Ethical Decision Making
Rachael Hopson
Alverno College
MSN 620
Abstract
This paper discusses processes as observed in the deliberation of two cases in a
downtown hospital Ethics Committee meeting. It discusses ethical principles and
frameworks, facilitation strategies and the deliberation processes that were
implemented in these cases. It concludes with how an Advanced Practice Nurse (APN)
can impact ethical decision making and the significant role they may play. As
healthcare providers, one is constantly faced with ethical dilemmas which can
sometimes be very threatening. However, working in an environment where
collaboration amongst, empowerment of and encouragement of reflection by team
members is promoted, makes resolution of these dilemmas better. The APN is well
skilled to impact and facilitate such an environment.
Dictionary.com describes ethics as “that branch of philosophy dealing with
values relating to human conduct, with respect to the rightness and wrongness of
certain actions and to the goodness and badness of the motives and ends of such
actions.” As nurses working with patients, whether in the hospital or in the community,
we are constantly faced with ethical or moral dilemmas where we must choose between
conflicting and sometimes unacceptable alternatives of action. From a nursing
perspective, Jameton distinguishes two types of moral problems: “moral uncertainty”
where a nurse faces some unease as to what the right course of action should be, and
“moral distress” where a nurse is aware of what the right action would be but for one
reason or another, such as institutional policies or legal constraints, they cannot perform
that action (Hamric, Spross & Hanson, 2009, p. 315). To help overcome such dilemmas,
hospitals and various organizational bodies have Ethics Committees that anticipate
such dilemmas and come up with policies to assuage the problem, as well as provide
avenues where to discuss issues that may come up during patient care.
At a downtown Milwaukee hospital, the Ethics Committee meets every month. It
is an advisory group that is appointed by the hospital’s Executive Board. They may
meet either on request to provide advisory consultation and review on cases where
ethical dilemmas are brought up by the patient/patient's family, the physician/medical
team, or other hospital employees, or as a discussion forum whereby to talk about
various popular ethical topics as relates to the community being served. When meeting
on the basis of consultation the main purpose of the Committee is to encourage
conversation, educate, identify issues, offer options and additional resources, and
encourage problem resolution at the healthcare provider/patient level. To achieve their
goals they use ethical decision-making frameworks to come up with such resolutions;
working their way through the frameworks of gathering information, identifying the
type of problem, then using ethical theories to analyze the problem, coming up with
some alternative actions, settling on the best fit for the patient and then evaluating to
see how effective they were in their choices (Hamric, Spross & Hanson, 2009, p. 328).
The Ethics Committee essentially acts as a patient’s advocate. It also develops and
recommends hospital policies and guidelines that define ethical principles for conduct
within the hospital. Recognizing the benefits of multidisciplinary involvement towards
creative and collaborative decision making, Committee members include doctors,
residents, the vice president of nursing, nurse managers, social workers, lawyers,
someone from the philanthropy department, quality administrators, hospital
administrators, a chaplain, a medical ethics professional and a member from the
community. The Committee meeting is often chaired by a medical ethics professional
who also happens to be a neurology surgeon. Introductions go around the room as in
addition to my presence, as an observing masters nursing student, there are also some
new faces to the group. The minutes from last months’ meeting are approved as
distributed and discussion is opened for this months’ meeting.
For discussion are two main objectives: (i) further evaluation of an ICU consult
from the previous week and (ii) life support for patients without a surrogate decision
maker. The first objective relates to a patient in her forties admitted with ascites – fluid
in her abdominal cavities. A long time and heavy drug and alcohol user she keeps
going in and out of consciousness and it is unsure whether or not she can make
decisions for herself. She also cannot be on anything below five units of oxygen. She has
no children but has a fiancée here in Milwaukee. The rest of her family while not in
Wisconsin, reside in other states within the Midwest. The committee members agree
that a psychiatry consult be obtained for the patient to evaluate competency and
recommend guardianship as well. Communication about care has been between the
patient (to a certain degree), the fiancée and by phone with the family. However, the
fiancée and the family have been budding heads as to what decisions to make. At this
point the patient’s doctors and social worker recommend, against the fiancée’s wishes,
that the family be recommended for guardianship as they want very much to be
involved. Should the fiancée continue objecting, he can contest this idea in court. The
hearing has been scheduled for next month. Several theories evolved during this
discussion but the most dominant was the Principle-Based Model in which resolutions
are guided by principles and rules around “respect for persons, autonomy, beneficence,
no maleficence and justice” (Hamric, Spross & Hanson, 2009, p. 324). During her lucid
moments the patient’s nurses and doctors gathered that she wanted her family involved
and though the fiancée does not want this, the committee is devoted to making sure the
patient’s autonomy is respected by siding with family involvement. Also at this time
there is no suspicion that the decisions made by the family are not in the patient’s best
interest. Some committee members use casuistry theories, relating past cases/situation
to this one and decisions that were taken in the past. It is then agreed that the case will
be reviewed again after the court hearing scheduled for next month.
To address the second topic, life support for patients without a surrogate
decision maker, members use preventive ethics principles. Here the discussion does not
revolve around a current case/issue but instead, around recent research and the impact
it may have in the hospital should such a case arise. A few cases have come up in the
past with regards to the topic of who should bear the responsibility of decision making
where there is not a surrogate decision maker. The committee, using preventive ethics
thus sought to review what policies the hospital has in place so far and develop them
further to accommodate this evolving wing. As the dialogues progress members’
conflicting morals and values become clear. The question is that in cases where nothing
is known about patient preferences, the patient for one reason or another is unable to
communicate their wishes, and has a poor prognosis, how is the decision to withdraw
life support made. The case was presented by a lawyer through review of a research
article. According to the article overall, 5.5% of deaths in the intensive care units
happened with “incapacitated patients who lacked a surrogate decision maker and an
advance directive” (White et al., 2007). The article points out the fact that there is wide
variability in hospital policies and state laws with regards to who is responsible for lifesupport decisions for this population of incapacitated patients. A good sense of
collaboration was observed but also a degree of accommodation as some individuals
were very forceful and persistent with their arguments. The chairman acted mainly in
the role of facilitator as he encouraged more opinions and tried to calm everyone when
it got too heated. Inviting people to keep returning to serve themselves with lunch he
encourages a less formal atmosphere where individuals can relax and be forthcoming
with their ideas. It is agreed that the hospital’s current policies be brought in to next
month’s meeting for review and further exploration. Future potential topic ideas were
discussed as well as speakers. At the end of the hour, the meeting was adjourned.
In ethical dilemmas, “effective communication is the first key to negotiating and
facilitating a resolution” (Hamric, Spross & Hanson, 2009, p. 316) and the ability to
listen is just as crucial. I saw members apply this skill as the lawyer presented the case,
gathering all the information that was being laid before them and starting various
frameworks. Attending this meeting was a very pleasurable experience. One thing that
stood out to me was the lack of bedside nurses in attendance. Advanced Practice Nurses
(APNs) should encourage their staff to attend these meetings or have a box where
nurses can write ethical dilemmas they face on the job so these issues can be discussed.
As an APN, I will be playing a very important role in the identification, negotiations
and navigation through ethical dilemmas. Provision Six of the Code of Ethics for nurses
calls for the “establishing, maintaining and improving healthcare environments” (2008)
such that staff work in an environment where their personal values and morals are in
line with their work surroundings ensuring that conflicts are reduced and ultimate care
to provided to patients. Getting though an ethical dilemma is most effective when the
decision is taken through a collaborative effort amongst a multidisciplinary team and
individuals feel a sense of empowerment towards making these sometimes very
difficult choices.
In conclusion, APNs are in the good position where they can serve as facilitators
and better discussion outcomes. Using the Fifth Discipline Model of personal mastery
(constantly redefining and clarifying one’s own personal vision and assuring personal
growth), mental models (how one views the world and attains new insights and allows
for scrutiny of these views by others), shared vision (how the APN helps the team
sustain a shared future goal), team learning (listening the other viewpoints and thinking
together as a team) and systems thinking (looking at the whole picture to see how
actions impact the system as a whole), APNs can ensure team member empowerment
(Hamric, Spross & Hanson, 2009, p. 257). Developing distinct individualized ethical
frameworks demands that the APN continue to develop and clarify their own personal
and professional values that affect their care and learn the theories and principles, codes
and relevant laws concerning ethical decision making. As these are achieved a sense of
trust and respect is built and the team ultimately feels good about the work they do.
The work environment is conducive to growth and the measurable outcomes are
significantly abundant.
References
American Nurses Association. (2004). Nursing: Scope & standards of practice. Washington,
D. C.: Author.
Fowler, M.D.M. (2008). Guide to the code of ethics for nurses interpretation and application.
Silver Spring, MD: American Nurses Association.
Hamric, A. B., Spross, J. A., & Hanson, C. M. (2009). Advanced practice nursing An
integrative approach (4th ed.). St. Louis, MO: Elsevier Sa