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Nursing Ethics Paper
Nursing Ethics Paper
ANA Code of Ethics Provision & Subcategory
As a Vascular Access Specialist and member of a PICC/IV team, I have witnessed many
instances in which ethical principles were in conflict or question. I am fortunate to be a part of a
nursing specialty that is called specifically to evaluate patients for the most appropriate access, as
opposed to simply carrying out a provider’s orders. This aspect is most in line with Provision 8
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of the American Nurses Association (ANA) Code of Ethics which states, “The nurse collaborates
with other health professionals and the public to protect human rights, promote health
diplomacy, and reduce health disparities” (American Nurses Association [ANA], 2015, p.31).
When called to evaluate a patient for access, it is important to consider the entire plan of
care. For example, a PICC line is typically reserved for patients receiving long-term antibiotics
or vesicant medications that can be damaging to peripheral vasculature. With that in mind, it may
be more appropriate to leave a PICC line in place in a patient who has downgraded from
intensive to palliative care to avoid additional venipunctures during a time when the focus has
shifted to symptom management and patient comfort. When determining the most appropriate
access for a patient with consideration for the overall plan of care, Provision 1 of the ANA Code
of Ethics is implicated, which states, “The nurse practices with compassion and respect for the
inherent dignity, worth, and unique attributes of every person” (American Nurses Association
[ANA], 2015, p.1).
Ethical Issue in a Workplace Setting
I was formerly working for a third-party service that provides vascular access (PICC
lines, midlines and even peripheral IV’s) to all phases of care, including: inpatient acute care,
long-term acute care, outpatient infusion clinics and skilled nursing facilities. As a patient in a
skilled nursing facility is under the care of an attending physician just as they would be in a
hospital, it was very common to receive requests for vascular access services for IV antibiotic
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administration in order to avoid a hospital admission/re-admission. One particular instance that
stood out to me was a request for a PICC line on a 93-year-old female nursing home resident
with recurrent urinary tract infections who was to receive a 6-week course of IV antibiotics. This
patient was incontinent, bed-bound, had suffered from advanced dementia for many years and
had an out-of-hospital do-not-resuscitate (DNR) order in place. My colleagues were there the
previous two days placing and replacing PICC lines because the patient did not understand her
treatment plan, required restraint during the procedure and was removing the lines herself when
not under direct supervision of medical staff. She had only received two doses of a q8 hour
antibiotic over the last 72 hours. After reviewing her nursing home chart and the documentation
my colleagues left about their procedures, I determined that a PICC line was no longer the most
appropriate access for this patient. It was dangerous to staff and patient to attempt to restrain
them during an invasive sterile bedside procedure and the patient was at increased risk for vessel
trauma/hematoma/air embolism/inadvertent arterial puncture with repeated venipuncture
attempts to deep veins. It was safer for her to either: receive a peripheral IV, since it is the least
invasive access and the lowest risk to the patient if removed by self; have her medication
switched to PO, which will not be as effective; or be admitted to a hospital, where she can be
closely monitored while she receives definitive care. I discussed this with the bedside vocational
nurse (LVN) who disagreed with my assessment and stated, “We called you to put a PICC line
in. That’s the order, the family has consented to this procedure for the third time, now go do your
job.” As this was not the Provision 8 ANA Code of Ethics health professional collaboration I
was looking for, I consulted my shift lead about the best course of action. My shift lead
instructed me to place the PICC line and move on. My company is compensated per task and we
receive the highest compensation for PICC lines versus less invasive access. It was conveyed to
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me that I had already spent too much time reviewing the case and inquiring about the plan of
care when I could have fulfilled the request and moved on to the next facility. Also, I was
compensated per task as opposed to hourly/salary and it was not even in my own personal
interest to refuse to place a line in that situation.
Effects of the Subcategory Violation on the Patient, Staff or Others
This patient was ultimately not receiving the appropriate level of care for her condition
with consideration for the fact that she cannot advocate for herself, does not understand her
treatment plan, has a degenerative cognitive condition that is terminal in nature, and that
alternative/less invasive therapies (such as palliative care vs inpatient acute care) had not been
considered or discussed with family. The nursing home LVN violated the ethical provision of
health professional collaboration and I felt my shift lead violated the ethical provision of conflict
of interest and patient advocacy in putting customer service to the nursing home and increased
compensation to our company over what was most appropriate for the patient.
Nursing Actions to Prevent Violations
Several preventative measures could have been implemented to avoid ethical violations
in this situation. While it is understandable for a provider to escalate care on an algorithmic basis
considering the patient suffered from urinary tract infections on a recurrent basis, special care is
warranted to avoid aggressive interventions on a patient with limited cognitive ability with
whom treatment noncompliance is high (Blais & Hayes, 2016). The LVN in this situation is
obligated to advocate in the patient’s best interest and should have questioned the plan of care,
specifically after additional PICC lines were being self-removed and multiple doses of antibiotics
were being missed (Blais & Hayes, 2016). My shift lead should have considered my point of
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view about what was most appropriate for the patient instead of focusing on my productivity as
an employee and the monetary compensation our company would receive from providing the
service as ordered.
Ethical Dilemma
In this situation, there were several ethical dilemmas. Both myself and the bedside LVN
for this patient were experiencing the dilemma of preserving sanctity of life vs nonmaleficence,
just from different viewpoints. While I thought her attitude did not promote health professional
collaboration, she was still attempting to implement the prescribed plan of care that would have,
under ideal circumstances preserved the sanctity of life (Blais & Hayes, 2016). From my point of
view, I felt strongly about the principle of nonmaleficence, in that aggressive interventions at this
stage would cause more suffering than they would alleviate (Blais & Hayes, 2016).
Nurse Advocate Actions to Avoid Violations or an Ethical Dilemma
While there was a moment that I questioned whether or not that I may be in the wrong
since I was receiving no support from my shift lead or the bedside LVN, I still elected to discuss
my concerns with the ordering provider. Over telephone I explained at length my assessment of
the situation. He admitted that palliative care had not been discussed with the family and that
they were generally resistant to the patient being admitted to the hospital; they pushed for
treatment to remain at the skilled nursing facility whenever possible. I continued to advocate for
the patient throughout our discussion and he ultimately canceled the order, pending a palliative
care consult.
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Unfortunately, because I violated a direct order from my shift lead, my actions were
deemed subordinate and escalated to my area manager. I was received a light disciplinary action
for the perceived infraction, likely due to lost revenue as a contributing factor.
Future Professional Nurse Actions
In the future, I will continue to advocate for my patients and share my experience as a
cautionary tale. I will continue utilize the code of ethics as a professional nurse (Blais & Hayes,
2016). I have since moved on from that company and work a hospital-based vascular access team
where we receive orders for evaluations, not specific lines. This removes us from
aforementioned ethical conflicts and allows us to perform the most appropriate action for the
patient at the given time.
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References
American Nurses Association. (2015). Code of ethics for nurses with interpretive statements.
https://www.nursingworld.org/coe-view-only
Blais, K. K., & Hayes, J. S. (2016). Professional nursing practice: Concepts and perspectives.
(7th Ed.) Pearson.