Ethical Dilemmas for Certified Emergency Nursing (CEN)

Ethical Dilemmas

Ethics:

• Principles, professional standards, and behavior
• Autonomy – Right to make one’s own choices and have those choices respected
• Beneficence – Duty to help others by providing care to improve health or quality of life
• Nonmaleficence – Duty to do no harm and not risk harm to others
• Justice – to be fair and impartial

Professional Negligence:

• Malpractice
  • Four factors must be present
    • Duty — Relationship between the healthcare provider and the patient
    • Breach of duty — Care received was below the standard of care
    • Proximate cause — Breach of duty was the likely cause of the injury
    • Injury — A bad outcome for the patient

Cultural Considerations:

• Cultural assessment – healthcare beliefs, decision-making process
• Cultural competence – become aware of own bias, identify culturally diverse groups in the community, identify core cultural issues and practices, develop trust with empathy and respect, communicate with the patient and family regarding needs and wishes
• Communication – language barriers, determine patient’s preferred language, translate with a professional interpreter (not family members)
• Family presence – Variations in definition of family, support policies and guidelines to promote presence
• Grief and loss – cultural differences and preferences may be more significant with grief and loss, obtain appropriate support for family

Consent:

Express-

• General consent given by patient, legal guardian, or family member for general/low-risk care and procedures
• Patient signs into the ED and signs consent for treatment
• Patient holds out arm when approached by nurse for phlebotomy

Implied-

• Patients with life- or limb-threatening conditions who are unable to give consent because of condition
• Only applicable until the patient can provide express consent
• Unconscious trauma patient with head injury may be treated by trauma team

Involuntary-

• Consent used to provide treatment to patients who are deemed not competent – Psychiatric hold

Informed-

• Consent for high-risk or invasive procedures which requires the following to be disclosed (e.g., surgical consent) – description, alternatives, risks, benefits
• Nurses can sign as witnesses
• Provider performing the procedure obtains informed consent – includes allowing the patient the opportunity to ask questions and obtain satisfactory answers
• Individual obtaining the consent should have the patient sign the consent form

Dilemmas-

• Serious or life-threatening situations – implied consent rules
• Minors – laws vary by state, parents refusing lifesaving treatment, consider involving hospital legal counsel to obtain court order
• Refusal by religious exemption – Jehovah’s Witnesses refusing blood administration
• Patient with HMO insurance presents to a nonparticipating hospital; gatekeeper does not give permission for the patient to be treated in the ED – consent for treatment and refusal remains the sole responsibility of the patient
• Refusal of treatment/leaving against medical advice (AMA) – ensure patient is competent, provider must provide a comprehensive explanation of the risk of refusing care, have the patient sign a release
• Questionable competency – obtain court order for treatment
• Patients in custody of law enforcement, consent remains with the individual, the patient who is under arrest can refuse to allow withdrawal of blood and body fluid, and can refuse treatment, certain laws may override patient’s rights under very specific circumstances, procedures, consult risk management or hospital legal counsel with complicated patient care matters or in doubt

Mandatory Reporting-

• Some may vary from state to state
• Crime-related incident
• Suicide attempts
• Suspected maltreatment – children, elderly, developmentally disabled
• Certain communicable diseases
• Deaths
• Special circumstances – mental health related to firearms owner’s identification

Patient Confidentiality-

• HIPAA — Health Insurance Portability and Accountability Act (HIPAA) (1996)
• Protected health information (PHI) may be used by the medical provider only for treatment, payment, and healthcare operation activities
• PHI must be protected in all public and uncontrolled settings
• Communication is with the patient or their authorized representative
• Release of information to law enforcement in specific circumstances