Dr.

Aidah Abu Elsoud Alkaissi

Devision of Intensive Care and
Anesthesiology
University of Linköping-
1 Sweden
 Ethics of Nursing

 Ethics includes values, codes, and principles that govern

decisions in nursing practice and relationships

 Nursing Ethics is the discipline of evaluating the merits,

risks, and social concerns of activities in the field of nursing

 Ethical principles are necessary to guide to professional

development

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 Code of Ethics for Nursing Students

Code of Academic and Clinical Conduct

 The code of Academic and Clinical conduct is based

on an understanding that to practice nursing as a
student is an agreement to uphold the trust with
which society has placed in us

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 A CODE FOR NURSING STUDENTS

 Advocate the rights of all clients

 Maintain client confidentiality

 Take appropriate action to ensure the safety of clients, self ,

and others

 Provide care for the client in a timely, compassionate and

professional manner

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 A CODE FOR NURSING STUDENTS

 Communicate client care in a truthful

 Promote excellence in nursing by encouraging

lifelong learning and professional development

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 A CODE FOR NURSING STUDENTS

 Treat others with respect and promote environment that

respects human rights, values, an choice of cultural and
spiritual beliefs

 Collaborate in every reasonable manner with the academic

faculty and clinical staff to ensure the highest quality of
client care

 Use every opportunity to improve faculty and clinical staff

understanding of the learning needs of nursing students

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 A CODE FOR NURSING STUDENTS

 Encourage faculty, clinical staff, and peers to mentor

nursing students

 Refrain from performing any technique or procedure for

which the student has not been adequately trained

 Refrain from any deliberate action or omission of care in the

academic or clinical setting that creates unnecessary risk of
injury to client, self or others

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 A CODE FOR NURSING STUDENTS

 Assist in ensuring that there is full disclosure and

that consent is obtained from clients regarding any
form of treatment or research

 Abstain from the use of alcoholic beverages or any

substances in the academic and clinical setting that
impair judgment

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 Principles of Health Care Ethics

 Beneficence: means doing or promoting good in such a

manner as to safeguard and promote the interest and well
being of patients and clients

 Nonmaleficence means to avoid doing harm, to remove

from harm, and to prevent harm

 Harm can be physical and so include pain, disability,

discomfort and death but it can also be psychological and
thus include mental stress

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 Principles of Health Care Ethics

 Autonomy and consent: Principles of self determination

 The cardinal principles of autonomy

 The right to full disclosure- the right to know

 The right to privacy
 The right to receive care and treatment

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 Principles of Health Care Ethics

 Justice: The principle of fairness is the basis for the

obligation to treat all clients equally and fairly

 Veracity: telling the truth. Clients prefer to receive

accurate information about their conditions and
prognosis even when the outlook is bleak

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 Principles of Health Care Ethics

 Privacy:
 To ensure that the patient’s body is appropriate

covered

 To establish a culture of privacy to ensure that

personal information of patients is kept as private
as possible

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 Principles of Health Care Ethics
 Confidentiality

 To preserving the human dignity of patients

 Discussing clients outside the clinical setting, telling

friends or family about clients, or even discussing clients
in the elevator with other workers violates client
confidentiality and must be a voided

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 Principles of Health Care Ethics
 Responsibility: A nurse, who neglects to give a patient pain
relief can be said to have caused that patient harm

 Proving negligence (i.e. that the nurse is legally responsible)

 It is not only human beings who can cause something to

happen, since conditions (e.g. staff shortages, poor
equipment, inadequate resources, and so forth) may also
cause accidents or result in a patient being injured

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 Principles of Health Care
Ethics
 Accountability

 Is about justifying actions, explaining why something

was (or was not) done

 The purpose of calling people to account for their actions

is therefore to establish whether they had good enough
reasons for acting in the way they did

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 Principles of Health Care Ethics

 FIDELITY

 The professional´s faithfulness or loyalty to agreements

& responsibilities accepted as part of the practice of the
profession

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 Be competent in your
practice
 The nurses are always responsible for their behaviours

 Has to refuse to perform procedures for which they haven´t

been prepared

 Ignorance isn’t a legal defence. Neither will lack of sleep or

overwork be accepted as a legal reason for carelessness
about safety measures or mistakes

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 The ICN- Code of Ethics for Nurses
(2006)

 Nurses have four fundamental responsibilities:

 To promote health
 To prevent illness
 To restore health
 To alleviate suffering

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 The ICN Code of Ethics

 Nursing care is respectful of and unrestricted by

considerations of age, color, creed, culture, disability
or illness, gender, sexual orientation, nationality,
politics, race or social status

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 NURSES AND PEOPLE

 The nurse shares with society the responsibility for

initiating and supporting action to meet the health and social
needs of the public, in particular those of vulnerable
populations

 The nurse also shares responsibility to sustain and protect

the natural environment from depletion, pollution,
degradation and destruction

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 NURSES AND THE PROFESSION

 The nurse is active in developing a core of research-based

professional knowledge

 The nurse, acting through the professional organization,

participates in creating and maintaining safe, equitable
social and economic working conditions in nursing

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 Future Implications
Please take with you home and discuss
it with your colleagues
 Scientific research over the past two decades has resulted in
rapidly developing technology, greatly altering health care
and medical and nursing practice

 Research has forced health care providers to address such

issues as:
 Who should receive the benefits of technology
 What are the long-term results of life-supporting and life-
extending procedures
 What kind of future generations we are preparing

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 Future Implications

 Having addressed these issues, can we say that our

decisions are ethical?

 What will be the ultimate cost in consumer health?

 What will be the actual cost to society?

 Where do nursing responsibilities lie?

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 Future Implications

 To ensure the best possible consumer health

care in the future, physicians and nurses will
have to forge a closer, more collegial
relationship

 Such a relationship will demand a high

order of ethical and professional obligation
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 A CASE STUDY

Helping patients and their families

through difficult times is never easy

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 The case of Mr. P
 A 65 year old retired man was diagnosed to
have motor neuron disease 4 years prior to
retirement and had become progressively
worse
 Seen in various ‘corporate’ speciality
hospitals- poor prognosis conveyed
 Sent to CMC Hospital for a feeding
gastrostomy- difficulty swallowing
 Bed ridden, could not talk, communicated
by
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writing; fully alert and compos mentis
 Encounters in CMC
 During the procedure he developed
respiratory arrest and was put on life
support
 3 months later the ICU head called for a
clinical ethics committee meeting
 Failed attempts to wean off respirator

 Opinion backed by evidence that

further attempts would be futile
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 The ethical dilemma begins
 His family had spent more than 8 lakhs and
wanted to remove him off the respirator
 They knew of the prognosis
 They had no more money to spend.
 They owed money for treatment at CMC
 He had a wife, one grown up son, one married
daughter whose husband is a lawyer and two
other smaller children who were studying.
 All shared the same opinion about what they wish
to do.
 They did not express the wish to take him home
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 Intensive dilemma in
intensive care
 He has heard of home respirators
and wished to have one.
 Did not wish to die
 The family and Mr. P had not
discussed these issues with each
other
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Not just another day at the office
 The ICU doctors know treatment is futile
 There is no longer any money to pay for expensive
treatments; the family wish to take Mr. P off life
support
 Mr. P wishes to live; wants a home ventilator
 Where does this come from?
 Mr. P did not want a tracheostomy
 There are limited ICU beds and many potentially
treatable people who need these beds
 This is a Christian institution with certain values
 Conflicting ethical principles: every one of them
 Legal issues
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What would you do?

THE BUCK STOPS HERE

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 The ethics committee’s
recommendations
 Independent review of medical notes
and physical condition
 Transfer to Neuro-ICU: try to wean off
respirator
 Hospital bears further costs
 Try to get money from ex-employers
 Explore issue of home respirator
 Talk with patient and family
32Meet in one month to review situation
 Conversations with the
family
 Wife very distressed by Mr. P’s condition
and prognosis; fears having to deal with
him on her own if he worsened
 Distressed about lack of adequate medical
care in her village in Jharkhand
 Would rather kill herself than take him home
to manage on her own
 Did not want to sacrifice her younger
children's’ futures in futile treatments
 Rational; distressed; not clinically
33depressed
 Conversations with the
family
 Very supportive of mother in law
and his own wife
 Fully aware of legal issues

 Was in communication with family

back home, including Mr. P’s son
 Did not see any other practical
solution
34Pleaded for help
 The elusive home ventilator
 Costs 2,00,000 Rs
 Needs uninterrupted power supply,
technical support
 Family live in a village in Jharkhand
 Wife not willing to try nursing him on a
ventilator at home
 Transport home by rail or air not possible
 Ambulance journey to Jharkhand also not
feasible
35Money from employer not forthcoming
 Independent medical review
and Neuro-ICU efforts

 Confirmed diagnosis, prognosis

 Attempts at weaning off
respirator not proving
successful

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 Conversations with Mr. P
 Knew of his prognosis
 Wished to live
 Agreed to the tracheostomy
 Agreed to try hard to get off the ventilator
 Soon realized this was not possible
 Began to accept that
 his illness would progress;
 that a home respirator was not possible
 even if it were, his QOL would be poor
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 Further conversations
with Mr. P
 Asked to be sent home to die
surrounded by his family
 Not possible

 I suggested his family be brought

here
 List of 15 names of 90 family
members produced
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 Of death and dying
 Acknowledged a good life
 Felt at peace with his maker

 Feared the moment of death: “ did not want to choke to

death’’
 Promise that this would not happen

 Much more at peace about dying after that

 Wrote that he was willing to be taken off life support after

his family came
 Family came on a Monday with return tickets booked for
the following Friday
 Shifted to a private room with technical support

 Family finalized many issues, said their goodbyes

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 The final ethical review
 The family met ethics committee
 All issues reviewed, documented

 My goodbye

 The sedative

 Withdrawal of life support

 Mr. P, in your death, you taught us

about
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the sanctity of life
 The aftermath
 Mr. P’s death affected everyone involved
 Contrast with the situation 25 years ago
 Happens everyday without any ethical
review
 Withdrawal of life support not the central
issue: was it a good death?
 Should we publish this and call for
discussion, legal guidance?
 Guidelines for procedures in similar
situations
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 Lets also remember
 Nursing is about : “Can we?”
 Ethics is about: “Should we?”

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 Dr. Aidah Abu Elsoud Alkaissi
Devision of Intensive Care and
Anesthesiology
University of Linköping-
43 Sweden