care, and thus this process is necessary to resolve a problematic area of major concern. Ethical scenarios are guided by the principles and knowledge of ethics, and the medical decisions are guided by medical or clinical knowledge. Therefore sensitivity to the given situation and allegiance to the specific set of principles ultimately determine which knowledge domain to draw upon in practice. Moral sensitivity and ethical awareness raises sensitivity to the details of the situation, case, or scenario, and promotes the professional to raise questions in order to justify the right and good, just and fair, respect for individual human dignity, benefits, and burdens. It signifies that ethical decision making a complex process with multiple angles with mainly social implications that tends to analyze factors such as ethical principles, social and interactional aspects, and situational and contextual factors. It is important to remain aware that all these factors need to be considered while making a decision in clinical practice. Taking the example of the issue of autonomic "right to die", this is common issue in clinical practice, especially in the critical care nursing practice. However, practically the issues surrounding death and dying is no longer simple for its legal implications and technological advances that can sustain life for unimaginable duration of time. In these situations, the nurses face dilemma for allocating resources to these patients, and this often enters into the decision making process. The patient's wishes and concerns of the family also impact decisions. For nurses, these ethical situations become more crucial due to invariable conflicts between professional duties and obligations and ethical responsibilities. This means the nurses are faced with the conflicts between the duty to meet the needs of the patients and the obligations to follow hospital policy in that particular issue, implying they are obligated to comply with doctor's orders and legal implications of various interventions and patient-related actions even though the ethical principles do not permit them. In the current scenario, the critical ethical principles will be examined in a critical manner based on this preamble and evidence for current policies would be sought as it is relevant to practice and clinical decision making (Vanlaere, L. and Gastmans, C., 2007). Case: This is the story of a 67-year-old man, who lost control of his vehicle and had struck a guardrail in a single-vehicle collision. He was not wearing a seatbelt and was ejected through the windshield and sustained severely traumatic closed head and chest injuries. He was brought to the trauma center via helicopter and was admitted to the neurological intensive care unit. The staff provided support to the patient as per medical advice, and he was receiving mechanical ventilation and was unresponsive. Obviously he was surrounded by multiple invasive catheters and equipment. The trauma team briefly met the patient's daughter who was the only family present, soon after the admission, and they explained the grave prognosis of her father to her. This patient's care was complex, and the nurse preceptor along with a junior postgraduate nurse was administering the care. The investigations revealed that the patient had severe internal hemorrhage in the brain and in the chest, and some trauma to the heart could not be ruled out. The patient was on mechanical ventilation through intubation, was in deep coma, was nil orally until the consciousness was restored. The other parameters that were being monitored did not show any sign of improvement, and the patient could not be stabilized to the required degree so as to be able to perform some surgery to explore the traumatized anatomical locations. Meanwhile, it was revealed that the patient had no advanced directive to withdraw life supports if such situation arises, and his daughter was his designated decision maker according to his living will. His daughter was very anxious and was obviously under distress and was repeatedly asking about his condition. Just after her morning visit, the alarms of the monitors for the cardiac and arterial catheters sounded indicating a cardiac arrest, and a CPR was initiated. This code situation was efficiently managed by the team including the nurses and doctors, but over days, the situation did not improve, and he became virtually unresponsive to all forms of treatment. In this situation, his daughter requested for withdrawal of all life support systems and critical care, and the medical team could not agree on a decision to discontinue treatment despite repeated requests from her daughter. The daughter felt angry and nurses felt frustrated and torn. Intensive care is heavily reliant upon the input of nursing: in fact, without the high ratio of nurses to patients intensive care does not exist. In this environment, each patient is supposed to be cared for according to the ratio of one nurse to one patient and that there is a doctor present on the unit. There is a tendency to regard intensive care as the area within the hospital which has the concentration of ethical issues. With technological advances in life support systems that are used in the intensive care setting, once it was feasible to maintain life by means of mechanical support while damaged organs recovered or not, the end of life became a far uncertain entity, and this uncertainty brought in moral dilemmas in relation to such decisions. Moral outrage and distress are common when there is coexistence of conflicting perspectives, and usually, as in this case, the question regarding what is right and what is good is also often a matter of perspectives. The major ethical principles that guide such decision making include beneficence, non-maleficence, justice, and autonomy. Briefly, for making the context clear, these by conscious design, are ethical principles utilized in practice for professionals. These are thus a set of standard behavioural preconditions that are necessary for agreement and professional interactions in the healthcare setting. The right to autonomy is the right to be self and to the desired value; the right to freedom is the right to uninterfered persuasion of one's own purposes, the right to objectivity is right to act on an objective view of reality and of own life without being deceived or being stressed; non-maleficence indicates one's right to be not harmed; right to justice is access to liberty and equality. It is to be remembered that ethical situations are not objective realities, rather a conglomeration of subjective meanings. Scientifically interpreted, ethics arose from the necessity of making decisions within adversity or conflicts, and as guiding principles, the mutual recognition of these rights is the most essential element of ethical interactions between the nurse and the patient. In the ethical context of healthcare practice, therefore, that which increases human welfare is ethically acceptable and not those which contradicts human welfare. The demands of a successful living in a human life looks at the human condition and ethics could also involve the ethical conditions of interactions. In order to decide what is right for the person, ethics examines the process of decision making and the ways actions reach or fail to reach the ethical goals (Cortis, JD and Kendrick, K., 2003). The ethical issues which arise in this intensive care unit are in many ways the same as those which arise in any area of clinical practice, and as explained, they have, among other things, to do with respect for persons and the balance between doing good and causing harm. It is therefore expected that an analysis of this decision making process although set in the back drop of ICU, would construe the critical analysis of the dilemmas to carry a lesson for others who practice in a less dramatic and less acute settings. By virtue of the condition of this patient, the ethical issues are functions of that setting. This patient is obviously vulnerable, unconscious, and is completely unable to conduct his own affairs, and for that matter fails to exercise his choices. The ethical perspective of care, nursing or medical will fundamentally thus transcend the moral concerns directly determined by this setting. For example according to the principles of autonomy, the nurses are charged with actions that are in the best interests of the patient, and in this case, they have to act even without knowing what they are, since the patient cannot autonomize his own affairs in this setting. Nevertheless, this case can be a very useful example of ethical decision making process on the face of dilemmas, and the setting is ideal since ethical issues arise routinely in all cases in an ICU. The clinical practice in the ICU setting are designed to meet the critical needs of the patients, but the effects decisions in such settings can be far reaching since the existence of these intensive care practices and technologies causes a rise in expectations of provision in other areas of care. The application of four principles approach in the ICU setting tends to sharpen the debate, and the moral issues that arise often present in the form of a dilemma, where decision making is of utmost importance, and it is the area, where question of prolongation of life arises very frequently (Cronqvist, A., Theorell, T., Burns, T., and Ltzn, K., 2004). Scenarios such as this are not uncommon in the intensive care units, which are areas of clinical practice where teamwork is essential. As exemplified by this case, different professional cultures work in close proximity to each other. Any ethical debate arising in such situations regarding decision making, is bound to demonstrate the conflict between the power relationships of the nurses and physicians. The existence of intensive care and the fact that admission and management in an ICU is a possible course of action in the treatment of life-threatening, severe illness has an impact on our perceptions of what is possible about life even in the grimmest outlook. However, ethical and financial issues are often known to constraint the practice in an intensive care unit. It is an expensive resource, hence question often comes from them who are spending, especially when the patient belongs to an older age group, is it worth having care in the intensive care unit The ethical dilemmas that arise specially when taking a decision about withdrawing life support systems from a patient, and it is often the case that this is an area of practice which has problems of a different ethical order from the rest of healthcare arenas (Ferrand, E. et al., 2003). Intensive care offers aggressive management which may offer benefits in the short term, and it has been acknowledged that in the long run, such a course of management may not prove to be in the best interests of many patients. The next point arises, since the care and management in the ICU are of different order and priorities are different due simply to the fact that management decisions often follow the urgent need of saving a life, which is the basic ethical principle of healthcare. Whether this magnitude of battle against odds is ethically permissible when the outcome is evidently negative, when healthcare measures appear more like an academic and technical exercise of the personnel involved is another issue. So, the answer to the question, as to which ethical principles to follow to make clinical decisions, nursing, medical, or healthcare, the safest response is healthcare ethics, but unfortunately, the healthcare ethics may be in stark opposition to the nursing ethics. It is then when the ethical dilemma arises, and the decision is not simply easy (Elpern, EH., Covert, B., and Kleinpell, R., 2005). Thus putting the patient in the center, this working formula would emphasize the importance of and obedience to interdisciplinary teamwork in the healthcare system. In the clinical practice, complex issues like this may arise, and the questions and problems are solved around professional teamwork, power relationships, ethical and legal considerations, and the mandates from hospital organizations. In this scenario, only one aspect of end-of-life care in the ICU setting has been discussed, but it must be remembered that those caring for such patients would need to be proficient only in saving lives, but also would be able to deliver expert care at the end of life. The expectancy in life is higher than before or otherwise due to new drugs, devices, and tools, and they are parts of the American medical culture since they are perceived as tools to counteract or modify the fatality of a disease, and this culture belongs to the patients, their families, and caregivers. This enthusiastic technology-dependent practice often overlooks the patient's wishes, quality of life, and financial burdens against benefits. Moreover, the patient's highly dependent clinical condition and the complexity of ICU environment, often lead to a situation where the determination and certainty of personal preferences and values are not always possible, always difficult, and not infrequently ignored (Vincent, JL., Berr, J., and Creteur, J., 2004). The technological flurry of intense activities often swallows the quality and content of communication and relationship with patients and their families. Several studies have pointed out the ethical deficiencies in the decision making process for withholding or withdrawing life support systems in the ICU. Most often due to resource burdens, decisions to forego life-sustaining treatment measures are common in such settings. Several studies have also pointed out these ethical shortcomings while the decision is made, and nurses' opinions and perspectives are often ignored due to power distribution in the team. In these cases, physicians in the ICU focus on curing their patients, and nurses are primarily concerned with the impact of care on their patients. The major issue and dilemma, however, is same for all, whether the consent of the patient or a surrogate as in this case is sufficient ethical support to make decisions to forego life-supporting treatments legitimate, when there are disagreements among care givers (Kinoshita, S., 2007). Understanding human conditions and respect for human dignity are core ethical principles of human care. Attentions to cues that facilitate connections with the human being are essential for the morally reflective practitioner. These cues may give the patient an identity beyond his clinical condition. To be able to make a decision which is ethically sound, the nurse is required to broaden her awareness beyond the situational and contextual aspects of the medical condition for which the patient is being treated and must consider the social aspects, which may appear irrelevant from the medical context, of the patient as a person, such that every patient has a right to be treated according to his unique character structure. In this scenario and in the given situation, the ethical decision must consider the fact that every patient has the right to decide and act on his own values to fulfill his own life plans. Nurses are conferred with considerable moral responsibility due to their proximity to the patients and his relatives, and their views must be considered in the decision making process. That, which is decision in favour of withdrawal of life supports by the physicians, is euthanasia and a chargeable offense from the nurses' perspectives. Therefore major dissents exist between the caregivers regarding ethical perspectives and consequent decision making, and nurses overall are greatly dissatisfied with these decisions. The major concern of the nurses with the limiting and withdrawal of treatment and life support systems are in cases where medical intervention and intensive care are deemed to be clinically and morally futile. The prime concern in the debate is to admit those who will benefit and to know when to stop when the benefit no longer is in prospect (Sibbald, R., Downar, J., and Hawryluck, L., 2007). The inclusion of a sociological analysis in the discussion of ethical issues provides some way out of this difficulty. It is to be remembered that many patients die in the ICU following the life-sustaining therapy is withheld or withdrawn. Obviously, this is a violation of ethical principles since the patients' preferences are not considered since they are not in a position to understand the outcomes and risks of specific interventions. There is evidence that despite themselves feeling that their education and clinical expertise about end of life decisions are even less than inadequate, both physicians and nurses continue to involve themselves in unethical decision making, more from the point to views of organizational demands (Kumas, G., ztun, G., and Alparslan, NZ., 2007). Now the question arises, what would be ethical The end of life decision making is the process when the healthcare providers, patients, and their families can have a chance to meticulously consider what treatment or treatments will or will not be used to treat a life-threatening illness. Advance directives such as a durable power of attorney for healthcare, is an opportunity for the patient to express their life preferences in anticipation before any such illness occurs. In reality, in the actual care setting, especially in the ICU, the advance directives have little if any decisive role to play and they have little impact on the care received in more than 50% of the cases. On the other hand studies have shown that patients who do not have advanced directives, they often receive orders of do not resuscitate. Moreover many patients continue to receive all aggressive modalities of treatment with the target of cure even when a do not resuscitate decision has been accepted if a cardiac arrest took place. On the other hand 70% of all ICU deaths occur after do not resuscitate orders have been written. As in this case the background of decision is a resuscitative effort, it is important that the patient's daughter has requested no resuscitative efforts, and since the decision may result in a do not resuscitate order, the content of that order needs to be decided. Ethically, it may be asked who will decide that and how. The matter that is pertinent here is withholding or withdrawing life-sustaining therapies, and ethically withdrawing therapy is equivalent to withholding therapy. In the absence of advanced directives, the patient's relatives have limited rights to participate in the decision making process where withholding care may lead to death (Downey, L., Engelberg, RA., Shannon, SE., and Curtis, JR., 2006). This discussion has implications to nursing practice and health policies. Health care ethics would fit teamwork if it is less adversarial. Nursing and medicine, the two main professional groups involved in the care, could adopt a less discipline-specific approach to ethics in healthcare. Healthcare ethics should keep in mind the multidisciplinary teamwork approach to care, the realities of organizational life and clinical practice. The recommendation would be that the two main professions in health care - medicine and nursing - should work toward a commonly agreed upon healthcare ethics, with a focus on the need of the patient instead of professional interests. It can be backed up by high quality decision making which is a process where collection of opinions and proposals of all involved. Sharing the information and decisions about grounds on which treatments are withdrawn or withheld, among the care providers and the family in all steps of care can lead to decisions about modalities of foregoing life-sustaining treatments ensuring involvement of all the parties in the decision making (Schneiderman, LJ. et al., 2003). This decision should consider factors like compliance with ethical principles and legal obligations. This process must ensure diffusion of specific information on patients within the caregiver team. The agreement must reflect consideration by all of the patient's prior quality of life, religious beliefs, expressed wishes to not receive resuscitation or receive it, family members and their wishes, history and prognosis of the disease, expected future life with the used management strategy. It is to be remembered that nurses' involvement in such decision making process is very much necessary, when the reality is that in most such cases, the nurses' opinions are given the least weightage, despite the suffering of the nurses from these ethical dilemma is the most, only second to the relatives. Reference List Cortis, JD and Kendrick, K., (2003). Nursing Ethics, Caring and Culture. Nursing Ethics; 10: 77 - 88. Cronqvist, A., Theorell, T., Burns, T., and Ltzn, K., (2004). Caring About - Caring For: moral obligations and work responsibilities in intensive care nursing. Nursing Ethics; 11: 63 - 76. Downey, L., Engelberg, RA., Shannon, SE., and Curtis, JR., (2006). Measuring Intensive Care Nurses' Perspectives on Family-Centered End-of-Life Care: Evaluation of 3 Questionnaires. Am. J. Crit. Care.; 15: 568 - 579. Elpern, EH., Covert, B., and Kleinpell, R., (2005). Moral Distress of Staff Nurses in a Medical Intensive Care Unit. Am. J. Crit. Care.; 14: 523 - 530. Ferrand, E. et al., (2003). Discrepancies between Perceptions by Physicians and Nursing Staff of Intensive Care Unit End-of-Life Decisions. Am. J. Respir. Crit. Care Med.; 167: 1310. Kinoshita, S., (2007). Respecting the Wishes of Patients in Intensive Care Units. Nursing Ethics; 14: 651 - 664. Kumas, G., ztun, G., and Alparslan, NZ., (2007). Intensive Care Unit Nurses' Opinions About Euthanasia. Nursing Ethics; 14: 637 - 650. Schneiderman, LJ. et al., (2003). Effect of Ethics Consultations on Nonbeneficial Life-Sustaining Treatments in the Intensive Care Setting: A Randomized Controlled Trial. JAMA; 290: 1166 - 1172. Sibbald, R., Downar, J., and Hawryluck, L., (2007). Perceptions of "futile care" among caregivers in intensive care units. Can. Med. Assoc. J.; 177: 1201 - 1208. Vanlaere, L. and Gastmans, C., (2007). Ethics in Nursing Education: Learning To Reflect On Care Practices. Nursing Ethics; 14: 758 - 766. Vincent, JL., Berr, J., and Creteur, J., (2004). Withholding and withdrawing life prolonging treatment in the intensive care unit: a current European perspective. Chronic Respiratory Disease; 1: 115 - 120. Read More