Ethical Dilemmas in Emergency Nursing

Chapter 5 Ethical Dilemmas in Emergency Nursing



Bernard Heilicser


Ethics are what a person’s conduct and actions should be with regard to self, other human beings, and the environment. Ethics does not necessarily represent what is actually happening or what the law demands.


Ethical dilemmas arise as emergency nurses are often placed in situations where they are expected to be simultaneously agents or advocates for patients, physicians, and the organization. They may have conflicting needs, wants, and goals, as well as different personal ethical beliefs. How the emergency nurse handles these situations affects patient care and the nurse’s moral satisfaction.


Emergency nurses sometimes need to choose among the available, but less than ideal, options. Using a systematic approach and available ethical tools will help nurses make better ethical decisions and feel confident about them.



Conflicts between the medical provider and the patient or family, within the family, or between medical providers often signal an ethical dilemma.



Ethical Frameworks for Decision Making1,2


Ethical frameworks assist in clarifying values and beliefs. Table 5-1 lists some of the most common ethical frameworks used in decision making.


TABLE 5-1 ETHICAL FRAMEWORKS























FRAMEWORK BASIC PREMISE EXAMPLE
Utilitarian Provide the greatest good for the greatest number of people Disaster scenario
Rights-based Individuals share basic inherent rights that should not be interfered with Right to refuse
Duty-based A duty to do something or to refrain from doing something Nurse does not scream back when a patient is yelling at the nurse
Intuitionist Each case weighted on a case-by-case basis to determine relative goals, duties, and rights Should a patient with severe lung disease be put on a mechanical ventilator when there is little chance of successful weaning?


Principles1–3


The most fundamental ethical principle is respect for all people. Major ethical principles stem from this concept. They include the following:



• Autonomy: self-determination or freedom of choice


• The patient may make a decision that is contrary to prudent medical treatment but, if done with full decision-making capacity, it is the patient’s right.

• Beneficence: promote good


• Nurses desire to do what is believed to be in the patient’s best interest. The dilemma occurs when it conflicts with patient autonomy. Professionalism is working with the patient to achieve a compromise or balance rather than erecting a barrier. Improved patient care will result from this compromise.

• Included in the principle of beneficence is paternalism. Paternalism exists when one individual believes that he or she knows what is best and attempts to influence decision making for another. This occurs when the health care professional does not give full regard to a patient’s wishes (e.g., advanced directives).

• Nonmaleficence: do no harm


• Hippocrates first declared it: do not interfere with normal healing processes nor impose individual beliefs on the patient. Withholding or withdrawing life support is included in this principle.

• Justice: fairness


• The uninsured patient has as much right to the same treatment as the chief executive officer of the hospital. Adhering to this principle demonstrates humanity and professionalism. However, circumstances and triage decisions in the emergency department can certainly challenge the nurse’s ability to do the same for everyone.

• Utility: good of many outweighs the wants and needs of the individual


• An infection-control measure that isolates a patient is one example of utility. Paternalism and utility are often related in cases when an individual’s right must be restricted.

• Veracity: truth telling


• The truth should be told, or a good reason should exist to present a deception. Hellen describes the role for a “therapeutic fib” in caring for Alzheimer’s patients.4 For instance, the nurse might tell an elderly woman with Alzheimer’s who insists on “feeding her baby” that the baby has been fed since the woman is incapable of comprehending and processing the truth (e.g., that her babies are grown up).4

• Truth telling also encompasses admitting a medical error. Although there is an instant fear of medical liability when an error occurs, an obligation to be honest with the patient exists. A patient or family, upon learning of a medical error that has not been disclosed, will certainly be more apt to pursue medical-legal redress than if honest disclosure of human error is revealed.5 Additionally, a patient who is left unaware of a mistake may be in greater clinical jeopardy when future symptoms or complication occur or when significant decisions become necessary. An example is a patient who received an inappropriate dose of anticoagulant medication and then has a bleeding episode and attributes this to something else, potentially requiring unneeded, dangerous medical procedures.

• Fidelity: keeping promises, loyalty, and accountability


• The focus of fidelity is the importance of honoring commitments. If there is conflict between multiple fidelity duties, the American Nurses Association’s (ANA) Code of Ethics indicates that the primary commitment is to the patient.6


One study of nurse practitioners found that the most frequent ethical issue encountered was patient refusal of appropriate treatment with a conflict between patient autonomy and beneficence.9



Code of Ethics


Professional codes of ethics do not have the power of law; however, they do provide a guide for nursing practice, providing implicit standards and values for the profession. ANA’s Code of Ethics has existed since 1950. The current 2001 edition includes the following concepts6:



• Specifically indicating that the most fundamental accountability is to the patient


• Assuring that the workplace is safe


• Addressing duty to self


Table 5-2 lists the provision statements guiding the nursing practice in the ANA’s Code of Ethics.


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TABLE 5-2 ANA CODE OF ETHICS PROVISIONS


Rights were not granted to include this table in electronic media. Please refer to the printed book.


Reproduced with permission of the American Nurses Association.


Other nursing associations, such as the Canadian Nurses Association and the International Council of Nurses, have also adopted ethic codes to help guide ethical decisions.



Decision Making


Various processes can be used in determining an ethical decision.



The Traditional Problem-Solving Process




• Define objectives clearly.


• Gather data carefully.


• Generate many alternatives.


• Think logically.


• Choose and act decisively.

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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Ethical Dilemmas in Emergency Nursing

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