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Discuss legal and ethical influences upon specialist nursing practice...
Throughout history nursing has been based on ethical principles. In conjunction with relevant nursing laws, which propose the minimum standards of care which must be achieved, these principles not only serve to protect the individual requiring healthcare but also as guidelines to the nurses themselves in order to resolve difficult situations.
It should be noted however that it is difficult to create laws that are neither too specific nor exclusive as each patient case presents a unique situation. As such, current laws provide a considerable amount of flexibility in decision making by the professional. By law all health professionals must strive to achieve the optimum care for any individual.
Irrespective of the specialist field, the basis of a nurses’ relationship with patients requires that nurses have an understanding of ethics in order to remain professional and subsequently make the correct choices for a particular scenario. The UKCC Code of Professional Conduct (UKCC 1992) is a guide for nurses and midwives on professional practice. This guide states that a nurse must avoid committing professional misconduct through an action or omission which harms the patient.
Nurses in all forms of practice have the duty to inform patients as much as possible on their health situation. The patients’ illness should be clearly explained along with the available types of treatment, the care available and prognosis. This is important not only to make the patient feel more empowered, as lack of knowledge can lead to feelings of helplessness, but also so the patient can make important decisions on their care and treatment. One of the main ethical principles to which nurses must adhere is ‘respect for patient autonomy’2. If the patient is deemed to have the capacity to make decisions upon the treatment they want then their requests should be fulfilled. However it remains unclear whether the nurse commits an offence if patient health is compromised further due to patient wishes being fulfilled2,.
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Nurses must explain their reasoning behind what treatment they think would be most suitable for a patient. Actions which ignore a patient’s decisions are considered paternalistic2. The desire for nurses to adhere to the ethical guidelines may become difficult when the treatment requested by the patient is considered harmful by the nurse or indeed where the patient refuses to have the treatment or care that is offered2. Conflicts may arise relating to religious beliefs. Jehovah’s Witnesses for example will object to blood transfusions. Nurses, as a result, may consider whether, acting against patient autonomy can be justified. Patient rationality may be affected by either the illness itself or the emotional stresses of having a serious illness. So whilst patient autonomy is a key ethical principle which nurses can support via information provision, two other principles, beneficence and non-maleficience, must also be considered2,5.
Specialist nurses work in a defined field of nursing, for example clinical nurse specialists and oncology nurses. This allows nurses to demonstrate greater levels of judgement. Considerable time spent with the patient results in greater levels of trust ensuring the patients feel supported. Specialist nurses are often faced with critically or terminally ill people, where fear becomes a factor for the patient. People look to the specialist nurse for help and guidance. Nurses must not abuse their position of power in these circumstances.
Specialist nurses may see the patient they have been involved in the care of for some time deteriorate rapidly. With modern day technology providing more effective life-sustaining interventions nurses face even more difficult choices e.g. should artificial nutrition and hydration be provided? Through conversation with the patient the nurse may know that the patient would not wish to be kept alive in this manner. But what is right? If the technology is available to sustain that life but the patient does not support the treatment, what is the correct judgement? Ultimately you would consent to the patients’, wishes however conflict with family members could arise. If conflicts cannot be sorted out then judicial review may be required1.
Apart from in a limited number of countries, such as the Netherlands, euthanasia is not an acceptable act. However cases in the media have brought this deeply controversial topic into the public arena. Euthanasia represents an important topic as it involves both legal and ethical considerations.This is particularly important for specialist practice nurses, where care can often continue up until the death of the patient. Nurses, being the main contact for information and advice, would have a key role to play in euthanasia should it ever become legalised.
Euthanasia can be classed broadly into two forms. The first, active euthanasia, is not deemed acceptable at present and is the causing of death through direct action. Passive euthanasia, which is more easily accepted, is causing death by omission. Nurses, with their daily contact with patients would know the patients’ desires. Sometimes cases regarding end-of-life decisions need judicial review (as stated previously laws are fairly flexible so when dispute arises court intervention is required to assess individual cases). As in the case of Diane Pretty, who was in the latter stages of motor neurone disease and wanted her husband to help her die6.
For specialist palliative care nurses looking after a patient with terminal cancer for example, a nurse may feel a moral obligation to ease the suffering of the patient or the patient may request assistance from the nurse. A nurse must ensure that the patient is kept as comfortable as possible but remember the legal implications of her actions. A nurses’ action is this situation would be influenced by both legal and ethical reasoning.
There is a need to maintain boundaries with the patient so when ethical dilemmas arise judgement can be made from a professional standpoint devoid of emotional attachment as this could impair judgement and decision making skills4.
All patients should be given the same standards of care irrespective or wealth. Laws are in place to prevent patient care being compromised due to costs4. Whilst it is important for the nurse to maintain a good relationship with the other medical staff, from a legal and ethical perspective, primary duty is to the patient. If a nurse suspects a co-worker is behaving inappropriately regarding the care of a patient the nurse must have the courage to speak up against her colleague.
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One study found that where nurses had been provided with considerable ethical education they were less stressed at work4. Nurses must adhere to the four main ethical principles – autonomy, beneficence, justice and non-maleficience5. Laws try to clarify what appropriate action should be taken but court intervention is sometimes necessary when actions would result in these principles conflicting. As each case is unique there is no black and white guide for specialist nurses. Their role in healthcare is an important one and for nurses to behave appropriately they must be aware of both the legal and ethical issues surrounding their work. With the advances in genetic techniques nurses now face even more challenging situations where knowledge of ethics is a substantial requirement.
References
Doyal,L., Larcher, V F. (2000). Drafting guidelines for the withholding or withdrawing of life-sustaining treatment in critically ill children and neonates. Archives of Disease in Childhood 83(1), pF60-F63.
Dugas, R. (2005). Nursing and genetics: applying the American nurses association code of ethics. Journal of Professional Nursing 21(2), 103-113.
Haddad, A. (2003). When advocacy crosses the line. RN 66(1), 27-28,30.
Moody, J. (2003). Euthanasia: a need for reform. Nursing Standard 17(25), 40-44.
O’Sullivan Maillet, J., Potter, R L., Heller, L. (2002). Ethical and legal issues in nutrition, hydration and feeding. American Dietietic Association 102, 716-726.
Scanlon, C. (2003). Ethical concerns in end-of-life care: when questions about advance directives and the withdrawl of life sustaining interventions arise, how should decisions be made? American Journal of Nursing 103(1), 48-55.
Seifert, P C. (2002). Ethics in perioperative practice – commitment to the patient. The Association of Perioperative Registered Nurses76(1), 153-154, 156-160.
Woodward, V. (1998). Caring, patient autonomy and the stigma of paternalism. Journal of Advanced Nursing 28(5), 1046-1052.
http://news.bbc.co.uk/1/hi/health/background_briefings/euthanasia/1044740.stm
http://www.nurses.info/law_for_nurses_ethics.htm
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