Legal and Ethical Issues in Nursing in Treatment of Older Population
Introduction
Nurses play crucial role in healthcare system accomplishing multiple goals and achieving various purposes. Their diverse personal traits have to correlate with a great number of responsibilities in the field in terms of profession, activities, decisions, and leadership. A nurse is a professional who bring the locus of control for high-quality care from the administrative field to the providers delivering care services. Being responsible for numerous tasks and interventions, nurses, despite exceptional personal skills, have to serve as a role model in their community, advocating for the evolution of the profession and professional activities, maintaining continued competence within the profession, and comprehending their authentic role as health care providers. At the same time, it is essential for nurses to recognize ethical and legal issues within the profession which will determine their activity in the hospital.
During the personal practice in the hospital I had to encounter with a challenging situation that involved ethical and legal issues. Due to the confidentiality, the names of the persons involved are not mentioned. During one of my shifts an elderly patient was admitted. He suffered from diabetes and hypertension and the personnel took him to the accident and emergency department due to issues with his foot. As the situation was critical and the surgeon estimated high risks for the health of the patient, he advised the client to amputate the foot. However, both the patient and his relative refused the operation. Even after I have explained that the foot is gangrenous and if the infection reaches the bone, there will be no possible way to treat him, their opinion remained the same. Moreover, the patient continued to explain that he has already encountered with the same issue and he was able to heal with the help of treatment received abroad. The patient signed Leave against Medical Advice (LAMA) agreement and left. The next day, the patient was admitted in critical condition due to sepsis resulted from the gangrenous foot, thus, he was taken to intensive care unit.
Aims and Objectives
It is estimated by NHS that the percentage of people with diabetes increased disproportionately for the last several years. Specifically, 3.9 million people today live with diabetes in the UK, which is doubled since the 1996 when it was 1.4 million (NHS, 2015). It is expected that in 20125, there will be 5 million people living with this disease (NHS, 2015). Also, the number of amputations increased due to the diabetes, namely from 18,080 in 2010 to 21,125 in 2014 (NHS, 2015). One of the major concerns in this issue is the complaints provided by the patients with diabetes. Particularly, it was reported that a lot of patients claimed their feet were not checked thoroughly during the usual examination in the hospitals (Campbell, 2015). This issue creates a problem for the health providers that has to be mitigated by the adequate documentation and informed personnel regarding the issue.
The current case involves several issues related to different frameworks. First of all the case applies to practical ethical conduct for nurses in terms of providing the patient of full information about the health issue and consequences of treatment refusal. Secondly, the theoretical basis of the ethical issue may be implemented according to the situation. Finally, the legal outcomes have to be evaluated in order to predict possible law suits and complaints from the patients and his relatives. It is customary for the family as well as the patients to seek reimbursement for their medical treatment from the hospitals by suing the health care providers as well as personnel. Therefore, the main objective of the current research is to reveal if the current case may lead to the ethical and/or legal outcomes for the nurse and the health care provider. The present study aims to assess the ethical code of conduct for nurses as well as the UK legislation regarding the current issue. The issue is addressed by evaluating the legal and ethical framework of the UK regarding the problem provided in the description of the case.
Discussion
Ethical Framework in Nursing
Being an advocate for the profession, a nurse has to understand the concept of its meaning. Advocates are the supporters of cause or the proposal. Applying this notion to the nursing practice, one can state that nurse have to elaborate the strategy to support the profession by their mastered excellence of achieving multiple goals defined by their responsibilities. A nurse has not only direct responsibility to advocate nursing profession in the nurse-patient relationship, supporting the profession among the colleagues is one of the main goals in this issue. Tomajan (2012) suggests that the majority of nurses embrace the responsibility of the professional nurses’ advocacy role considering patients, though the advocacy on behalf of colleagues may not be absolutely clear for the leaders.
While advocating for the profession, nurses have to take into account the issues of problem solving, communication, influence, and collaboration. At this point, it is important for nurse leaders to develop their own problem-solving model to address multiple problems. A professional nurse leader has to develop exceptional communicational skills to address the issue or concern (Soliman, 2012). This feature will help to influence the others conducting a certain action. To demonstrate the excellence in the skills described above, a nurse has to maintain positive collaborative relationship with the colleagues and the patients (Fabre, 2005). The advocacy is not the only responsibility of the nurse leaders, a professional in this field has to maintain professional responsibilities in nursing.
Nurses function in a specific system following particular rules and connections between its subsystems, elements, and components. Scholars define “the nurse as a professional who ensures a fit between an individual’s biology and their material environment” (Hendrickson & Tankard, 1997, p.43). The nurses as the agents of healthcare are facing the process of implication of new technologies on the daily basis. Professional responsibilities of every nurse dwell in the field of ethical and moral obligations piercing this profession. Such standards occupy the area of patients’ care, productive communication with the colleagues, continuity, and responsibility to accomplish social change.
As to the community, a nurse has to target these goals and encourage the other medical professionals to follow ethical and moral principles while accomplishing their professional responsibilities (Doran et al., 2015). Additionally, a nurse has the direct responsibility to detect violations conducted by the other medical professionals, to communicate them through and if necessary, to report them to the superior managers of the unit (Nursing and Midwifery Council, 2015). Nurses have to monitor their own work and professional responsibilities as well to evaluate their own personal decisions for following moral and ethical principles required by the profession. However, to achieve all mentioned goals, a nurse has to master continued competence in the profession.
The case presented in the current research creates implications for nursing ethical practices. While the nurse is not directly responsible for the success or failure of a surgery, it is her/his personal responsibility to explain the patient about all options existing for accepting or refusing the treatment. While the ethical framework designed for nurses requires the balance between the patient’s physical needs and privacy, there is also a suggestion that the nurses are morally obliged to make everything possible to make the patient to undergo a treatment, if they believe it will benefit the patient. For instance, Aveyard (2003) conducted a research among nurses in order to score their level of effectiveness; the results revealed that the most effective nurses are those who give the patient the information about certain necessary medical procedure until the patient finally accedes to the procedure. However, the same study acknowledged that the extent to which this agreement stays voluntary is impossible to assert due to the limitation of the study (Aveyard, 2003). Another research showed that nurses are pushed to change the mind of the patients to the level when they had to administer the care without patients’ consent (Barton, 1991). This pattern is particularly disturbing, as the nurse violates the legal as well as ethical rights of the patient even if the care is benefiting for the person.
The majority of studies usually express concern over the refusal of treatment of the terminally ill patients, omitting to investigate the role of a nurse in the cases when the patients do not want to undergo usual treatment. This lack of interest to the problem raises an important question in the paradigm of nursing ethics. The healthcare professionals are hold accountable for almost every event that has happened to the patient, even those connected to the patient’s refusal to be treated. While such approach is plausible in a variety of situations, from the lack of knowledge to the specificity of the psychological state of a patient; other cases have to take into account the character of nursing role in the patient’s care as well.
Nursing and Midwifery Council (NMC) of the UK determined a set of essential principles that have to be followed by the nurses in the country. Overall, the code of conduct provides 25 rules and requirements that have to be employed by every professional working within this area (NMC, 2015). Specifically, one of the ethical requirements concerns the need to take care of all people and make sure they are in good health. According to the NMC (2015), a nurse has “ to pay special attention to promoting wellbeing, preventing ill health and meeting the changing health and care needs of people during all life stages” (p. 5). Such requirement prevents the discrimination of patients on the basis of their age and state of health. Also, the nurse has to find balance between the requirements to provide health care and to respect the privacy of a person to refuse the treatment (NMC, 2015). It is quite difficult sometimes to find the harmony between these demands, as not all patients have the ability to understand the specificity of their state and the procedures that have to be implemented.
However, it is particularly important to remember that despite the prescribed code of conduct, a nurse has to employ the principles of beneficence and nonmaleficence that foster the need to do no harm to the patience and to accomplish actions that will benefit the patients. Kinsinger (2009) emphasized that beneficence is a moral obligation as well as the act of mercy referring to patient. Nonmaleficence relates to the requirement of avoiding the ability or intention to implement any actions that can be harmful to the patient. By following both of these rules, the nurses are obligated to make sure the interests of patients are taken into account and their actions will cause no harm. It is essential for the nurses to consult the patient and persuade him/her in the need to undergo a procedure. At the same time, exaggerated persuasion can be seen as the interference of patient’s privacy. In this situation, the only thing a nurse can accomplish is to use his/her judgment and professional experience by informing the patients about the inevitable conclusions of LAMA.
Patient’s reluctance to undergo procedure may be connected to the previous negative experience or, as in this situation, a false belief into the non-traditional methods. The best way to implement beneficence is to find out what procedures the patient underwent abroad and to consult with the physician regarding the effectiveness of such procedures comparing to the surgery. Nonmaleficence relates to the failure to take into account the main reasons why the patient refuses to undergo a necessary procedure that threatens his life. Here, the nurse can express more interest in the state of health of the patient and his awareness regarding the consequences, which could not be mitigated.
At the same time, the real-life situations are quite complex and the abstract principles of beneficence and nonmaleficence are not always can be applied in their pure form. The principles have to be implemented with the clear understanding of the main case with its implications and limitations. For instance, the principle of autonomy of the client cannot be perceived as the justification to use a “hands-off” attitude when the patient simply needs more information on particular procedure. At the same time, the principle of beneficence cannot be applied by tying a patient to the medical bed and performing surgery even if he/he requires it. In this case, it is important to preserve the balance when the patients take responsibility for their actions or absence of such on their own.
Legal Issues
Individuals who prefer to sign LAMA agreement remain a great concern for the healthcare providers. The reasons for such actions may be different, from lack of trust in medicine to misunderstanding of the information. Therefore, it is essential to provide clear and precise documentation in order to avoid the law suits and complaints from the patients and their families. One of the main problems of LAMA discharge forms is that they do not always protect the caregivers from the further legal suits for malpractice (Tingle, 2014). According to researchers, the discharge forms have to be particularly detailed in order to prevent legal charges (Northway, Jenkins, & McMillan, 2014; Toffoli, Rudge, & Barnes, 2011). Moreover, if the patient is in the critical condition, the more detailed document has to be for protecting the caregivers. Also, the healthcare of the elderly patients requires special attention, as some of the patients have certain mental states, like dementia, that can prevent them from understanding of the situation.
According to the research, “it is now a criminal offence for a person providing care to someone who lacks capacity to ill-treat or willfully neglect them” (Joint Committee on Human Rights, 2006). It was noted in the Mental Capacity Act (2005) that if an elderly person suffers from a metal deterioration due to the age, it is possible that he/she does not understand the reality of the situation (Section 44 Mental Capacity Act, 2005). Therefore, the LAMA discharge form may be ineffective if the trial is launched. The responsibility of a caregiver, both legally and ethically, is to provide the documents for the family members to sign in order to avoid possible problems in future (Jackson et al., 2014; Tye, 2008). If the patient dies or sustains critical health damages to his health, the possibility of the law suit increases. One of the main methods to escape the problem is to inform the social agencies or to provide the psychological evaluation for the patient and reveal his/her mental state. Mental Capacity Act also emphasizes the balance between the patients’ need to be treated accordingly as well as the need of the medical personnel to respect the decision of the patient to refuse treatment if the mental and psychological health enables them to.
There are several other legislations that mitigate the risks of going to the trial due to the inadequate documentations. First of all, the human rights state that a person may refuse the treatment if he/she desires so. Human Rights Act (1998) claims that the right to liberty has to be maintained by the health provider (Human Rights Act, 1998). However, article 5 gives the permission to the health provider to disregard the LAMA claim if there is a case of infectious disease (Human Rights Act, 1998). If a person is mentally healthy and the health provider does not need to use the third party opinion regarding the patient’s mental state, he or she can sign a written consent regarding the refusal to undergo a treatment, which will not lead to law suit. Also, there is a possibility to provide the arguments for the patient in favor of treatment, like reduction of pain, elimination of the possibility of sepsis, and mitigating the risks of further infection. The nurse has to be sure that all information is provided and the risks are known for the patient and/or their legal guardian if it applies.
Human rights claim that a patient has a right to refuse any procedure, yet the legislation does not draw a precise line between the responsibility of the healthcare professionals and the patient’s privacy. It is necessary to imply that the healthcare professionals also have the same rights as patients sand their inability to persuade them to undergo necessary procedure has to be perceived not as mistake, but as the choice of the patient. In the situation described for the current research, the nurses as well as physicians cannot make surgery without the consent of the patient. Moreover, the healthcare personnel have to respect the privacy of the patient to act as they want to even if it means that their life will be in danger. Further law suit will not be an issue of the healthcare facility, but the failure of the patient as well as his family to take care about themselves.
Nevertheless, there are no other ways to prevent a patient from LAMA and refusal to undergo needed treatment, except for the self-inflicted injuries including suicide attempts, harm caused by the next of kin or legal guardian, extreme cases like illegal abortion or genital mutilation, and any other harm caused by criminal activities (Wheeler, 2012). In such a case, the caregivers have to announce the police, social services, and any other legal authorities that will resolve the situation (Al Ayed, 2009). It is a legal responsibility of the caregivers to provide necessary healthcare and support, yet there are no methods of pressuring the elderly patients and their family to undergo a procedure even if it leads to the further deterioration of health or lethal consequences.
The current case does not have the issues of malpractice and negligence, as the LAMA agreement was signed by the legal caretakers. However, the next of kin and the patient himself may file a legal complaint due to lack of information and/or inconsistent information provided by the nurse and the surgeon (Dimond, 2008). In this case, it will be essential to provide clear proof that the patient and the family were informed about the consequences of the refusal to be treated.
Conclusion
It is quite clear that the profession of a nurse requires thorough ethical and legal competence. While ethical conduct may relate to the unwritten rules that lead to complaints or fines, legal responsibility may cause more serious and complicated outcomes resulting in the termination of the license. The nurses are ethically responsible to take care about the patients and foster their human rights, yet the patients themselves have to take the responsibility for their actions as well.
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