Posts Tagged ‘nursing ethics’

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Military Metaphors, Unnecessary Admissions, New Blogs, Keeping Secrets

September 29, 2011

It’s a common scenario: a 90-year-old resident of a U.S. nursing home — call her Ms. B. — has moderately advanced Alzheimer’s disease, congestive heart failure with severe left-ventricular dysfunction, and chronic pain from degenerative joint disease. She develops a nonproductive cough and a fever of 100.4°F. The night nurse calls an on-call physician who is unfamiliar with Ms. B. Told that she has a cough and fever, the physician says to send her to the emergency room, where she’s found to have normal vital signs except for the low-grade fever, a normal basic-chemistry panel and white-cell count, but a possible infiltrate on chest x-ray. She is admitted to the hospital and treated with intravenous fluids and antibiotics. During her second night in the hospital, Ms. B. becomes confused and agitated, climbs out of bed, and falls, fracturing her hip. One week after admission, she is discharged back to the nursing home with coverage under the Medicare Part A benefit. The episode results in about $10,000 in Medicare expenditures, as well as discomfort and disability for Ms. B.

There is an alternative scenario, however . . .

That’s from an article in NEJM called “Reducing Unnecessary Hospitalizations of Nursing Home Residents.” In any health care system of as much complexity as ours, there’s bound to be a huge amount of waste. The article gives a good example of how the skills of NPs might be put to excellent use both saving a lot of money for Medicare and making the lives of nursing home residents a whole lot nicer. It may be cheaper, but it’s not “rationing”—it’s rational.

Now a matter of language rather than money: the Viewpoint essay by Kathleen Thies in the October issue of AJN is about the use of military language to refer to nursing staff. Here’s how it begins, and you can click the link to read the whole article, including the author’s suggestion for an alternative terminology. We’d love to know whether the author’s perspective resonates with you:

How often have you heard the term frontline staff used to refer to direct care nurses and others working at a patient’s bedside? It conjures images of the great world wars, of soldiers marching across battlefields to fight the enemy. The infantry are invariably young, dispensable, interchangeable. Commands are issued by generals and passed down through the ranks. No questions are asked.

Blog roll update: We’ve added some interesting new blogs to our blogroll (they’re not new blogs, actually, just new to our blogroll). A few of them are by MDs, such as The Carlat Psychiatry Blog and Movin’ Meat, and a couple of are by nurses, such as madness: tales of an emergency room nurse, which has a good short post about why it doesn’t always help to be a nurse when your family member is in the hospital (there have been a few posts on this topic lately in different venues, I think?). Also added: The Nursing Ethics Blog, which is run by two people, a nursing professor/ethicist and a philosopher. It should be interesting to explore.

As the editor of the Reflections column (and this blog), I read hundreds of submissions each year about dying patients, with a subgenre of submissions devoted to dying infants or miscarriages. Read the rest of this entry ?

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Want to Achieve the ‘Greatest Good’? Listen to Your Patients

February 9, 2010

Ethical dilemmas abound in nursing practice. Consider these commonplace scenarios:

* An angry patient threatens to leave the hospital against medical advice. Should you hold him against his will?

* A cancer patient fears chemotherapy. Should you give less detailed information about the effects of anticancer drugs?

* An obese home care patient with pressure ulcers refuses to cooperate in turning. Should you turn her anyway?

Such conflicts between the patient’s wishes and the nurse’s perception of the patient’s best interests occur regularly. That doesn’t make these ethical dilemmas any easier to resolve, but how nurses approach them can significantly affect clinical outcomes. Taking the time to listen to patients—and to integrate relationship skills with principles of ethical practice—can help nurses achieve solutions that are both ethical and appropriate for individual patients.

ky olsen/via Flickr

That’s from the February issue of AJN, in which nurse–ethicist Doug Olsen (who has in the past written for this blog on ethical issues related to mandated H1N1 vaccinations for nurses) offers a thoughtful discussion that may resonate for all nurses who’ve ever faced a situation like those in the above examples. It may seem obvious or cliched to say that listening to patients can help solve apparently intractable problems—but just because listening as a skill is hard to measure doesn’t mean that it’s not sometimes effective where more rigid tactics would fail.

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Is It Ethical for a Nurse to Decline the H1N1 Vaccine?

August 26, 2009

By Douglas Olsen, PhD, RN. Olsen is an AJN contributing editor who co-coordinates the journal’s Ethical Issues department and a nurse ethicist with the National Center for Ethics in Health Care at the Veterans Health Administration in Washington, DC. The views he expresses here are meant to stimulate discussion of this topic and not to serve as pronouncements guiding what nurses should or shound not do. The views are his alone and should not be construed as representing those of AJN or of the National Center for Ethics in Health Care or the Veterans Health Administration.

MailOnlineFluJabScreenshotPublic health experts advocate widespread flu vaccination for people who give direct care to patients. However, in the past less than 40% of health care workers have been vaccinated for flu, and in a recent Nursing Times survey from the UK 30% of nurses said they would decline H1N1 vaccine and only 37% said “Yes” they would take the vaccine. Here are some thoughts on how to sort out the question from an ethical perspective.

Nurses, as patients, should be accorded the same respect for their decisions about health care, including the right to refuse a treatment, that is due to all patients. In ethics this is called respect for patient autonomy.

Professional obligation. However, nurses have a professional obligation to do as much as is reasonably possible to care for their patients. This includes incurring a certain amount of personal risk in giving care. Nurses incur risk on the job all the time from infections, violent patients, and many other sources.

In 2006 the American Nurses Association (ANA) put out a position paper that gives some guidance on the degree of risk that’s reasonable for nurses to accept in giving patient care: “[t]he benefit the patient will gain outweighs any harm the nurse might incur and does not present more than an acceptable risk to the nurse.”

Risk versus benefit. And so, the question is whether the degree of benefit expected for patients outweighs the degree of risk from the vaccine.  Read the rest of this entry ?

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