Throughout nursing professions, nurses face many legal or ethical dilemmas. Every nurse is required to know the ethical and legal aspects of health care. Nurses must understand these codes to practice safely and protect their patients. Although understanding the difference between law and ethics is important for nurses. Ethics respect moral values and actions. Such values include autonomy, utilitarianism, confidentiality, and much more. On the other hand, laws are the rules of conduct that are required. Nurses must comply with these rules or face disciplinary action.
Advance directives are an expression of a patient’s choice and wish for medical care that is based on a person’s values and beliefs. Advance directives also require selecting a proxy, someone who can represent the interests of the patient in making decisions. Discussions about advance care planning can continue in the outpatient setting. At any point during their last year of life, it is common for patients with prolonged chronic disease to seek treatment in outpatient settings. Recognition of the terminal nature or stage of an illness is a stimulus for conversations regarding patient needs and an alternative identification.
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Presented with a dilemma, knowing nothing can be done because a patient living will, or advance directive say do not resuscitate. And having a patient die knowing full well that CPR could have revived such a person. However, there is a legal aspect as the family might proceed with a lawsuit against the hospital and have the nurse punished due to lack of action on their loved ones as it is the choice of their deceased to inform them or not. This is allied with the patient legal rights as a person.
Nurses play an advocate role in facilitating conversations with patients, families, and health care team members at the end of life care. Decision-making is a very important, yet complicated process, and it poses various challenges for patients and their families to make up a decision on end-of-life care before a life-threatening crisis occurs. Patients have the right to state their expectations for end-of-life care. And if the patient’s wishes are uncertain, the final decision made will be in the patient’s best interest. The Patient Self-Determination Act (PSDA) encourages contact between health care providers and patients. The right of the patient to voice their end-of-life care decisions autonomously must be protected ethically by the light of the use of advanced treatment options and their prognosis. This right to autonomy has certain limits and is thus faced with an ethical dilemma. There are still difficulties and uncertainty about not resuscitating (DNR) orders, given patient, family, and proxy decision-makers making informed choices. The health care professional should respect the autonomy of the patient while taking into account its limitations and conduct their duties to support the patient without harm.
As everyone is different, so is our belief system. A person may consider classifying a thing as right, which can be seen as a taboo in another’s. Some nurses whose beliefs, values are different from that of the patient most likely would want to be assigned to a patient with similar beliefs. However, as a nurse, if such circumstances occur and go against one belief or values, it is required to report to the charge nurse as he or she will be reassigned to a more comfortable circumstance.
Nurses are required to provide comprehensive and compassionate end-of-life care. This incorporates recognizing when death is close and passing on such information to the families. Nurses and other health care providers have to develop decision-making mechanisms that embody medical conditions, a patient needs an awareness of what may or may not be done clinically. Establishing treatment priorities for this patient at this time might provide a basis for debate on what care should be provided. Sometimes, this process includes cooperation with decision-making professionals, such as ethics boards or palliative care teams. (ANA, 2016).
A good end of life should focus more on what care a nurse can provide than what they forgo. Don't try to deal with issues yourself. Share your thoughts with your head nurse. Unless the policy of the facility is vague, which will include the ethics committee. Nonetheless, if the policy isn’t clear the manager can notify the physician for assistance. Risk management will also be contacted for medical leadership to assess the condition, and likely resolve the question of medical practice.
The perception of nurses shouldn’t impact end-of-life care as everyone is equal no matter what advance directives say. Just because a patient has DNR on their record, doesn’t mean such person will be treated less by demonstrating less care regarding he or she is about to die and focus the attention of care on those who want to live. Even if such a decision is made by the patient, that should not change or interfere with the comfort and safety of the patient. Every patient has the right to be treated fairly no matter what the status or level of terminally ill the disease is. Nurses are accountable for respecting the patients' wishes no matter what the circumstances are. If the living will or advance directives say no CPR, nurses should refrain from it, and if it does, do everything possible to save the patient's life. If such an order is disobeyed, it could lead to termination, license suspension or withdrawal, lawsuits, and so on.
There are numerous moral principles to see while examining DNR orders like beneficence, non-maleficence, autonomy. However, it is difficult to figure out which rule is most significant when they contradict one another. DNR order makes a gray area of when and what number of nurses can intercede with a patient before CPR is necessary. A DNR shows that CPR isn't to be started but allows all other clinical interventions to happen. Nurses are regularly excluded in the plan of action of a DNR request, which makes advocacy hard. An instance is a nurse who chooses to rescue a patient whose wishes were otherwise, however, were not stated on their end-of-life care. The nurse in this scenario battled a choice between negligence versus non-maleficence. A DNR request doesn't mean, do not care.
In Texas, the legislature passed a law that regulates inpatient do not resuscitate orders (DNRs) which have gone into effect in hospitals across the state (BCM, 2019). It is intended to protect patient autonomy, but also raises ethical concerns. If a patient can make medical decisions and applies for an inpatient DNR order to be issued, then two competent adults will serve as a witness to the patient's consent. Including observing requirements, the new regulations also limit who may act as a witness. Any witness cannot be an employee of the attending physician of the patient, or a health care facility employee where the patient seeks medical treatment. If the patient loses ability, the current rules provide for the discontinuation of the patient's DNR order by a legal guardian (as assigned by the court) or by an agent named in a medical attorney's document. While at first sight, this provision may not seem problematic, the language of legislation authorizes the doctor to reinstate the request, even if it is against the patient's wishes, which violates the values of autonomy. Considering that new regulations limit the ability of a legal guardian or an attorney to revoke the DNR order, it remains unclear when and if the DNR order could be revoked by another suitable proxy (e.g., spouse). The new regulations also created several uncertainties for physicians and other related healthcare professionals to practice.
As a coworker or nurse manager, I will assign such patients to a nurse who is more comfortable providing care. Doing this proves teamwork, where everyone's opinion is valued without being judged. Showing the workplace is meant to be safe, to prevent negligence, malpractice, and many more, as this is against the ethics of nursing if the standard of care is not performed well. By allowing such nurses to state concerns about the situation while respecting confidentiality. After which is identified as a non-discriminating act, but rather values, then such a nurse can be transferred or reassigned to different patients. However, if negligence or malpractice is noticed, such will be reported to the proper hierarchy to intervene before it escalates into a bigger problem.
According to the Oklahoma Nursing practice act, a punishable act means any criminal action allowed by the state's laws which is imposed by the licensing board against a nurse, including actions against such person license or multistate licensure privileges such as revoking, suspending, probation, limiting and monitoring of licensee's practice, or other restraint on licensure that can affect a nurse to practice.
In summary, nurses must be advocates for the patients. Without being a part of the decision-making process during ethical dilemmas, they are unable to fulfill their responsibility to advocate. Nurses and others must have the knowledge and communication skills to explain to patients, and more often to families why organ transplantation, chemotherapy, CPR, or an IV cannot help this patient and therefore should not be provided.
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