Moral distress and patients who forego care due to cost.

BACKGROUND: In the US, many patients forgo recommended care due to cost. The ANA Code of Ethics requires nurses to give care based on need. Therefore, US nurses are compelled to practice in a context which breaches their professional ethical code. RESEARCH OBJECTIVES: This study sought to determine if nurses do care for patients who forgo treatment due to cost (PFTDC) and if so, does this result in an experience of moral distress (MD). RESEARCH DESIGN: Semi-structured interviews were transcribed and analyzed using a qualitative content analysis. PARTICIPANTS AND RESEARCH CONTEXT: A convenience sample of 20 nurses in practice for at least one year from a variety of health care setting participated. ETHICAL CONSIDERATIONS: This project was approved by the Michigan State University Biomedical Institutional Review Board. RESULTS: There were 19 female and one male nurse-participants, averaging 47 years old with an average of 10 years in practice. 18 reported caring for PFTDC. These 17 nurse-participants experienced a moderate degree of MD as a result, averaging 5.4 of 10 on the Moral Distress Thermometer. In the interviews, the following themes were identified, strategies to help PFTDC, and the broken US health care system which had the subthemes of preference for business over patient-oriented benefit, PFTDC using the emergency department, and limited support for treatment/management of PFTDC. CONCLUSIONS: The existence of this phenomenon places the profession of nursing in the US in a position of moral compromise and threatens to corrupt the institution of nursing in the US.

Enabling Advance Directive Completion: Feasibility of a New Nurse-Supported Advance Care Planning Intervention.

Adults who complete an advance directive (AD) are not consistently offered information about the risks, benefits, or alternatives (RBA) of the life-sustaining medical procedures addressed on standardized forms. The current article describes a new patient-centered nurse-supported advance care planning (NSACP) intervention focused on providing information about RBA of life-sustaining procedures. Fifty participants (mean age = 50.26 years) at a Veterans Affairs medical center were randomized to the NSACP intervention or a comparison condition. Before randomization, 78% (n = 39) expressed interest in RBA information. Of participants in the NSACP group, 94% (n = 30) completed an AD. Participants who received NSACP made more decisions to decline life-sustaining treatment than those who were randomized to the comparison group. Promising feasibility data include brevity (mean = 46 minutes), high patient satisfaction, participant retention, and treatment fidelity. The NSACP holds promise as a brief, educational intervention to support patients in completing an AD. [Journal of Gerontological Nursing, 44(7), 31-42.].

Ethically Relevant Differences in Advance Directives for Psychiatric and End-of-Life Care.

BACKGROUND: Psychiatric advance directives (PADs) represent a shift from more coercive to more recovery-oriented care and hold the promise of empowering patients while helping fill the gap in treatment of non-dangerous patients lacking decision-making capacity. Advance directives for end-of-life and psychiatric care share an underlying rationale of extending respect for patient autonomy and preventing the harm of unwanted treatment for patients lacking the decision-making capacity to participate meaningfully in planning their care. OBJECTIVE: Ethically relevant differences in applying advance directives to end-of-life and psychiatric care are discussed. DESIGN: These differences fall into three categories: (1) patient factors, including decision-making capacity, ability to communicate, and prior experience; (2) decisional factors, including expected outcome and the nature of the decisions; and (3) historical-legal precedent. RESULTS: Specific recommendations are offered. CONCLUSIONS: Clinicians need to appreciate the ethical implications of these differences to effectively invoke PADs or assist patients in creating PADs.

Care and Ethics: Inseparable and Relational.

The background ethical dimension of care is often overlooked but always present.

Informed consent practices of Chinese nurse researchers.

Nursing research in China is at an early stage of development and little is known about the practices of Chinese nurse researchers. This interview study carried out at a university in central China explores the informed consent practices of Chinese nurse researchers and the cultural considerations of using a western technique. Nine semistructured interviews were conducted in English with assistance and simultaneous translation from a Chinese nurse with research experience. The interviews were analyzed by one western and two Chinese researchers and major themes were identified. All participants endorsed informed consent as ethically required. Differences were noted between some of the informed consent practices typically recommended in the USA and those identified in this study, such as: recruitment using local and government officials, recruiting directly from medical records without special permission, family consultation in consent and consent control, and not revealing randomization to intervention groups receiving different treatments.

The Moral Distress of Nurses When Patients Forgo Treatment Because of Cost.

Nursing must recognize an ethical obligation to respond on behalf of these patients.

Ethical Considerations When Dismissing Patients for Noncompliance.

APRNs remain guided, first of all, by the ANA Code of Ethics.

The Ethical and Legal Implications of a Nurse's Arrest in Utah.

Editor's note: On July 26, 2017, Alex Wubbels, the charge nurse on the burn unit at the University of Utah Hospital in Salt Lake City, was arrested for refusing to allow a police officer to draw blood from an unconscious patient in her care. Her arrest, during which she was forcefully placed in handcuffs and dragged out of the hospital, was documented on body camera video and drew national attention. We asked our ethical and legal contributing editors to provide some insight on the issues of this case.

What Nurses Talk About When They Are Talking About Ethics.

The first step toward solutions to ethical problems.

Lessons Learned from Litigation: Legal and Ethical Consequences of Social Media.

Editor's note: To the surprise of many, a Canadian nurse's Facebook post complaining about the medical care a family member had received resulted in disciplinary action by the licensing board. We asked our legal and ethical contributing editors to provide some insight on the issues of this case.

Determining When an Activity Is or Is Not Research.

Practical and ethical considerations for nurses engaged in QI and other projects.

Ethical Case Study of the Researcher-Participant Relationship in End-of-Life Research.

Nurse-researchers studying interventions for patients at the end-of-life may become close with participants due to the nature of interactions within the research protocol. In such studies, participants may request further interactions that would constitute clinical care beyond the scope of the protocol. Nurse-researchers may feel a conflict of values between their obligation to the research goals and their inclinations and obligations as nurses to care for their patients. Nurse-researchers in this situation aspire to honor the bonds developed through close contact and ensure participants receive standard of care while maintaining standards of research ethics. Analysis of a case and review of applicable concepts in research ethics, including ethical relationships, therapeutic misconception, equipoise, and population vulnerability, are used to develop recommendations regarding the decision parameters for similar cases.

Privacy concerns of patients and nurse practitioners in primary care--an APRNet study.

PURPOSE: This study explores and compares the privacy concerns of primary care nurse practitioners (NPs) and their patients. DATA SOURCES: Privacy concerns were identified in separate focus groups of NPs and patients, and then parallel survey instruments were designed and administered to 27 NPs and 185 of their patients. All subjects were recruited through APRNet, a regional practice-based research network of NPs in southern New England encompassing 58 practices. CONCLUSIONS: Both groups demonstrated high levels of concern regarding privacy. While NPs and patients had similar levels of concern about most issues, there were some notable differences regarding breeches because of carelessness, disclosures for research, and which disorders require the most care in maintaining privacy. IMPLICATIONS FOR PRACTICE: These results allow NPs to anticipate patient privacy concerns and to enhance trust in the clinical relationship. These results also indicate the need to educate patients regarding privacy rights and expectations.

Teaching Crucial Knowledge vs. Helping Out on the Unit.

When a clinical instructor must weigh the duty to educate against urgent patient care needs.

The ethics of denying smokers employment in health care.

Such policies send a powerful message, but are the underlying assumptions defensible?

Ethical issues for nurses in force-feeding Guantánamo Bay detainees.

Military nurses face conflicting ethical imperatives.