Ethical Care Decisions in Wartime Nursing
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Making the Hard Decisions: Ethical Care Decisions in Wartime Nursing Janice Agazio, PhD, CRNP, RN, FAANP, FAAN Assistant Dean for Doctoral Programs and Ordinary Professor School of Nursing The Catholic University of America Codes of ethics set forth standards of ethical conduct for nurses. However nurses involved in wartime operations, or disasters, may often have their moral compass challenged by the patient care decisions necessary under adverse conditions. Reverse triage, resource allocation, and promotion of patient autonomy present multiple challenges to meeting commonly applied ethical principles. This study used the ICN code of ethics as a framework to organize the ethical issues emerging from war time nursing. This paper represents a secondary analysis of two studies using thematic analysis to identify ethical issues encountered by military nurses during the recent conflicts in Iraq and Afghanistan. Data were collected during focused interviews from 111 military nurses. Across both studies issues as resource allocation; patient triage; cultural differences; and equitable treatment for all emerged as challenges. Nurses were at a loss at times about how to best manage the situations and recommended more education in ethical decision making before, during, and after deployment as a debriefing strategy. Similar issues have been documented in military and disaster literature indicating such challenges are not limited to the recent conflicts but cross time and location. By better understanding how nurses define, assess, and manage the ethical situations they encounter in wartime nursing practice, military nurses can better prepare for future conflicts; provide mentorship and targeted education to reduce feelings of moral distress; and promote ethical decision making t promote outcomes in accordance with nursing’s ethical codes. Consent and Authorization David Atenasio, PhD candidate Loyola University Chicago, Chicago, IL The terms “authorization” and “consent” are often used interchangeably in discussions of ethics and health care. Other times, the concept of informed consent is defined as a form of authorization. I will argue that this is a mistake. We ought to keep authorization and consent distinct, as they denote two different morally transformative relationships. Consenting involves giving permission to another to perform actions that are ordinarily impermissible. Authorization entails obligating another to advance one’s interests on one’s behalf. Many medical agreements involve consenting and authorizing. By agreeing to surgery, one typically gives a health care professional permission to touch or operate on one’s person and requests that the health care professional perform the procedure on one’s behalf. But some forms of research participation may involve only consenting to the study without authorizing anyone to advance one’s interests in any way. Conversely, in giving an advance directive, one may authorize another to make medical decisions on one’s behalf without necessarily consenting to any specific procedure. By making this distinction, we can inquire into whether or not consent and authorization relationships ought to conform to different standards. It could be that the norms for a valid authorization relationship are identical to the norms of a valid consent relationship. But it may be that one relationship ought to require more stringent epistemic or volitional criteria than the other. Medical Ethics in the Hospital: Era of Ethical Decision-Making and Standards for Consultation in the Healthcare System Jasia Baig, B.S., M.S., Ph.D. Center for Healthcare Ethics, Duquesne University Pittsburgh, Pennsylvania During the past few decades, the healthcare system has undergone profound changes in their healthcare decision-making competencies and moral aptitudes due to advancement in technology, clinical skills and scientific knowledge. Healthcare decision-making deals with morally contentious dilemmas ranging from illness, disability, and life and death judgments that require sensitivity and awareness of patients’ preferences and consideration of medicine’s abilities and boundaries. As the ever-evolving field of medicine continues to become more scientifically and morally multifarious, physicians and hospital administrators increasingly rely on ethics committees to resolve problems that arise in everyday patient care. The role and latitude of these committee’s responsibilities: dispute intermediaries, moral analysts, policy educators, counseling, advocating, and reviewing suggest the importance and effectiveness of a fully integrated ethics committee. Despite achievements on Integrated Ethics and progress in developing standards and competencies, there remains a necessity for improvement in ethics consultation in areas of credentialing, professionalism and standards of quality. These concerns can be resolved by pursuing various approaches using hard and soft models oriented towards education and intervention outcomes. Adopting stronger standards of quality by implementing a credentialing process, upholding normative significance for the American Society for bioethics and the Humanities’ core competencies, advocating for professional Codes of Ethics, and further clarifying best practices is absolutely vital in improved productivity, patient satisfaction and institutional integrity. Enhanced operational skills, ethical reasoning, core knowledge, credentialing and training can be achieved by professionals to enhance quality in ethics consultations. Addressing Incivility in Nursing: Use of Moral Courage by Nurse Leaders Kimberly A. Brooks, MSN, RN Magee-Womens Hospital of UPMC Pittsburgh, PA Incivility, also known as bullying or horizontal violence, can take many forms from derogatory statements to physical harm. Incivility can create physical, emotional, and psychological symptoms leading to job dissatisfaction and increased turnover. Incivility can impact patient care and patient safety. Organizational impacts include: increased turnover and decreased productivity. Regulatory and professional agencies have issued recommendations for leaders of organizations to address incivility in the workplace. The purpose of the study was to determine if an educational program for nurse leaders can improve the perceived ability of the leaders to act with moral courage to address uncivil behavior. Two theories, identified as relevant to incivility in the workplace, Freire’s Oppression Theory and Kanter’s Structural Theory of Power guided this quasi-experimental design. A one group pretest-posttest was used. The study took place in a 363-bed tertiary care facility. A convenience sample of nurse leaders completed a pre-survey, education and a post-survey. Analysis was conducted on 37 matched pairs of surveys. The tool that was used was the Professional Moral Courage (PMC) Scale. It is comprised of fifteen statements divided into five themes with three statements per theme. Three areas of statistical significance were found using a paired t-test comparing the pre-survey to the post-survey scores. The results indicated improvement in two of five themes, acting morally and using a proactive approach, and in the overall score. The researcher concluded that leaders need to utilize moral courage and address incivility. By witnessing the leaders’ role modeling civil behaviors and taking action in the face of incivility, staff should also demonstrate the same behaviors. Getting It Right: Tools for Teaching Ethical Analysis Jill E. Burkemper, PhD Saint Louis University – Albert Gneagi Center for Health Care Ethics Saint Louis, MO 63014 When instructed to write about or discuss cases entailing an ethical dilemma, nursing students often struggle in their ability to identify the case’s ethically relevant factors and to articulate a clear argument supporting an ethically preferred response. Publications devoted to ethical reasoning in health care often fail to provide sufficient guidance for this task. This presentation will address why this task can be particularly challenging for nurses and why frameworks in popular health care ethics textbooks are insufficiently helpful. It will present an original case analysis method that has proven effective both in the presenter’s several years of teaching graduate nursing students and in her and her colleagues’ experience teaching undergraduate health care ethics courses. End of Artificial Life Ethics Cynthia C Coleman, D. Bioethics (c) MA, RN John J Lynch Center for Ethics, Medstar Washington Hospital Center Washington, DC Left Ventricular Assist Devices (LVAD) offer permanent CPR to patients with advanced heart failure. Some of these patients are eligible for heart transplants, others are not. It is a regulatory requirement to do psychological testing on patients prior to implant. Known complications of the therapy include major depression. Although a detailed life style consent is completed prior to implantation, yet no discussion can ever convey the difficulty of living dependent upon wires and battery packs. Three case studies of patients who requested cessation of LVAD therapy after implantation will be discussed. One patient never left the hospital after implant; the second is a married, employed man with young children who is living an independent life but is unhappy with the burdens of his equipment; the third is a woman with the onset of severe paranoia. Her family advocated for cessation, citing her pre-surgical Advance Directive. What is an ethical process relating to lifestyle consenting?