50 unit 1 | Professional Considerations
opinion has not been solicited. This is generally
unwarranted, unless the issue involves a violation of
the professional code of ethics.
Nurses are frequently in the position of hearing
both sides of an ethical dilemma. Often, all that is
wanted is an empathetic listener. At other times,
when guidance is requested, nurses can help people
work through the decision-making process (remem-
ber the principle of autonomy).
Collecting data from all the decision makers
helps identify the reasoning process being used by
these individuals as they struggle with the issue.
The following questions assist in the information-
gathering process:
■What are the medical facts?Find out how the
physicians, physical and occupational therapists,
dietitians, and nurses view the patient’s condi-
tion and treatment options. Speak with the
patient, if possible, and determine his or her
understanding of the situation.
■What are the psychosocial facts?In what
emotional state is the patient right now? The
patient’s family? What kind of relationship
exists between the patient and his or her family?
What are the patient’s living conditions? Who
are the individuals who form the patient’s
support system? How are they involved in the
patient’s care? What is the patient’s ability to
make medical decisions about his or her care?
Do financial considerations need to be taken
into account? What does the patient value?
What does the patient’s family value? The
answers to these questions will provide a better
understanding of the situation. Ask more ques-
tions, if necessary, to complete the picture. The
social facts of a situation also include institu-
tional policies, legal aspects, and economic
factors. The personal belief systems of physicians
and other health-care professionals also influ-
ence this aspect.
■What are the cultural beliefs?Cultural beliefs play a
major role in ethical decisions. Some cultures do
not allow surgical interventions as they fear that
the “life force” may escape. Many cultures forbid
organ donation. Other cultures focus on the sanc-
tity of life, thereby requesting all methods for sus-
taining life be used regardless of the futility.
■What are the patient’s wishes?Remember the
ethical principle of autonomy. With very few
exceptions, if the patient is competent, his or her
decisions take precedence. Too often, the fami-
ly’s or physician’s worldview and belief system
overshadow those of the patient. Nurses can
assist by maintaining the focus on the patient.
If the patient is unable to communicate, try to
discover whether the individual has discussed the
issue in the past. If the patient has completed
a living will or designated a health-care
surrogate, this will help determine the patient’s
wishes. By interviewing family members, the
nurse can often learn about conversations in
which the patient has voiced his or her feelings
about treatment decisions. Through guided
interviewing, the nurse can encourage the family
to tell anecdotes that provide relevant insights
into the patient’s values and beliefs.
■What values are in conflict?To assess values,
begin by listing each person involved in the
situation. Then identify the values represented
by each person. Ask such questions as, “What
do you feel is the most pressing issue here?” and
“Tell me more about your feelings regarding this
situation.” In some cases, there may be little
disagreement among the people involved, just a
different way of expressing beliefs. In others,
however, a serious value conflict may exist.Planning
For planning to be successful, everyone involved in
the decision must be included in the process.
Thompson and Thompson (1992) listed three spe-
cific and integrated phases of this planning:1 .Determine the goals of treatment.Is cure a goal,
or is the goal to keep the patient comfortable?
Is life at any cost the goal, or is the goal a
peaceful death at home? These goals need to
be patient-focused, reality-centered, and attain-
able. They should be consistent with current
medical treatment and, if possible, be measura-
ble according to an established period.- Identify the decision makers.As mentioned earlier,
nurses may or may not be decision makers in
box 4-2
Questions to Help Resolve Ethical
Dilemmas- What are the medical facts?
- What are the psychosocial facts?
- What are the patient’s wishes?
- What values are in conflict?