COMPETENCIES 740.1.4 : Professional Accountability The graduate analyzes the responsibilities and accountability of the professional nurse. 740.1.5 : Self Advocacy of the Nurse The graduate integrates strategies of self-awareness and self-care into professional practice to ensure personal health and well-being. 740.1.7 : Roles of the Nurse The graduate analyzes the roles of the nurse as a scientist, a detective, and a manager of the healing environment. 740.1.10 : The Nursing Profession The graduate applies historical and contemporary nursing theories and models to define their professional nursing practice. 740.1.13 : The Professional Nurse The graduate integrates knowledge, skills, and attitudes of the nursing profession into personal and professional interactions and ethical decision making. 740.1.15 : Healthcare Work Environment The graduate evaluates how the vision, values, mission, and philosophy of an organization align with an individual’s professional values, beliefs, and approaches to inter-professional collegiality. INTRODUCTION The purpose of this task is to explore how nursing ethics, self-advocacy, and professional accountability can be applied in clinical practice. Using the provided case scenario, you will be required to think about how ethical concepts can be used to make clinical decisions and explore the differences in personal and professional beliefs. You will develop personalized stress management plans that rely on the use of adaptive coping strategies to ensure personal health and well-being. SCENARIO You have been working as a nurse in the adult oncology unit for the past year. You have developed a close relationship with many of your patients, but Mr. Newcomb has a special place in your heart. He has been diagnosed with stage 4 pancreatic cancer and has undergone aggressive chemotherapy. Each day his wife has come to the unit to be with her husband. They have been married for over 40 years and share a deep love. Mr. and Mrs. Newcomb have made the decision to no longer continue with treatment and have decided that hospice care is needed. Over the past few days, you have watched Mr. Newcomb’s health decline, and you can tell from your experience that he does not have much time left to live. Mr. Newcomb has been very open about discussing his death, and you have had the opportunity to learn about his life and the legacy he will leave behind. While you are completing your rounds, you stop in Mr. Newcomb’s room to see how he is doing. You ask, “Is there anything else I can do for you?” Mr. Newcomb has rarely asked for anything, but today he has one request. Mr. Newcomb states, “Before I die, I would like to see my mistress one more time. Mrs. Newcomb is always here. Do you think you could tell her that I will be busy for a few hours tomorrow so I can make arrangements to see my mistress one more time?” Reflect on the following questions before you begin working on this task: • What would you do in this scenario? • How can your knowledge of ethical principles be utilized to determine your response to Mr. Newcomb? • How would this affect you as a nurse and direct provider of care for Mr. Newcomb? REQUIREMENTS Your submission must be your original work. No more than a combined total of 30% of the submission and no more than a 10% match to any one individual source can be directly quoted or closely paraphrased from sources, even if cited correctly. An originality report is provided when you submit your task that can be used as a guide. You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions of the course. A. Summarize how the principles of beneficence, non-maleficence, autonomy, and justice apply to the scenario by doing the following: 1. Describe how you would respond to Mr. Newcomb’s request. 2. Evaluate how you applied the principles of beneficence, non-maleficence, autonomy, and justice to the scenario. 3. Examine how personal beliefs and values influenced your response to the scenario. 4. Describe three strategies to promote self-care. B. Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or summarized. C. Demonstrate professional communication in the content and presentation of your submission. Ethical theory Ethical theory is a system of principles by which a person can determine what should and should not be done. Although there are others, utilitarianism and deontology are the theories most frequently cited in the Western world as foundational for processing ethical dilemmas. Utilitarianism Utilitarianism is an approach that supports what is best for most people, rooted in the assumption that an action or practice is right if it leads to the greatest possible balance of good consequences or to the least possible balance of bad consequences. For instance, the utilitarian approach would be at work if the government made a decision to forgo Medicare funding treatment for a particular population with terminal disease and to redistribute funding to other Medicare-eligible individuals with a greater likelihood for longevity or quality of life. Utilitarian ethics are noted to be the strongest approach used in bioethical decision making. An attempt is made to determine which actions will lead to the highest ratio of benefit to harm for all persons involved in the dilemma. Deontology Deontology is an approach that is rooted in the assumption that humans are rational and act out of principles that are consistent and objective and compel them to do what is right. Ethics are based on a sense of a universal principle to consistently act one way. For instance, the deontological approach would be at work if a decision is made to resuscitate and provide mechanical ventilation to a 23-week, otherwise viable fetus, despite ability to pay for care and availability of newborn intensive care beds. In bioethical decision making, moral rightness is the act that is determined not by the consequences of the actions it produces but by the intentions and moral qualities intrinsic to the act itself. Deontological theory claims that a decision is right only if it conforms to an overriding moral duty and wrong only if it violates that moral duty. All decisions must be made in such a way that the decision could become universal law. Persons are to be treated as ends in themselves and never as means to the ends of others. Ethical principles Perhaps the most useful tool for the morally mature professional nurse is a set of principles, standards, or truths on which to base ethical actions. Common ground must be established between the nurse and the patient and family, between fellow nurses, between the nurse and other health care providers, and between the nurse and other members of society. Such common ground can be established by adhering to a set of principles that can move everyone involved toward understanding and agreement. The practice of ethics involves applying principles to the two ethical theories described—utilitarianism and deontology—or to other theories that are described elsewhere. Principles can permit people to take a consistent position on specific or related issues. If the principles, when applied to a particular act, make the act right or wrong in one situation, it seems reasonable to assume that the same principle, when applied to a new situation, can have the same result. Three principles have proven to be highly relevant in bioethics: (1) autonomy, (2) beneficence and nonmaleficence, and (3) veracity. These principles do not form a complete moral framework. One principle may be relevant to a particular situation but the others are not. Yet these principles are sufficiently comprehensive to provide an analytic framework by which moral problems can be evaluated. Autonomy Autonomy, the principle of respect for a person, is sometimes called the primary moral principle. This concept holds that humans have incalculable worth or moral dignity not possessed by other objects or creatures. There is unconditional intrinsic value for everyone. People are free to form their own judgments and whatever actions they choose. They are self-determining agents, entitled to determine their own destiny. If an autonomous person’s actions do not infringe on the autonomous actions of others, that person should be free to decide whatever he or she wishes. This freedom should be applied even if the decision creates risk to his or her health and even if the decision seems unwise to others. Concepts of freedom and informed consent are grounded in the principle of autonomy. Although the principle of autonomy may seem basic and universal, there are times when this principle may be in conflict with other principles, such a familial ones. For instance, in some male-dominated or patriarchal cultures, the family leader’s rights may override the individual and autonomous rights of a family member. In this situation, action based on the moral principle of autonomy may perpetuate conflict. Beneficence and nonmaleficence In general terms, to be beneficent is to promote goodness, kindness, and charity. A different yet related principle is nonmaleficence, which is a duty not to inflict harm. In ethical terms nonmaleficence is abstaining from injuring others and helping others further their own well-being by removing harm and eliminating threats, whereas beneficence is to provide benefits to others by promoting their good. The beneficence-nonmaleficence principle is largely a balance of risk and benefit. At times, the risk for harm must be weighed against the possible benefits. The risk should never be greater than the importance of the problem to be solved. Although it may seem natural to promote good at all times, the most common bioethical conflicts result from an imbalance between the demands of beneficence and those acts and decisions within the health care delivery system that might pose threats. For instance, it is not always clearly evident what is good and what is harmful. Is the resuscitation effort for the 90-year-old woman good or harmful to her overall sense of well-being? How much beneficence is there in supporting someone toward a peaceful death? What is the balance between beneficence and nonmaleficence in an understaffed emergency department? Is it better to do as much good as you can with the limited resources you have or to refuse to assume care in an effort to prevent harm that can come from being understaffed? Veracity Most contemporary professionals believe that telling the truth in personal communication is a moral and ethical requirement. If there is the belief in health care that truth telling is always right, then the principle of veracity can itself pose some interesting challenges. In the past, truth telling was sometimes viewed as inconvenient, distressing, or even harmful to patients and families. In fact, the first American Medical Association Code of Ethics in 1847 contained such a message: “The life of a sick person can be shortened not only by the acts, but also by the words or the manner of a physician. It is, therefore, a sacred duty to guard himself carefully in this respect, and to avoid all things that have a tendency to discourage the patient and to depress his spirits.” The belief that the truth could at times be harmful was held for many years. Only recently, with the shift from a provider-driven system to a consumer-driven system, has the adherence to silence begun to break down. With this shift have come interesting questions. Is the provider-patient relationship generally understood by both parties to include the right of the provider to control the truth by withholding some or all of the relevant information until an appropriate time for disclosure? How much deception of patients is morally acceptable in the communication of a poor or terminal prognosis? Difficult questions surface, but at the heart of the principle of veracity is trust. Health care consumers today expect accurate and precise information that is revealed in an honest and respectful manner. A few generations ago, the trust factor may have been such that it was acceptable for providers to share parts of truth or to distort the truth in the name of beneficence. Today, however, for trust to develop between providers and patients there must be truthful interaction and meaningful communication. The moral conflict that results from being less than truthful to patients is too troublesome for today’s practitioner. The deontologic theory that the health care provider has a duty to tell the patient the truth has taken precedence over the fear of harm that might result if the truth is revealed. The challenge today is to mesh the need for truthful communication with the need to protect. Health care providers must lay aside fears that the truth will be harmful to patients and come to the realization that more often than not, the truth can alleviate anxiety, increase pain tolerance, facilitate recovery, and enhance cooperation with treatment. With a pledge to human decency, health care providers must commit themselves to truth telling in all interactions and relationships.