👩‍⚕️Foundations of Nursing Practice Unit 20 – Nursing Ethics and Legal Issues

Key Ethical Principles in Nursing

• Autonomy respects the patient's right to make their own informed decisions about their healthcare (self-determination)
• Beneficence obligates nurses to act in the best interest of their patients and promote their well-being
  • Includes providing safe, competent, and compassionate care
  • Involves advocating for patients' needs and preferences
• Non-maleficence requires nurses to avoid causing harm to patients, both intentionally and unintentionally (primum non nocere)
• Justice ensures fair and equitable distribution of healthcare resources and treatment for all patients, regardless of their background or status
• Veracity upholds the importance of truthfulness and honesty in the nurse-patient relationship, fostering trust and ethical decision-making
• Fidelity emphasizes the nurse's commitment to keeping promises and fulfilling professional responsibilities towards patients
• Confidentiality protects the patient's right to privacy and safeguards their personal health information from unauthorized disclosure (HIPAA)

Legal Framework for Nursing Practice

• Nurse Practice Acts (NPAs) are state-specific laws that define the scope of nursing practice, licensure requirements, and disciplinary processes for each state
• Standards of care establish the minimum acceptable level of nursing care that a reasonably prudent nurse would provide in similar circumstances
• Negligence occurs when a nurse fails to meet the standard of care, resulting in harm to the patient
  • Elements of negligence include duty, breach of duty, causation, and damages
• Malpractice is professional negligence involving failure to meet the standard of care, resulting in injury or harm to the patient
• Licensure ensures that nurses have met the necessary educational and competency requirements to practice nursing in their state
• Delegation involves transferring authority to perform a specific task to another healthcare team member while retaining accountability for the outcome
• Documentation provides a legal record of patient care, communication, and decision-making, serving as evidence in legal proceedings
• Mandatory reporting laws require nurses to report suspected cases of abuse, neglect, or exploitation of vulnerable populations (children, elderly, disabled)

Patient Rights and Informed Consent

• Informed consent is the process by which patients receive information about their condition, treatment options, risks, and benefits, and make voluntary decisions about their care
  • Elements of informed consent include capacity, disclosure, understanding, and voluntariness
• Right to refuse treatment allows patients to decline recommended treatments or procedures, even if it may result in adverse health outcomes
• Advance directives are legal documents that specify a patient's preferences for medical care in the event they become incapacitated (living wills, healthcare power of attorney)
• Privacy and confidentiality protect patients' personal health information from unauthorized access or disclosure, as mandated by HIPAA
• Right to access medical records ensures patients can review and obtain copies of their health information, facilitating informed decision-making and continuity of care
• Informed refusal occurs when a patient declines a recommended treatment after receiving adequate information about the risks and consequences of refusal
• Capacity refers to a patient's ability to understand information, appreciate the implications of their decisions, and communicate their choices effectively

Ethical Decision-Making Models

• Principlism applies the four core ethical principles (autonomy, beneficence, non-maleficence, and justice) to guide decision-making in healthcare dilemmas
• Virtue ethics focuses on the moral character and virtues of the decision-maker, emphasizing qualities such as compassion, integrity, and wisdom
• Casuistry involves comparing the current ethical dilemma to similar cases and precedents to determine the most appropriate course of action
• Narrative ethics considers the patient's unique life story, values, and preferences in the context of their illness and treatment decisions
• Care ethics emphasizes the importance of empathy, compassion, and attentiveness to the patient's needs and relationships in ethical decision-making
• Utilitarianism seeks to maximize overall benefit and minimize harm for all involved parties, considering the consequences of each potential course of action
• Deontology focuses on the inherent rightness or wrongness of actions based on moral rules and duties, regardless of the consequences

Common Ethical Dilemmas in Nursing

• End-of-life care decisions involve balancing patient autonomy, quality of life, and the potential for prolonging suffering when considering interventions (artificial nutrition, hydration, ventilation)
• Allocation of scarce resources requires prioritizing patient needs and ensuring equitable distribution of limited healthcare resources (ICU beds, ventilators, medications)
• Confidentiality breaches can occur when nurses inadvertently or intentionally disclose patient information without proper authorization, violating trust and privacy rights
• Informed consent challenges arise when patients lack capacity, have limited health literacy, or face language barriers that hinder their understanding of treatment options and risks
• Moral distress occurs when nurses feel constrained from acting in accordance with their moral judgment due to institutional policies, hierarchies, or resource limitations
• Patient autonomy conflicts can emerge when patients' decisions contradict medical recommendations or the preferences of family members or healthcare providers
• Whistleblowing involves reporting unethical, illegal, or dangerous practices within a healthcare organization, which may lead to personal and professional risks for the reporting nurse

Professional Boundaries and Nurse-Patient Relationships

• Therapeutic relationship focuses on the patient's needs and goals, with clear boundaries that maintain professionalism and objectivity
• Boundary crossings are minor deviations from professional norms that may be well-intentioned but can blur the lines of the nurse-patient relationship (accepting small gifts, self-disclosure)
• Boundary violations are more severe transgressions that exploit the power differential and vulnerability in the nurse-patient relationship, causing harm to the patient (sexual misconduct, financial exploitation)
• Dual relationships occur when nurses have a secondary relationship with a patient outside of the professional context, potentially compromising objectivity and judgment (personal, business, or social ties)
• Social media interactions between nurses and patients can blur professional boundaries and raise concerns about privacy, confidentiality, and the appropriateness of online communication
• Gifts from patients can create a sense of obligation or favoritism, potentially influencing the nurse's decision-making and compromising professional impartiality
• Transference and countertransference involve the redirection of feelings and emotions from past relationships onto the nurse-patient relationship, requiring self-awareness and management to maintain appropriate boundaries

Documentation and Legal Liability

• Accurate and timely documentation is essential for ensuring continuity of care, communication among healthcare team members, and legal protection for nurses
• Charting by exception (CBE) is a documentation method that focuses on recording abnormal findings or deviations from expected outcomes, streamlining the documentation process
• Incident reports are formal records of adverse events, errors, or near-misses that occur during patient care, which help identify systemic issues and promote quality improvement
• Late entries are documentation additions made after the original entry, which should be clearly labeled as such and include the date, time, and reason for the delay
• Alteration of records is the act of modifying or deleting information in a patient's medical record after the fact, which is unethical and illegal, undermining the integrity of the documentation
• Retention of records refers to the legal requirement for healthcare organizations to maintain patient records for a specified period, which varies by state and facility policy
• Electronic health records (EHRs) present unique documentation challenges related to data security, user authentication, and the potential for errors or omissions in data entry and retrieval

Ethical Considerations in End-of-Life Care

• Advance care planning involves discussing and documenting a patient's preferences for end-of-life care before they lose the capacity to make decisions (advance directives, healthcare proxy)
• Palliative care focuses on relieving symptoms, managing pain, and improving quality of life for patients with serious or life-limiting illnesses, rather than seeking to cure the underlying condition
• Hospice care provides comprehensive support for terminally ill patients and their families, emphasizing comfort, dignity, and emotional and spiritual well-being in the final stages of life
• Withholding or withdrawing treatment refers to the decision to not initiate or to discontinue life-sustaining interventions (ventilation, dialysis, artificial nutrition) when they no longer align with the patient's goals or best interests
• Double effect principle justifies the use of interventions that may have unintended but foreseeable harmful consequences (such as hastening death) when the primary intention is to relieve suffering and the benefits outweigh the risks
• Physician-assisted suicide involves a physician providing a lethal medication to a terminally ill patient who requests it to end their life, which is legal in some states but remains controversial
• Euthanasia is the act of intentionally ending a person's life to relieve suffering, which is illegal in most jurisdictions and raises significant ethical and legal concerns in healthcare