Ethical Challenges in the Nursing Care of Elderly People - Essay Example

Introduction The integral part of nursing is a deferential recognition of human rights ly right to "life and choice, to dignity and to be treated with respect" (ICN, 2006, p.2). Providing nursing care it is necessary to make it deferential of and unlimited by such reasons as age and gender, social position and culture, disability and illness. As it is mentioned in the ICN Code of Ethics for Nurses there are four basic liabilities in nursing care: to contribute to health and regenerate it, to avert illnesses and to ease patient's sufferings (2006, p.3). The necessity of nursing care is a global one. In turn the questions of ethics nowadays obviously represent a key point for many discussions regarding nursing and health care. From this point of view the questions of aging and corresponding nursing care are also of great concern in modern society. Ethics always corresponds to norms and instruction, it is not neutral. It examines the issue of the way everything should be directed regarding fundamental ethical principles of nursing care which are considered by many experts as a cornerstone of ethical guidelines (i. e. autonomy, beneficence, nonmaleficence and justice). However it is important to remember that in nursing ethics usually there is no good or bad, "black" and "white"" (Stacey J., 1998). Resolving any ethical questions and dilemmas it is significant to study the situation taking into consideration not only your own cultural and moral values, but also those of other people concerned. Under the circumstances of ethical dilemma a nurse must respond to signals from another person involved for reasonable deciding the problem. It is necessary for every nurse to remember that the process of making ethical decision is comparatively easy but the results of such decisions may be irreversible. In the context of the proposed case study we'll analyze using the above mentioned major ethical principles ethical challenges in the nursing care of elderly people and examine correspondent ethical pros and cons in this area with the aim of stimulating and contributing to critical comprehending of ethics in nursing. Ethics in nursing A nurse in the first place is accountable to people who really need nursing care. While doing her or his job, the nurse promotes an atmosphere in which the human rights, values, customs and sacred beliefs of the person, family and community are high valued. And it is a nurse who together with the whole society is held liable for beginning and promoting activity to satisfy the requirements of people actually that of vulnerable persons in the area of health and social necessities of the public (ICN, 2006, p.6). Among main standards in nursing care are the hard-edged ability to provide this care that supports standards of personal health and the unprecedented ability to increase confidence of public that keeps up standards of personal conduct. Thus apparently these are both rules and laws that are commonly supposed to stand for the minimal written standards for nursing practice. For instance, there are also some laws that protect a patient from harm, though they certainly don't keep nurses responsible for the level of ethics that contributes to high quality nursing care. Hall (1996 p. 49) considers: "Law is the minimum ethic and, therefore, legal behavior is not necessarily the highest ethic" (cited by Silva, M. and Ludwick, R., 1999a, p.3). However nursing can not count only on external means such as laws and diplomas as well as just on self-reflection to give the profound guarantee of ethical competence in care. Nursing competency from the ethical point of view represents a complicated system that demands a great number of means. In order to practice nursing competently it is necessary both to obey external means of nursing competence and to reflect ethically about competence. A nurse must always bring up questions regarding the nature of ethical competence in their profession, for example, questions about general ethical standards in nursing care and ways to satisfy them (Thompson, E., Melia, K. M. and Boyd, K. M., 2001 p. 27). The American Nurses Association worked out a special code for nurses, explaining the purposes, ethics and values of the nurses. The explanatory assertions for the ANA code, for example, may be considered as a starting point for more profound realization of the nurse position in the conduct which corresponds to ethical standards of care. The extracts from the Code (1985) were determined by Ruth Ludwick to be central key points to the question of ethical competence: The nurse acts to protect the client and the public when health care and safety are influenced by the ignorant, unethical, or unlawful practice of any person. The nurse is responsible for personal nursing judgments. The nurse keeps up ethical competence in her/his job. The nurse exercises knowing judgment and uses personal ethical ability and qualifications as criteria in seeking consultation, accepting responsibility and delegating nursing activities to two others (cited by Silva, M. and Ludwick, R., 2002, p. 3) "Health and nursing care professionals like chaplains, become advocates for the patient," states Sarah Freeman (cited by Stacey J., 1998, p. 8). Trying to answer on a great number of questions in the area of nursing and health care, we face the challenge that the answers are neither "good" nor "bad" as well as neither "black" nor "white". Besides they should not be derived from any individual bias. Anyway we can find guiding principles for deciding many problems and dilemmas from an ethical outlook. The turning-point usually appears when those people who are involved cannot come to understanding about what is suitable from the ethical point of view in the situation concerned. "For the mutual benefit of the person we're serving - the patient - all members of the team must strive to understand and respect the ethical beliefs of everyone involved," writes Sarah Freeman. "We have to learn to come up with a resolution that leaves everyone feeling comfortable" (cited by Stacey J., 1998, p. 7). In order to create such a resolution and usually to resolve an ethical dilemma nurses use four fundamental ethical principles of nursing care and practice, which are considered by many experts as a cornerstone of ethical guidelines. Autonomy The first one is autonomy. This principle means "that individuals have a right to self-determination, that is, to make decisions about their lives without interference from others" (Silva, M. Ludwick, R., 1999b, p. 4). It is also possible to define empirically that autonomy consists of two elements: data acquired or proposed as a presupposition and reaching the decision as the action. Beneficence The second is beneficence. This principle is thought to be a basis of day-to-day nursing care and practice. "The principle of beneficence and utilitarianism direct health care professionals to make an ethical decision to provide the maximum benefit and to minimize harm to the greatest number of people involved" (Silva, M. Ludwick, R., 1999b, p. 4). Beauchamp and Childress (1994, p. 192) state that "Each of ... three forms of beneficence requires taking action by helping - preventing harm, removing harm and promoting good...." (cited by Silva, M. and Ludwick, R., 1999b, p. 4). This ethical principle may cause some ethical questions when a dilemma regarding performing of a patient's wishes appears. Though it is necessary to remember what actually has the priority if we will compare it with nurse's good, a nurse sometimes mixes up with what the nurse considers to be a patient's good. It is questionable what composes "good" for a patient without violating his or her autonomy or allowing the patient to suffer bitterly. And can it be ethical to abolish the choice of the patients. For example Beauchamp and Childress (1994, pp. 277-278) maintain that paternalism can obtain two forms a weak and a strong one. They assert that weak form paternalism implies is that a nurse defends the patient's good when he or she is incapable to resolve some questions as a consequence of problems like depression or the effect of medicaments. But a strong form of paternalism, they say "...involves interactions intended to benefit a person despite the fact that the person's risky choices and actions are informed, voluntary, and autonomous" (cited by Silva, M. and Ludwick, R., 1999b, p.5). Nonmaleficence The third fundamental ethical principle is nonmaleficence or "do no harm", which is easily connected with the obligation of a nurse to defend safe keeping of the patient. "Born out of the Hippocratic Oath, this principle dictates that we do not cause injury to our patients" (Silva, M. Ludwick, R., 1999b, p. 6). Justice The fourth basic ethical principle is justice. This principle implies "giving each person or group what he/she or they are due" (Silva, M. Ludwick, R., 1999b, p. 7). This principle applies to parity, integrity or another point that may be fundamental for the justice decision. In nursing care and practice the principle of justice usually centered on rightful admission to nursing care and on rightful allocation of scarce resource. Rightful admission to the care means that nurses are easy of access to provide nursing care and a patient as well as any member of a society realizes that nursing care is completely accessible. "The principle of justice guides health care professionals to treat every client with fairness and equity regardless the prognosis of illness, social and economic status of clients, the social and financial consequences impose on others" (Wilcockson, M., 1999, p. 21). If we try to use these four fundamental ethical principles to the case study that was chosen for our investigation beforehand we will be able to evaluate the deeds of nurse from ethical point of view. For example, it is clearly evident that nurse violated the principle of autonomy because autonomy of a patient means the opportunity to make decisions about his or her life without interference of others. If taking into account this principle then it was up to a seventy three year old woman to decide either she needs to obtain emergency CPR or not. This principle was thus violated by the nurse, and the reasons for such behavior are not deciding in this matter. She might have ignored this principle basing on the other principles that prevent a nurse from doing harm, meaning to rescue the life of her patient because human life is valuable and unique. But while the nurse deprived her patient of the possibility to choose life or death, the nurse thus made herself responsible for this decision, which is evidently wrong. At least, the nurse should have noted that the patient didn't want to be rescued. As for beneficence, we may suppose, on the other hand, that it was a demonstration of weak form of paternalism. In such case the nurse protected the good of a seventy three year old lady as she was incapable to resolve end-of-life questions as a result of her depression and decreasing of the quality of her life. Consequently the deeds of the nurse were well-taken and righteous. But the nature of the action is also ambivalent, as the nurse might have been directed by her own notion of good, or the notion that the nurse obtained while studying ethics. The nurse shouldn't have been define independently if the woman was really unable to make reasonable decisions, the nurse must have at least objectively estimate the problems and conditions of the patient that led to such patient's intention. This thought may also be confirmed and at the same time called in question by the principle of nonmaleficence. The nurse protected the safety of her patient, but without patient's wish. It is questionable, would be the note of DNR be regarded as the injury caused to the patient. If the life and conditions of this old woman were so poor, they made her suffer; the nurse must have taken it into account while deciding what would be more or less painful for her patient. This may be regarded as the intention to take off responsibility from the nurse. Observing the last principle of ethics, justice, it is necessary to note that this principle was violated by the nurse. Her patient was at least due to be heard. Her wishes and demands should have been taken into consideration, moreover, the patient did not ask to help her die, and she just wanted to prevent her from suffering in future. Thus taking into consideration these four main principles, the case seems to be contradictory. It seems that the nurse acted basing upon her own notion of what is good, safe and just for her patient, without taking into account the demands, wishes, living conditions and problems of her patient. Of course, definite peculiarities of these principles allow justifying the actions of the nurse, if we look at the situation form the point of view of value of human life. One more issue that should be examined is the absence of patient's order for DNR. This may also be a reason to justify the actions of the nurse. But as soon as the demands was heard by the nurse, the nurse should have defined this problems with the patient and helped the woman write a necessary order, if it was her wish. Nurses often can't decide what their actual point of view about some ethical dilemmas is and how far those perceptions go. Anyway nurses should have to do with their own system of moral values but at the same time to determine whether it "fits into the big picture" (Stacey, J., 1998, p.8). It is necessary for a nurse to take a turn for the better foreshortening of problems and challenges in the area of care by forming at any rate a "bifocal view" of the problems (Stacey, J., 1998, p.7) Of course, not all ethical dilemmas concern death. "Nurses deal with ethics on every eight-hour shift. for example, the Nursing Code of Ethics says to hold all things confidential, but sometimes there is information others need to know," explains Freeman (cited by Stacey, J., 1998, p.4). However nurses often can appear in the situation of resolving of a complex moral dilemma that regards an appeal for assisted death. This problem is one of the most complicated issues in nursing practice. This question is also a key one in the case study that we have in some way already investigated earlier. Given the poor quality of life that seventy-three years old woman would probable suffer she demanded not to perform any heroic measures in the event of cardiac arrest. So she does not want to live anymore. But when the nurse sees the patient next she is being resuscitated as there was no Do Not Resuscitate order (DNR) in her notes. Let's consider the nature of notion of a do-not-resuscitate (DNR) order, which gives a signal to a nurse not to perform CPR. This implies that nurses must not use emergency CPR if the breathing or heartbeat of the patient stops. If a DNR order is created for a patient at home than it means that a nurse must neither transport the patient to a hospital for CPR nor perform emergency resuscitation. As it is stated in report Deciding about CPR: Do-Not-Resuscitate (DNR) Orders, A Guide for Patients and Families: "CPR, when successful, restores heartbeat and breathing and allows patients to resume their previous lifestyle. The success of CPR depends on the patient's overall medical condition. Age alone does not determine whether CPR will be successful, although illnesses and frailties that go along with age often make CPR less successful". But in the cases of hard illnesses CPR often can not to resume previous lifestyle of a person, "leaving the patient brain-damaged or in a worse medical state than before the heart stopped. In these cases, some patients prefer to be cared for without aggressive efforts at resuscitation upon their death" (Courtesy of NYS Department of Health, p. 3). Young (2003, p. 4) develops some questions concerning practice connected with the end of life (cited by Silva, M., Ludwick, R., 2003, p. 5). She states the united organizations which provide nursing care usually determine some practice connected with the end of life in their Codes, but at the same time a great number of nurses view end-of-life questions through individual arguments. So the corresponding views that every other nurse involved may represent are aggravating the problem. Thus how to support and save the autonomy and self-determination of a dying person Let's consider the Code (ANA, 2001, p. 9), which can be of good help while deciding such difficult dilemmas of nursing care (cited by Shotton, L., 2003, p. 19). First of all they ask to remember about your primary duty to the dying person. And in the second place your obligation is to help the other people as well as yourself to understand the wishes of the dying person. It is explained like: "The nurse supports patient self-determination by participating in discussions with surrogates, providing guidance and referral to other resources as necessary, and identifying and addressing problems in the decision-making process" (Shotton, L., 2003, p. 20). In the proposed case study the old lady didn't write DNR order, thus, the nurse behaved just adequately. She remembered about her duty to a patient to preserve her autonomy but it was no possibility for her and for her patient to "identifying and addressing problems in the decision-making process" as the lady was too depressed. Her quality of life was decreasing ad she couldn't live independently but it was still questionable were these reasons adequate enough to make end-of-life decision. On this ground it is necessary to investigate the notion of "quality of life". This obscure notion implied the situations when decisions concerning the question of withdrawing nursing care are formed and "based on the likely low levels of self-awareness, reasoning, communication and activity that the patient will have and the low probability of improvement" (Thompson, E., Melia, K. M. and Boyd, K. M., 2001, p. 44). Usually it is not up to patient to make quality-of-life decisions as they are often reached by doctors or relatives. In other words "quality of life" should be determined by patients themselves being able to evaluate it adequately. The unproved understanding of notion is often used in statements like: "After all, we shouldn't waste any more money on this person because their quality of life will be so low, anyway" (Hunt, G., 1994, p. 125) But there is completely another point of view on this matter: "Whose definition of quality do we use This was the way that Nazi Germany rationalized killing mentally ill and handicapped patients. They essentially maintained that the conditions of life that these people led were not worth saving. It would be an act of mercy to kill them. Eventually, it became almost an obligation to the remainder of the Aryan race to dispose of these subhuman elements. Eventually the Nazis killed millions of Jews and Gypsies for similar reasons. These undesirables were polluting the overall quality of life for the great Aryan race" (Cranston, R.). Supporters of the "sanctity of life" represent the side end of a choice and look at free will spectrum in the light of some other ethical and moral values. Followers of "quality of life" uphold right-to-die possibilities while followers of "sanctity of life" consider it is obligatory to maintain the lifestyle of a patient paying no attention on possible result. "The extreme sanctity position is that everything possible must be done for every patient regardless of expense in time, money or personal sacrifice" (Shotton, L., 2003, p. 8) . Such tendency is named "vitalism". Followers of "sanctity of life" also admit the possibility of taking away "feeding tubes from patients in persistent vegetative state" (Cranston, R.) under certain strict circumstances. Scott Rae, in Moral Choices, explains that under the certain circumstances described below such a situation can be acquitted only if: a patient is not able to absorb nutrition; feeding is a load for a patient rather than a benefit; there is no any rational and worthwhile hope of benefit; in the case when "written advance directives dictate, removal may be considered" (cited by Cranston, R.). Considering the case study we may that the "quality of life" of the old lady was not so low as to bring to end-of-life solution. However it was up to the patient to decide that problem independently as it was her right to create DNR order but she didn't do it, besides her depressed state and, thus, low self-determination was among the main reasons for reasonable nurse's acts. It is important for nurses to try to make decisions about a patient without including their own ethical expectations. But anyway there are three fundamental questions that it is possible to put under the conditions of nursing practice while trying to settle an ethical dilemma taking into account any essential action that you are thinking over: Is it lawful Are you going to break any laws by making this decision Is it proportional Is it impartially to all the parties concerned Would you be satisfied with this deed if you were on the place of another party concerned Is it right Are you proud of yourself for the act you are going to do Would you be proud if you are to tell the others about your decision (Hunt, G.,1994 p., 40) Though it is necessary for every nurse to remember that the process of making ethical decision is comparatively easy but the results of such decisions may be irreversible. Anyway generally ethics is the acts that an individual performs for himself or herself with the aim to provide optimum survival. That's why ethical acts have always been survival acts. Thus as history shows us without effective use of ethical values an organization will not survive (Shotton, L., 2003, p.5). One may say that survival is a barest necessity. But it's wrong as survival even for elderly people is "a graduated scale with infinity or immortality at the top and death and pain at the bottom" (Shotton, L., 2003, p.4). Besides nursing ethics should consider "real-world" questions and problems. There are general theories but in the context of different actual case studies they are also transformed in some way. "It's easy in the abstract to say that every person has the right to autonomy," Freeman says, "but when you put real names and cases to the test, you see how to apply those theories. That's what's important" (cited by Stacey J., 1998, p. 2) Freeman suggests that besides ethics provides general base for deciding everyday ethical dilemmas, "it also gives us a desire to deal with the problems. It's easy to say, 'I don't have a choice, I have to report the woman who is going blind,' without looking at the long-term dilemma. If we simply fall back on the rules without examining the real problem, that elderly woman will lose her independence. The real issues too easily get lost. My own position is that I do not have The Truth," she adds. "I have some truths that come from my own life experiences, which are not the same for everyone. I would not try to enforce anything, but would try to understand, to discuss, to influence, and be influenced by. There is something very arrogant about individuals who want to impose their way on others as if it is the only way. Much harm has been done in the name of a specific definition of good" (cited by Stacey J., 1998, p.10). Ethical problems are always difficult, explains Freeman, a highly-qualified hospital nurse. "At its core, nursing involves dealing with the personal aspects of people's lives. And like it or not, that also involves a person's spiritual beliefs" (cited by Stacey J., 1998, p. 12). Conclusion A nurse in the first place is accountable to people who are in need of nursing care. Among main standards in nursing care are the hard-edged ability to provide this care that supports standards of personal health and the unprecedented ability to increase confidence of public that keeps up standards of personal conduct. However nursing can not count only on external means such as laws and diplomas as well as just on self-reflection to give the profound guarantee of ethical competence in care. Nursing care deals with people and their lives and its dependence on person's spiritual beliefs is indisputable. Contents Introduction1 Ethics in nursing.2 Autonomy4 Beneficence.4 Nonmaleficence...5 Justice..5 Conclusion.12 Reference List Courtesy of NYS Department of Health. [n.d.] Deciding about CPR: Do-Not-Resuscitate (DNR) Orders A Guide for Patients and Families [online]. Available from http://www.nys.com [Accessed 14 February 2006] Cranston, R. [n.d.] Finding Your Way Through The Morass of Today's Overwhelming Medical Ethical Dilemmas. Bioethical Decisions [online], [n.p.]. Available from http://www.freemethodistchurch.org [Accessed 17 February 2006] Hunt, G. (1994) Ethical issues in nursing. Routledge. International Council of Nurses (2006) The ICN Code of Ethics for Nurses. ICN [online]. Available from http://www.icn.org. [Accessed 14 February 2006] Shotton, L. (2003) The role of older people in our communities. Hodder Arnold Journals. Nursing Ethics [online], 10(1), 1 January, 2003. Available from http://www.ingenta.com [Accessed 15 February 2006] Silva, M. and Ludwick, R (1999a). Ethical Thoughtfulness and Nursing Competency. Online Journal of Issues in Nursing, 10 December, 1999. Available from http://www.nursingworld.org/ojin/ethicol/ethics_2.htm [Accessed 17 February 2006] Silva, M. and Ludwick, R. (1999b). Interstate Nursing Practice and Regulation: Ethical Issues for the 21st Century. Online Journal of Issues in Nursing, 2 July, 1999. Available from http://www.nursingworld.org/ojin/ethicol/ethics_1.htm [Accessed 14 February 2006] Silva, M. and Ludwick, R. (2002). Ethical Grounding for Entry into Practice: Respect, Collaboration, and Accountability. Online Journal of Issues in Nursing, 30 August, 2002. Available from http://www.nursingworld.org/ojin/ethicol/ethics_9.htm [Accessed 14 February 2006] Silva, M. Ludwick, R., (2003) Ethical Challenges in the Care of Elderly Person. Online Journal of Issues in Nursing, 19 December, 2003. Available from http://nursingworld.org/ojin/ethicol/ethics_14.htm [Accessed 15 February 2006] Stacey J. (1998) A Question of Ethics. Emory Nursing University[online]. Available from http://www.whsc.emory.edu/_pubs/en/ [Accessed 17 February 2006] Thompson, E., Melia, K. M. and Boyd, K. M. (2001) Nursing Ethics. 4th ed. [n.p.] Wilcockson, M. (1999) Issues of life and death. [n.p.] Read More