Essentials of Nursing Leadership and Management, 5th Edition

chapter 4 | Questions of Values and Ethics 51

these health-related ethical dilemmas. It is
important to know who the decision makers are
and what their belief systems are. When the
patient is a capable participant, this task is
much easier. However, people who are ill are
often too exhausted to speak for themselves or
to ensure that their voices are heard. When this
happens, the patient needs an advocate. Family,
friends, spiritual advisers, and nurses often act
as advocates. A family member may need to be
designated as the primary decision maker, a role
often called the health-care surrogate.
The creation of living wills, establishment
of advance directives, and appointment of a
health-care surrogate while a person is still
healthy often ease the burden for the decision
makers during a later crisis. Patients can exer-
cise autonomy through these mechanisms, even
though they may no longer be able to commu-
nicate their wishes directly. When these
documents are not available, the information
gathered during the assessment of social factors
helps identify those individuals who may be
able to act in the patient’s best interest.
3.List and rank all the options.Performing this
task involves all the decision makers. It is
sometimes helpful to begin with the least
desired choice and methodically work toward
the preferred treatment choice that is most
likely to lead to the desired outcome. Asking
all participating parties to discuss what they
believe are reasonable outcomes to be attained
with the use of available medical treatment
often helps in the decision process. By listening
to others in a controlled situation, family mem-
bers and health-care professionals discover that
they actually want the same result as the patient
but had different ideas about how to achieve
their goal.

Implementation

During the implementation phase, the patient or
the surrogate (substitute) decision maker(s) and
members of the health-care team reach a mutually
acceptable decision. This occurs through open dis-
cussion and sometimes negotiation. An example of
negotiation follows:

Elena’s mother has metastatic ovarian cancer. She

and Elena have discussed treatment options. Her

physician suggested the use of a new chemotherapeutic

agent that has demonstrated success in many

cases. But Elena’s mother emphatically states that

she has “had enough” and prefers to spend her

remaining time doing whatever she chooses. Elena

wants her mother to try the drug. To resolve the

dilemma, the oncology nurse practitioner and the

physician talk with Elena and her mother.

Everyone reviews the facts and expresses their feel-

ings about the situation. Seeing Elena’s distress,

Elena’s mother says, “OK, I will try the Taxol for a

month. If there is no improvement after this time,

I want to stop all treatment and live out the time

I have with my daughter and her family.” All

agreed that this was a reasonable decision.

The role of the nurse during the implementation

phase is to ensure that communication does not

break down. Ethical dilemmas are often emotional

issues, filled with guilt, sorrow, anger, and other

strong emotions. These strong feelings can cause

communication failures among decision makers.

Remind yourself, “I am here to do what is best for

this patient.”

Keep in mind that an ethical dilemma is not

always a choice between two attractive alternatives.

Many are between two unattractive, even unpleas-

ant, choices. Elena’s mother’s options did not

include the choice she really wanted: good health

and a long life.

Once an agreement is reached, the decision

makers must accept it. Sometimes, an agreement is

not reached because the parties cannot reconcile

their conflicting belief systems or values. At other

times, caregivers are unable to recognize the worth

of the patient’s point of view. Occasionally, the

patient or the surrogate may make a request that is

not institutionally or legally possible. In some

cases, a different institution or physician may be

able to honor the request. In other cases, the

patient or surrogate may request information from

the nurse regarding illegal acts. When this hap-

pens, the nurse should ask the patient and family

to consider the consequences of their proposed

actions. It may be necessary to bring other coun-

selors into the discussion (with the patient’s

permission) to negotiate an agreement.

Evaluation

As in the nursing process, the purpose of evaluation

in resolving ethical dilemmas is to determine

whether the desired outcomes have occurred. In the