Malinda Smith Instructor Mr. Curl Nursing 101 21 October 2009 ETHICAL CHALLENGES FOR THE ELDERLY When patient problems arise in the nursing profession, our knowledge and education usually help us find the obvious and correct solution. There are, however, situations that arise where the correct choice is not readily apparent. These situations are difficult enough to handle when the patient is young and able to understand what’s going. As the patient ages, she’s less able to assist in the decision making process and the decision making responsibility shifts onto the nurse’s shoulders.
The resulting doubt and stress can adversely affect the nurse for a prolonged period of time. Unless and until we understand the unique challenges presented when caring for elderly patients we can’t be comfortable with our profession. In the next 25 years, the number of persons over 65 years of age will increase from 40 million to 70 million. In the year 2030, 1 out of 5 people will be over 65. As a nurse, we can’t afford not to learn about the specific challenges that face us when attending to the elderly.
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When our education and the knowledge we’ve gained throughout life doesn’t provide us with the one correct answer, we need a way to pick the best of alternative answers. When the questions have serious immediate and long term consequences, finding the best answer becomes very important. This is where ethics comes into play. Ethics is a set of moral principals, a code for behavior. It provides us with a rational process for determining the best course of action in the face of conflicting choices. If we can’t find the one correct answer at least the answer we find is consistent and coherent.
This is often the best we can expect. When we are faced with serious questions that have no answers we are confronted with an ethical dilemma. We desperately want to do the right thing, but we’re not sure of the correct answer. When dealing with the elderly we are faced with many ethical dilemmas. The cost of legal care is sometimes prohibitive and it’s only going to get worse. The elderly do not always have the resources or insurance coverage to pay for the medication and procedures that they require.
Similarly, the needed treatment is not always available where the patient lives or there is a shortage in needed nurses. Today we live longer on average than our parents. In the past, we were only concerned with treating the patient and making them well. Now we have questions where we have to weigh the longevity of a patient against her quality of life. Living as long as possible is not always the goal or desire of the patient. As the patient gets older, she’s less able to decide for herself. As a result, the family feels compelled to make some of the decisions.
Very often the wishes of family members do not coincide with the wishes of the patient or even other member of the family. The nurse needs to be a facilitator in these situations. Many of the dilemmas facing the elderly have religious or cultural aspects. Without knowledge of the Jewish or Muslim faiths, for example, a nurse cannot possibly understand what challenges face a terminal patient of one of those faiths. As a person ages a degree of dementia sets in. How is it possible for a nurse to intelligently discuss topics such as organ donation with a patient that doesn’t know where she is?
When faced with these and other ethical dilemmas, it is necessary for the nurse to have tools that help her arrive at a decision she can live with. What follows is a discussion of certain resources that a nurse can turn to for assistance. The American Nurses Association has established a Code of Ethics to provide a basis for difficult decisions. Provision 1 provides that: “The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems. Remembering this can help us get past some of the biases we may have toward the aged. Provision 2 reminds us that: “The nurse’s primary commitment is to the patient……” This provision can help us focus when the caring family has strong differing opinions as to what’s course of action is correct. Every nurse should take time to read and reread the Code of Ethics and the corresponding standards. Similar to the Code of Ethics is the Nightingale Pledge. This pledge, which is a nurse’s adaptation of the Hippocratic Oath, provides as follows: I solemnly pledge yself before God and in the presence of this assembly, to pass my life in purity and to practice my profession faithfully. I will abstain from whatever is deleterious and mischievous, and will not take or knowingly administer any harmful drug. I will do all in my power to maintain and elevate the standard of my profession, and will hold in confidence all personal matters committed to my keeping and all family affairs coming to my knowledge in the practice of my calling. With loyalty will I endeavor to aid the physician, in his work, and devote myself to the welfare of those committed to my care.
After having looked to our profession, we can next look to the law. With regard to the elderly, the legislature has provided us with some tools and guidance. Specifically, Ohio and Kentucky have laws regarding health care directives that allow a person to thoughtfully document who they would like to make decisions and what life sustaining treatment they wish to receive if they reach a point when they can no longer decide for themselves. This was a central topic in the Terry Schaivo case. There were competing opinions as to what treatments should be given. If Mrs.
Schaivo had completed a Living Will and/or appointed one person to make the life and death decisions for her, the dilemma would have ended before it started. Unfortunately, these professional statements and the law can only take us so far in our decision making process. We need to adopt a formula for addressing the various tough questions that arise. As I researched this paper I was amazed at how many approaches there were to tackle difficult questions. One that I found most helpful was a 5 step approach: When a dilemma presents itself, you first have to ASSESS or identify the problem and the people involved.
Next is the requirement to DIAGNOSE or gather data and explore the various solutions. With this information, we next have to PLAN or outline our options and consider our various choices. Having decided on a plan, we need to IMPLEMENT or act on it. Finally, after having taken action we need to later look back and EVALUATE the outcome so that we will add the result to our knowledge base for the next difficult decision we face. All of the codes, laws and decision making processes will never be enough to allow us to adequately deal with the many ethical dilemmas we will face when attending to the elderly.
Continuing to gather knowledge about medicine, culture, religion, family psychology, law and anything that has to do with our elderly patients is the only way we can adequately address our patient’s concerns. We need to be familiar with nursing homes and assisted living. A general knowledge of the insurance industry and Medicaid is a must when we try to step into the shoes of our patients and their families to share their concerns. How can we possibly hope to help someone decide an issue controlled by their religion or culture when we don’t know the first thing about what their beliefs are?
Continuing our education on medical matters is only a start. Proper care of the elderly requires that we go several steps further. Only then can we hope to sleep at night and feel at peace with our actions after facing the many ethical dilemmas we are sure to face in the years ahead. Works Cited ANA (July 2001). The Code of Ethics. Retrieved March 20, 2005, from http://www. nursingworld. org Buehler, DA. (Sept. 2, 1999). Informed Consent and the Elderly. Retrieved March 17, 2005, from http://www. ncbi. nlm. nih. gov Cipriano Silva, Mary, PhD, RN, FAAN (Dec. 3 1998).
Organizational and Administrative Ethics in Health Care: An Ethics Gap. Retrieved March 3, 2005, from http://www. nursingworld. org Cooke, Jolyn M. , RN, MN (August 29, 2003). Required Criteria for Completion of Assignments and Evaluations. Retrieved March 17, 2005, from http//www. muw. edu Gordon, Michael, MD, MSc, FRCPC (April 2002). Beyond the Hippocratic Oath: Ethical Challenges in the Care of Elders. Retrieved March 20, 2005, from http://www. JournalofGeriatricCare. com Johnstone, Megan-Jane (June 2002). Ethics in HealthCare. Retrieved March 20, 2005, from http://www. ontemporarynurse. com Ludwick, Ruth, PhD, RN, C, & Cipriano, Silva, Mary, PhD, RN, FAAN (Dec. 19, 2003). Retrieved March 20, 2005, from http://www. nursingworld. org Office of the Attorney General (No date). Living Wills in Kentucky. Retrieved March 5, 2005, from http://ag. ky. gov Ohio Hospice & Palliative Care Organization (Dec. 2004). Ohio’s Living Will and Healthcare Power of Attorney. Retrieved March 5, 2005, from http://ohpco. org U. S. Census Bureau (August 26, 2004). U. S. Interim Projections by Age, Sex, Race, and Hispanic Origin. Retrieved April 11, 2005, from http://www. census. gov