Position Statement

Role of the Registered Professional Nurse in Ethical Decision-Making

The intent of this position statement is to offer guidance to registered professional nurses facing ethical issues in practice and to share a framework for ethical decision-making that can be utilized to recognize and resolve ethical dilemmas.

Position

The New York State Nurses Association believes the registered professional nurse should respond to ethical dilemmas by:

• Recognizing the increasingly complex ethical issues in practice
• Practicing in accordance with the American Nurses Association Code of Ethics for Nurses (ANA, 2001)
• Integrating ANA’s ethical provisions in practice and the corresponding measurement criteria identified in Standard 12 of the Scope and Standards of Practice (ANA, 2004, p. 39), which include:
  • Preserving and protecting patient autonomy, dignity and rights,
  • Acting as a patient advocate,
  • Maintaining a therapeutic and professional patient-nurse relationship,
  • Demonstrating a commitment to self-care,
  • Participating on ethics committees and contributing to resolving ethical issues of patients, colleagues, or systems, and
  • Reporting practices that are illegal, incompetent or impaired
• Demonstrating sensitivity to diverse cultural needs.

Background

The climate of advancing medical technology coupled with economic and human resource limitations contributes to the need for discussion about the evolving roles and responsibilities of registered professional nurses on ethics committees, as participants in ethics rounds and interdisciplinary ethical decision-making processes.

In the 1970’s, ethics committees began to be established in response to the Quinlan case in New Jersey (Fletcher & Hoffmann, 1994). These committees were convened to address patient care issues in practice. In 1990, the Center for Ethics and Human Rights became a part of the American Nurses Association structure in response to a House of Delegates recommendation that ethics and human rights issues be integrated throughout ANA. In 1991, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) mandated that institutions address ethical issues related to patient care and required that health professionals be educated about ethics (JCAHO, 2004).

In a 2004 National Ethics Teleconference, JCAHO emphasized that healthcare institutions need to “respect the culture and rights of patients” by “respecting patient autonomy and shared decision-making” (JCAHO, 2004, p3). JCAHO recommends that ethics committees be involved in issues such as:

• Advance directives;
• Informed consent;
• Do Not Resuscitate (DNR) orders;
• Assessment and management of pain;
• Privacy and confidentiality; and
• Organ and tissue procurement and donation.

Registered professional nurses are in the best position to advocate for the rights of their patients and are frequently involved in ethical issues and ethical decision-making processes. Ethical dilemmas arise daily when the nurse is confronted with a choice, in which ethical reasons both for and against the choice are equally desirable (Pierce, 1997). These issues are often emotionally charged. Recent literature (Donovan & Redman, n.d.; Cassells & Gaul, 1998; Clark, 2002; Dinc, 2003) has identified some of the more frequently occurring ethical issues confronting nurses today, including:

• Staffing patterns that limit a patient’s access to care
• Management/administration participation in down-sizing that reduces patient services and staff while maintaining quality care and access to that care
• The protection of patients’ rights and human dignity
• The right to refuse treatment
• The prolongation of the living and dying process and the need to consider the impact on the patient’s quality of life
• Informed consent
• Whether or not to use physical or chemical restraints
• Providing care that may be a risk to the nurse’s health
• Potential differences between nurse and patient belief systems regarding issues such as abortion, euthanasia, and organ and tissue donation
• Bioethical issues raised by medical technologies and treatment such as the use of stem cells from human embryos.

A vital component in nursing education, in both undergraduate and continuing education, is the need to:

• participate in ethical discourse,
• recognize and learn ethical principles, and
• participate in ethical decision-making processes to find solutions to the multitude of ethical dilemmas in practice (Matzo, et.al, 2004, p. 65).

The registered professional nurse, in facilitating the ethical decision-making process, can utilize different frameworks and models. First and foremost, the ANA Code of Ethics with Interpretative Statements offers a statement of every professional nurse’s ethical obligations and duties, ethical standard, and commitment to society (ANA, 2001). The first provision states, “The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems” (ANA, 2001, p. 18). Provision 5 supports the need to identify both personal and professional values, “The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.” The provision speaks to the nurse’s obligation to respect oneself and to “embrace the values of the profession, integrating them with personal values (ANA, 2001, p. 19).

A framework nurses may choose to use for ethical decision-making developed by Cassells (Cassells & Gaul, 1998) provides a systematic approach to processing an ethical issue in nursing practice:

• assess and identify the ethical issue,
• develop a plan based on ethical principles and
• demonstrate a process for implementation and evaluation. Refer to the Ethical Assessment Framework (EAF) (just one example), which could be initiated whenever ethical issues/dilemmas are identified.

Ethical Assessment Framework (EAF)*

Assessment

1. Identify the problem
   Issues, conflicts and/or uncertainties
2. Gather relevant facts
   Medical (objective data); contextual (subjective data); policies, state and federal laws etc.
3. Identify methods of ethical justification to help resolve the dilemma
   Consequentialism (consequences); deontology (duty); principalism (principles); care (relationships); casuistry (cases); virtue (character)
4. Consciously clarify relevant values, rights, and duties of patient, self and significant persons associated with the issue(s).
5. Identify if there is an ethical dilemma(s) present.
6. Identify guidelines from nursing and professional codes of ethics.
7. Identify and use relevant interdisciplinary resources.
   Ethics committee, ethics consultants, clergy, literature, administrators, lawyers, colleagues, etc.
8. Identify and prioritize alternative actions/options.

Plan of Action

1. Select a morally justified action/option from alternatives identified

Implementation

1. Act upon/support the action/option selected

Evaluation

1. Evaluate action/option(s) taken
   Short and long term

*©Framework: ASEAS Instrument:Cassells, J. & Silva, M. 1990
Revised: EAF/Nursing process:Cassells, J. Johnson, E & Littlejohn, J. 1996
Revised: EAFCassells, J. & Gaul, A.L 1997

© 1998: Ethical Assessment Framework (EAF)
Judith M. Casseus, RN, DNSC (et. al)
Reprinted from Maryland Nurse, 1998, p.9. Reprinted with permission of the author, Cassells, J.

Recommendations

The New York State Nurses Association recommends that registered professional nurses:

1. Evaluate their own personal and professional values and reassess them periodically
2. Utilize principles that guide ethical decision-making in practice:
   • Autonomy
   • Beneficence
   • Caring
   • Justice
   • Non-maleficence
3. Participate in interdisciplinary ethics committees and ethics rounds
4. Recognize the values and standards that guide ethical practice in nursing as represented in:
   • The ANA Code of Ethics for Nursing
   • The ANA Scope and Standards of Practice
   • The International Nursing Council Code of Ethics
5. Describe laws that govern nursing practice and address the rights of patients
6. Utilize a decision-making model or framework that will facilitate the recognition and resolution of ethical dilemmas
7. Contact the New York State Nurses Association’s Councils on Ethical Practice and Human Rights for consultation and support in ethical decision-making processes.

Reviewed and revised by the Councils on Ethical Practice and Human Rights on April 29, 2005.
Approved by the Board of Directors on June 8, 2005.

Note: The use of the term “patient” anywhere in this document is intended to be generic and refers to the recipient of nursing care.

Note: This position statement combines three previously developed position statements, Position Statement on Ethics Committees and the Role of the Professional Nurse (1988, Revised 1992 and 1999), Position Statement on Ethical Decision-making (1997) and Position Statement on Ethics Rounds (1982, Revised 1992)

Table 1 - Principles of Ethical Practice and Related Definitions

Autonomy: The right to self-determination. An ethical principle that involves the nurse’s willingness to respect patients’ rights to make decisions about and for themselves, even if the nurse does not agree with the patients’ decisions.

Beneficence: The duty to do good; prevent harm and remove harm.

Care: A broad concept that “in its simplest form, can be described as an attitude or orientation that leads to the beneficent attending, through acts or omissions, of one person towards another” (Cortis & Dendrick, 2003, p.78).

Ethics: The study of values in human conduct or the study of right conduct. Ethics offers a critical, rational, defensible, systematic and intellectual approach to determining what is right or best in a difficult situation.

Justice: The equitable distribution of risks and benefits. Equals ought to be treated equally and unequals may be treated unequally.

Moral: The personal beliefs and cultural values that are the basis for human conduct.

Nonmaleficence: The obligation not to inflict harm intentionally (Beauchamp & Childress, 2001).

Values: The set of personal beliefs and attitudes that we hold in high regard.

Advance Directive: Written instruction recognized under state law relating to the provision of healthcare when an individual is incapacitated. Advance Directives may take two forms:

• Health Care Proxy – a written directive designating a person to make health care decisions on behalf of an individual when he/she becomes unable to make such decisions. The person designated is the “agent.”
• Living Will – a written advance directive in which an individual specifies choices for medical treatment.

Table 2 - Examples of Ethical Dilemmas

Nurses, regardless of their practice setting, face inherent ethical situations. These situations may require consultation with an ethics committee and/or presentation in nursing or medical ethics rounds.

Long-term care:

Intravenous hydration and a feeding tube are ordered for a terminally ill patient with Alzheimer’s dementia who is no longer able to make his own decisions. The healthcare proxy states, “no artificial nutrition and hydration,” yet the healthcare agent insists that a feeding tube be inserted.

Medical/surgical unit:

An order for a feeding tube is written for a semi-comatose patient who has no healthcare proxy or advance directives. A distant relative who has had no recent contact with the patient objects to the feeding tube. New York State law does not recognize surrogate decision-making where family members or others close to the patient may make healthcare decisions when the patient cannot. In this situation, where the patient is incapacitated and without a health care proxy or an advance directive regarding hydration and nutrition, an ethics consult is warranted.

Hospice care:

Opioid medication is being provided around the clock for an advanced lung cancer patient with several weeks of refractory pain. The patient's level of sedation has recently changed and the patient now appears to be in a light to deep sleep most of the time. The family members have asked the Hospice RN to request that the doctor reduce the dosage of the pain medication because they fear this level of sedation could hasten death. The patient's advance directive states that pain medication should be administered to alleviate suffering.

References

American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Washington, DC: Author.

American Nurses Association. (2004) Nursing: scope and standards of practice. Washington, DC: Author.

Beauchamp, T. L. & Childress, J. F. (2001). Principles of biomedical ethics (5th Ed). New York: Oxford University Press.

Berkowitz, K. & Chanko, B. (2004, April 27). National ethics teleconference: ethical principles at the foundation of JCAHO’s ethics, rights and responsibilities standards. (Available from the Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL)

Blake, C.B. & Guare, R.E. (1997). Nurses’ reflections on ethical decision-making: implications for leaders. The Journal of the New York State Nurses Association. 28(4): 13-16.

Cassells, J.M. & Gaul, A.L. (1998). An ethical assessment framework for nursing practice. Maryland Nurse, 17(1): 9-12.

Clark, C. (2002). Ethical decisionmaking in the business of healthcare. Retrieved March 18, 2005, from http://itc.boisestate.edu/mediashowcase/media/EDM_Spring_2002.pdf

Cortis, J.D. & Kendrick, K. (2003). Nursing ethics, caring and culture. Nursing Ethics, 10, 77-88.

Dinc, L. (2003). Ethical issues regarding human cloning: a nursing perspective. Nursing Ethics,10, 238-254.

Donovan, C. & Redman, B. (n.d.) Ethics and human rights issues in nursing practice: a survey of Connecticut registered nurses. Retrieved February 18, 2005, from http://jmrileyrn.tripod.com/ene/research.html

Fedorka, P. & Husted, G. (2004) Ethical decision-making in clinical emergencies, Topics in Emergency Medicine, 26(1): 52-60.

Fletcher, J.C. & Hoffmann, D.E. (1994) Ethics committees: time to experiment with standards. Annals of Internal Medicine, 120, 335-338.

International Council of Nurses. (2000). International code of ethics. Geneva, Switzerland: Author.

Joint Commission for Accreditation of Healthcare Organizations. (2004). Comprehensive accreditation manual for hospitals. Oakbrook terrace, IL: Author.

Matzo,M.L., Sherman, D.W., Nelson-Marten, P., Rhome, A. & Grant, M. (2004). Ethical and legal issues in end-of-life care: content of the end-of-life nursing education consortium curriculum and teaching strategies. Journal for Nurses in Staff Development, 20(2), 59-66

McDaniel, C. (1998). Hospital ethics committees and nurses’ participation. Journal of Nursing Administration, 28 (9), 47-51.

Pierce, (1997).What is an ethical decision. Critical Care Nursing Clinics of North America, vol.9, 1 March, 1-11. #12 back.)

Phillips, B. (2003 ) Survival on the ethics committee: a nurse’s guide. Community Ethics, 4(1). Retrieved February 22, 2005 from www.pitt.edu/~cep/41.6.html

Powell, C. & Nicoll, L. (n.d.). Ethics and human rights issues in nursing practice: a survey of Maine registered nurses. Retrieved February 18, 2005, from http://jmrileyrn.tripod.com/ene/research.html

Re Quinlan, 70 N.J. 10, 355 A. 2d 647, 429 U.S. 922 (1976)

Smith, KV (1996). Ethical decision making in nursing: implications for continuing education. Journal of Continuing Education in Nursing, 27 (1), 42-4.

University of Buffalo Center for Clinical Ethics and Humanities in Health Care. (2000). Bioethics Law in New York State. Retrieved February 22, 2005, from http://wings.buffalo.edu/faculty/research/bioethics/legal.html

When judgments differ. (2004, July-August). Minnesota Nurses Accent, 76(4): 7

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