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The Role of the Nurse on Hospital Ethics Committees
Abstract
Sound decisions are characterized by assurance of adequate information, multiple perspectives, sufficiently deliberate thought, emotional support for all decision makers, and legal acceptability. Each of these features can be enhanced by appropriate involvement of the nurse on an ethics committee. As a result, the nurse will be helping to assure patient, family, and professional participants that they have done their best under difficult constraints.
Serving as a member of a hospital ethics committee is time consuming and challenging. Yet, it is one of the most important ways nurses can function in the role of patient advocate. The ethics committe can be the answer to the frustration that nurses confront every day when faced with increased technology, legislative inaction, and medical paternalism.
Even competent patients are often manipulated when they want to refuse treatment. Patients and families frequently have the illusion of choice but no real choice at all. If an ethics committee can provide some meaningful avenue for the exercise of patients’ and families’ rights, then they are worth the effort.
This research examined how the interpersonal dynamics between surgeons and surgical nurses in the operating room and their attitudes toward elderly patients affected the quality of care delivered. Qualitative data were gathered through in-depth interviews with surgeons and surgical nurses and from 5 months of participant observation in an operating room. The findings indicate that surgeons strongly influence how surgical personnel treat patients during surgery. The surgeon's ultimate control and unquestioned authority in surgery, when combined with depersonalization of patients, created situations in which the quality of care was compromised. The recommendations discussed include establishing the surgeon as a positive role model, specialized training for those working with elderly patients, and shared governance of the operating room.
The tradition of medicine has until now been characterized by an aspiration to provide as complete as possible a service of care to the populations to which it owes responsibility. The same holds for nursing and caring practices, but the tradition is loosening. Despite the collective assumption that medical and nursing practice rests on solid grounds of knowledge and is framed by a caring ethos, change in practice not only has typically come about in a complex and diffuse fashion, but has also come along with sacrifices, losses and deficits.
There is much controversy surrounding the issue of nurses in the role of patient advocate. Cancer patients are vulnerable due to their diagnoses, the anxiety that it generates, the nature of the disease and subsequent treatment and may have diminished autonomy as a result. It is questionable whether the nurse is able to promote the best interests of the patient in this situation. Models of advocacy and the nurse-patient relationship are discussed. The main arguments for taking on the role of patient advocate include: reference to long periods of time spent with the patient and the chance to build a relationship; the duty to care and the duty to do no harm. Criticisms of the appropriateness of the advocacy role for nurses include: inability for the patient to choose his or her nurse; promotion of self interests; charges of paternalism; challenges from other health care professionals and multiple and/or conflicting obligations. It is concluded that perhaps the most ethical way of caring is by empowering patients and promoting selfadvocacy. This concept needs to be further explored.
General Hospital Ethics Committees (GHECs) have emerged as institutional forums for addressing bioethical dilemmas. Hospital psychiatrists have important roles to play on these committees. Their skills in group process assessment, mental status examination, and character assessment have diverse applications. Psychiatrists can facilitate communication, both on the committee and as GHEC-based clinical ethics consultants. Ethics committees must be concerned with how they arrive at ethical decisions, guarding against political influence or individual monopolization. Psychiatrists can assist these efforts as organizational consultants to GHECs. The perception of psychiatrists as reflective, tolerant of ambiguity, humanizing, and approachable about moral aspects of health care suggests they would make excellent committee leaders. Hospital psychiatrists also have important committee roles to play as ethics educators and policy-makers. More demographic research is needed to investigate psychiatrists' participation on GHECs. Studies of how they are perceived by their ethics committee colleagues may reveal new roles and potential pitfalls for GHEC psychiatrists.
The Department of Health guidelines on local research ethics committees are now in operation. But, are they enforceable and what relevance do they have to nursing?
Nursing ethics was long reticent about ethical challenges that elderly patients pose for critical care nursing. One of these, the legal doctrine of informed consent, has important implications for critical care nursing ethics. Deriving from the principle of respect for persons and intended to preserve their autonomy, informed consent represents both a duty and an ideal for care givers to implement in the process of ethical decision making. All too often the ideal is lost, however, and the doctrine reduced to a sterile and bureaucratic procedure. When elderly patients are unable to give an adequately informed consent, advance directives can enable them to express their wishes by prior choosing. If they become cognitively impaired, however, it is much more difficult to determine what, if any, preferences such a patient might express if able to do so. Medical empowerment of the elderly, a laudable social goal, can be as contradictory as informed consent itself and many elderly patients may opt out of their own decision making. The resultant moral distress of such a complex process is still another ethical challenge that faces the critical care nurse. Because nursing holds a position of moral centrality among the health care professions, critical care nurses cannot avoid the prospect that issues like those identified in this article will continue to challenge and confront them in the coming decade. By turning to colleagues in nursing as well as other professions, nurses can best strengthen and consolidate their vital role as mediators of meaning and morality in life-and-death situations.
In order for nurses to be effective advocates, they must practice in an environment that fosters competency, collaboration, communication, and ethical values. This article addresses the meaning of advocacy, explores whether nurses can be effective advocates in complex practice environments, identifies barriers to advocacy, and suggests individual and systems approaches to support advocacy in critical care.
Nurses often encounter ethical dilemmas during the course of their practice and play a key role in the ethical decision-making process. This article identifies resources available to assist the nurse in making sound ethical decisions. Institution-based resources, such as institutional review boards and pastoral care, and unit-based resources, including nursing ethics rounds and peer support, are discussed.
Moral certainty, uncertainty, or both have an impact on every ethical decision confronted by the nurse. This article describes a qualitative study of the moral certainty and uncertainty experienced by long-term care nurses who are faced with the issue of withholding or withdrawing artificial nutrition and hydration from elders in the end stages of life. Moral certainty and uncertainty are analyzed as universal concepts, and the analysis is supported by the words of the study participants. Morally certain participants view tube feeding negatively and are likely to take some action when confronted with elders being tube-fed. The most common action is to educate families about tube feeding. Morally uncertain participants see the tube feeding as neutral or benign and are likely to take no action, but to maintain a strong belief that the elder should not suffer. Moral certainty and uncertainty are compared and contrasted and the findings discussed.
This article comprehensively addresses the composition, role, and functions of a hospital ethics committee (HEC). HECs are of particular interest to critical care specialists because they often participate in or lead such committees, extending their commitment to communication and caring beyond the borders of the intensive care unit (ICU). This article also demonstrates that a well-run ICU in a hospital with a strong HEC automatically will include many of the services that the HEC normally would provide, without the need for HEC assistance.
Progression of nurse education from apprentice to educational courses in response to demands for strengthening professional status has led to an increase of nursing research proposals at Level 3 and beyond. Accordingly, the demands on ethics committees in considering ethico-legal aspects of such proposals have also risen. Historically, this function has fallen to (medical) local research ethics committees. This paper considers one centre's response in creating a nurse-led research ethics committee to function in a symbiotic partnership with its medical counterparts. The authors consider arguments for and against such a committee, suggesting that nurse-led groups are generally more tolerant of the diversity revealed within nursing research proposals, including both quantitative and qualitative studies, than medical committees who are arguably steeped in the empirical tradition. The authors also consider the future viability of small ethics committees against the backdrop of national reorganization of nurse education. They contend that whilst organizational factors may encourage creation of regionally based multidisciplinary committees, the value of discrete local nurse-led ethics groups cannot be underestimated, and such groups should be retained.
As health care has become more complex in light of technological, economic, and organizational advances and changes, ethics has increasingly become a required component in decision making. This article examines four major trends: philosophical and practical problems with the place of ethics in health care, the necessity to broaden the focus of ethics committees, increase emphasis on interprofessional collaboration, and changes in the marketplace of health care delivery that will impact ethical decision making in the future.
Healthcare ethics committees (HEC) have emerged as institutional forums for addressing bioethical dilemmas. Psychiatrists have important roles to play on these committees. Their skills in group process assessment, mental status examination, and character assessment have diverse applications. Psychiatrists can facilitate communication within the committee and as HEC-based clinical ethics consultants. HECs must be concerned with how they arrive at ethical decisions, guarding against political influence or individual monopolization. Psychiatrists can assist these efforts as organizational consultants to HECs. The perception of psychiatrists as reflective, tolerant of ambiguity, humanizing, and approachable about ethical aspects of health care suggests they would make excellent committee leaders. Psychiatrists also have important committee roles to play as ethics educators and policy makers. More demographic data is needed to investigate psychiatrist participation on HECs. Studies of how they are perceived by their ethics committee colleagues may reveal new roles and potential pitfalls for HEC psychiatrists.
At the request of the Midwest Bioethics Center (MBC), we surveyed nurses' and physicians' attitudes and needs regarding Hospital Ethics Committees (HECs). The primary objective of this research project was to inform the practices and policies of the Ethics Committee Consortium of the Bioethics Center.
Four thousand eight hundred and twenty-nine surveys were distributed to the medical and nursing staff of eight Kansas City metropolitan area hospitals. One thousand and fifty-five surveys were returned, representing a response rate of 21%.
This survey examined five areas believed to be related to nurse and physician use of and participation on HECs: [1] Training in Biomedical Ethics; [2] Nature and Purpose of HECs; [3] HEC Functions-Case Consultation; [4] Ethical Decision-Making and Patient Care; and [5] Continuing Education. Important findings include lack of knowledge regarding whether case review is required or optional, and whether recommendations are binding or advisory; a perception that training in medical ethics was inadequate; and a strong indication that HECs should be accessible. These findings are consistent with and extend the findings of prior descriptive research in this area.
Hospital ethics committees have been hailed as providing a promising way to resolve ethical dilemmas in patient care. Although ethics committees may have various tasks, such as confirming prognoses, educating care givers, or developing hospital policies, their most innovative role is making recommendations in individual cases.1 2 3 4 5 This role has been supported by the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, the American Medical Association, and the American Hospital Association. Strictly speaking, such recommendations are not binding, but they undoubtedly carry great weight, especially if they are cogently justified.6 It is predicted that . . .
Now that ethics committees are firmly established in a majority of U.S. hospitals (60%, according to recent surveys), attention is shifting to the roles they play and the problems they face. Administrative concerns focus on secretarial and staff support and the difficulty that busy committee members have in fitting in consultations. The three main categories of committee endeavor are education, policy development, and consultation. Emerging social issues such as care of the uninsured or indigent, organ procurement, and patient care vs. economic constraints are new areas for policy development, while the trend in consultation is toward on-call or informal consults in place of periodic meetings involving all committee members. Although committee members see their roles as discussants and facilitators of consensus, there is some concern that the committees' recommendations may be followed despite patient or family opposition.
A question-and-answer format is used to provide background information on the status, organization, and role of hospital ethics committees. The information consists of a synthesis of published materials and of the views of Hastings Center staff, visiting scholars, and others experienced with ethics committees. Topics addressed include the number of hospital ethics committees in existence; the possible functions of such committees; their benefits and their disadvantages; organizational models; and the selection and education of ethics committee members.
An evolving transformation in nursing ethics is examined in terms of two basic metaphors of the nurse's role and its norms and virtues. Early discussions of nursing ethics portrayed nursing as military service in the battle against disease, associated with the virtue of loyalty and with the norms of obedience and the maintenance of patient confidence in physicians as authority figures. During the past decade, a metaphor of the nurse as advocate of patients' rights has largely replaced the older image. The author supports this change while cautioning that attention should be given to clarifying the meaning of advocacy, revising state laws to allow for expanded nursing roles, educating patients to accept the nurse as advocate, teaching nurses to cope with controversy, and identifying a legitimate place for loyalty to one's associates.
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