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Chapter 17: Ethical/Legal Principles and Issues Ethics of Care Compassion Equity Fairness Dignity Confidentiality Mindfulness of a person’s autonomy within the realm of a person’s abilities and mental capacity Ethical Concepts Principles that facilitate decision making and guide our professional behavior Evolve from our beliefs and values Ethical decision making is driven by moral reasoning – our determination of what is right and wrong Define our character and are expressed in our conduct and actions Code of Ethics: ANA Code for Nurses – A set of moral principles accepted by all members of the profession – Provides tools for identifying ethical responsibilities and to guide decision making Conflict and Dilemma Moral distress: occurs when someone wants to do the right thing but is limited by the constraints of the organization or society Moral uncertainty: defines the confusion surrounding situations in which a person is uncertain what the moral problem is or which moral principles or values apply Conflict and Dilemma (cont’d) Moral dilemma: arises when two or more moral principles apply that support mutually inconsistent actions True dilemma: occurs when it appears there are no acceptable choices Ethical/Moral Principles Advocacy – Championing of the needs and interests of others Autonomy – Person’s right to make independent choices/decisions – Respect for personal lifestyle, values, beliefs, and choices – Educate, provide support and resources but cannot force compliance with recommended treatment Informed consent Advance directives – Avoid paternalism Beneficence/Nonmaleficence To do good and do no harm To prevent or remove harm Failure to rescue – Effectiveness in rescuing a patient from a complication vs. preventing a complication Definitions Confidentiality – The right to privacy – HIPPA (need to know) Fidelity – Keeping promises or being true to another – Being faithful to commitments and responsibilities Fiduciary Responsibility – Good stewardship Definitions (cont’d) Justice – Fairness of an act or situation – Treat equals equally and treat those who are unequal according to their needs – QOL – Sanctity of life (right to live) ANA Code of Ethics for Nurses “Nurses may not act with the intent to end life but may support and act on well-thought-out decisions regarding resuscitation status, withholding and withdrawing of lifesustaining care including nutrition and hydration, and aggressively managing pain and other symptoms at the end of life even if such care hastens death.” (Mauk, page 592) More Definitions Reciprocity – Ability to be true to one’s self while respecting and supporting the values and views of another Veracity – Accuracy, truth – Not misleading or deceiving Patient Rights Advance Directives and Living Wills Durable Power of Attorney Competence – May be transient – Legal competence is determined by the courts Assisted Suicide – ANA does not support it in any form – ANA suggests that nurses focus on providing competent, comprehensive, and compassionate EOL care Ethics in Practice Mistakes happen – – – – – Admit the error Take steps to correct the situation Apologize Make amends if possible Evaluate how to prevent in the future Malpractice – deviation from standard of care than results in injury or damage Conflict of Interest – Competing loyalties and opportunities Chapter 21: Alternative Health Modalities What is Complementary and Alternative Medicine? NCCAM: “A group of diverse medical and health care systems, practices, and products that are not presently considered part of conventional medicine” 5 domains or classifications – – – – – Whole medical systems Mind-body medicine Biologically based practices Manipulative and body-based practices Energy medicine Whole Medical Systems Homeopathy – Goal: Stimulate the body’s own healing responses to prevent or treat illnesses – Dilution process Naturopathic medicine – Body is supported and barriers to cure are removed – Diet and nutrition – Hydrotherapy – Spine and soft tissue manipulation – Acupuncture and acupressure – Herbs, Exercise, Counseling, Light Therapy Whole Medical Systems (cont’d) Ayurveda – Comprehensive system that encompasses the body, mind, and consciousness connection – Seeks to restore a person’s harmony or balance – Includes diet, exercise, meditation, herbs, massage, exposure to sunlight, controlled breathing, and detoxification – 5 elements and 3 types of energy Traditional Chinese medicine – Includes acupuncture, herbal medicine, massage, and meditation – Two apposing forces: Yin and yang Acupuncture Promotes the flow of qi through pathways in the body called meridians According to WHO, there is support for the use in the following: – – – – Post-op pain Chemotherapy induced n/v Pregnancy induced nausea Dental pain It is believed that it releases endogenous opioids similar to TENS Promising in the treatment of – Headache, CVA rehab, OA, LBP, carpel tunnel, and asthma Mind-Body Interventions Acknowledge that emotional, mental, social, spiritual, and behavioral factors can directly affect health Includes: – – – – – – – – Prayer Deep breathing Meditation Yoga Biofeedback Tai chi Guided imagery Pet Therapy and Music Therapy Biologically Based Therapies Botanicals Animal-derived extracts Vitamins/Minerals Fatty acids Proteins Prebiotics and probiotics Whole diets: vegetarian, macrobiotic, Atkins, Zone (see page 674 of text) Myth: “If a little is good, more must be better.” Manipulation and Body-Based Practices Believe that parts of the body are interdependent and the body has the ability to heal itself Includes: – Chiropractic and osteopathic medicine – Massage therapy – Reflexology – Rolfing Energy Medicine Veritable energy fields – Mechanical vibration – Electromagnetic forces Putative energy fields – – – – Reiki qi gong Healing (or therapeutic) touch Prayer for the health of others (intercessory prayer) Most controversial because they can’t be measured Reasons for CAM Use Pain relief Increased quality of life Maintain health and fitness Sense of well being Dissatisfaction with traditional Western medicine Supplement to traditional medicine Kinder and gentler medicine Difficulty with accessing health system Nursing Interventions Ask about use of CAM Ask specifically about use of vitamins and herbs Some herbs/vitamins may interfere with prescribed medications Integrated care may be best for the older adult Chapter 24: End-of-Life Care EOL Initiatives EPEC: Education in Palliative and EOL Care ELNEC: EOL Nursing Education Consortium CAPC: Center to Advance Palliative Care Historical Attitudes “In the Orient, dying is a requirement. In Europe, dying is inevitable. In America, dying appears to be an option.” Results in expensive medical care – Medicare pays out 5-6 times more for care within the last 12 months of life than any other time Background information Every person has the right to a peaceful death and some control at the end of life. 80% of Americans say their wish is to die at home but less than 25% get to do so. Nurses have the opportunity to influence the process – Nurses spend more time with patients and families – Can provide support, education, and guidance Communication Talk about the elephant in the room EPEC 6 steps – Get started: plan what to say – Find out what the patient knows – Find out how much the patient wants to know – Share information – Respond to feelings – Plan/follow up Advance Directives Durable Medical Power of Attorney Living Will – 5 Wishes (legal in 40 states) CPR Directive – Colorado specific – MD order – Allow natural death (AND) Curative Care There are patients, families, and cultures who choose the lifeprolonging focus of care of a hospital death Usually an ICU setting Promotes doing everything possible Don’t make judgments Hospice Dying is a normal part of the life cycle Promotes the idea of “living until you die” Provides comfort and dignity at EOL Care is provided in multiple settings and supports the patient/family through the dying process as well as providing later bereavement support to surviving family Eligibility is based on life expectancy of 6 months or less Palliative Care “Seeks to prevent, relieve, reduce, or soothe the symptoms of disease or disorder without effecting a cure” (Field & Cassel, 1997). Whole-person care for those with lifelimiting illnesses who are not yet eligible for hospice Care, not cure, oriented Goal is highest quality of life possible for patients and their families in their given situation Control pain and other symptoms Symptom Management: Respiratory Dyspnea – – – – – Morphine po or sc Relaxation techniques Use fans and/or cool, humidified air Elevate the head of the bed Oxygen Anxiety r/t fear of suffocating – Lorazepam Excessive overload secretions results from fluid – Scopolamine – Atropine Symptom Management: Gastrointestinal/Nutritional Constipation – Combination softner/stimulant – Relistor (methylnaltrexone bromide): an injectable medication, approved for patients with later-stage advanced illness who use a continual regimen of opioids Nausea/vomiting – – – – – – Dexamethasone Meclizine Scopolamine Compazine pr or po Metoclopramide Zofran, Kytril Symptom Management: Gastrointestinal/Nutritional Decreased appetite – Eating for pleasure is the goal - provide favorite foods – No dietary restrictions - high calorie, small frequent meals – PEG tubes and TPN have limited role – Less nourishment required Hydration – – – – May be detrimental to comfort Contributes to fluid overload Popsicles, ice chips Meticulous mouth care Symptom Management: Anxiety/Delirium Realize that these often occur together in the elderly especially Delirium – Occurs in last hours to days of life – Causes: pain, dyspnea, constipation, urinary retention – Reduce stimuli – Family/loved one at bedside – Re-orient if possible – Provide emotional support – Music therapy – Anti-anxiety meds may be helpful Symptom Management: Anxiety/Delirium/Depression Anxiety – Relieve physical symptoms, i.e. pain, SOB – Family/loved one at bedside – Anti-anxiety medication Maximize symptom management Assist persons to draw on sources of strength Encourage verbalization/Acknowledge fears Educate (help sort real fears from imagined) Listen Symptom Management: Pain Unrelieved pain can contribute to unnecessary suffering Pain may actually hasten death by increasing physiological stress Under-appreciated, under-reported, and under-treated Misconceptions About Pain in the Elderly Pain is a natural outcome of growing old. Pain perception or sensitivity decreases with age. If an elderly person does not report pain, he or she doesn’t have pain. If an elderly patient appears to be asleep or otherwise distracted, he or she doesn’t have pain. Potential side effects of opioids make them too dangerous to use to relieve pain in the elderly. Alzheimer patients and others with cognitive impairments do not have pain, and their reports of pain are most likely invalid. Pain Pain is subjective Pain is whatever the experiencing person says it is, existing whenever he says it does.” (McCaffery, 1968) There are many different descriptions of pain: sharp, dull, nagging, burning, tingling, electrical, shooting, aching, throbbing, squeezing, cramping. Fear of addiction should not be a factor in pain control. Types of Pain Nociceptive – Somatic Tissue, bone, joint, connective tissue injury Can localize NSAIDS, steroids, opioids, may require combo Ex: fracture, bone mets, muscle strain – Visceral Internal organs Unable to localize Opioids Ex: shoulder pain, lung or liver mets Neuropathic – Injury to peripheral or central nerves – Anticonvulsants or tricyclic antidepressants – Ex: shingles, diabetic neuropathy Pain Management Good assessment of pain is the first step in treatment Suffering can increase pain Excellent and safe medications are available so that persons should not have to die in uncontrolled pain. Other therapeutic modalities can also help relieve pain and suffering Pain Management Step 1: Mild pain (1–3 on 0–10 scale) – Acetaminophen and NSAIDs – Acetaminophen should be dosed at 4,000 mg/day or less. An adjuvant may also be used Step 2: Moderate pain (4–6 on a 0–10 scale) – Low-dose, short-acting opioids, in combination with acetaminophen and NSAIDs – Combination medications have a ceiling dose – Adjuvants may also be used Step 3: Severe pain (7–10 on a 0–10 scale) – Opioids; not used in combination with Tylenol or NSAIDs so there is no ceiling for dosing – Allows for the use of higher doses of these opioids – Nonopioids and adjuvants may also be used Grief, Loss, Bereavement The dying process involves loss. Most losses trigger mourning and grief reactions. Grief is an emotional response to a loss. It is an individual process, not an event. Mourning is the outward expression of a loss. How one mourns is often influenced by culture and religion. Bereavement includes grief and mourning. This includes inner feelings and outward behavior. Communication 80% of communication is nonverbal We should communicate respect, acceptance, a value of human life, an understanding of suffering, a compassion for the dying as well as the living We should advocate for the patient’s best interest Patients and families want to know that we will not abandon them, but will listen, tell the truth, and be there for them Hope A patient can hear a terminal diagnosis and still have hopes for the type of life remaining Hope for appropriate help and support A good death is possible – – – – – Instilling good memories Uniting family Avoiding suffering and pain Becoming spiritually ready Saying good-bye Death Death is a universal process 10% sudden 90% from chronic illness Advocacy, communication, education and support are key Be ready and prepared to assist families with the death vigil The Dying Process No one can predict the exact time of death. It is determined by a number of variables. The dying process is a natural slowing down of all biological and mental functions. The Dying Process Some patients seem to know when death will occur. Listen to what they tell you and believe them. When hydration and nutrition are removed, death often does not occur “quickly”, as family members might expect. Help them be prepared. Physical Signs and Symptoms of End of Life Confusion, disorientation, delirium Weakness and fatigue with surges of energy at times Change in sleeping patterns Decreased oral intake Decreased swallow reflex Restlessness, agitation, picking at things Change in bowel and bladder patterns Signs and Symptoms of Impending Death Decreased urine output Cold and mottled extremities (earlobes may mottle first) Vital sign changes Respiratory congestion Breathing pattern changes Signs and Symptoms of Death Non-responsive No heart beat and respirations Incontinence of stool and urine possible Pupils fixed and dilated Skin is pale, waxen, and cool to the touch Eyes may remain open Jaw may fall open Nursing Interventions Be there. Remember that you may be there as much for the family as for the patient. Listen Touch Pray Make accommodations for any cultural issues/beliefs Nursing Interventions Give the family something to do. For example, keeping the cool wash cloth on the forehead. Some family members will need a “job”. Give the family time to rest. Remember that the death vigil may be long. Promote family involvement. Nursing Interventions Educate the family as to what to expect. Remember that they may not only feel grief, but also guilt, uncertainty, frustration and other emotions. Encourage family members to talk to the dying person. Provide a peaceful environment. Allow the person to die the way they wish. Questions How do I feel about palliative (comfort-based) care? How would I feel if I knew that I was going to die?