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- A foreword. Ethics as a complex of behaviour’s rules.
- The ethical norms in society’s and state life.
- The links between ethics and medical service.
- The ethical principles in medical worker’s activity.
- The JCAHO and its Patients Rights Standarts.
Ethics is a branch of philosophy that considers and examines the moral life. Law and ethics are similar in that they have developed in the same historical, social, cultural and philosophical soil. The law may be better defined as the sum total of rules and regulations by which a society is governed. Ethics, on the other hand, are informal or formal rules of behavior that guide individuals or groups of people. Legal rights are grounded in the law and ethical rights are grounded in ethical principles and values.
Every profession that deals with human rights and liberties eventually develops a professional ethic (either formally or informally) to guide the responsible behavior of its members. In healthcare, the deductive process by which ethical principles are applied to situations common to the profession is called bioethics. The concept of bioethics as a branch of applied ethical theory is both as old as the Hippocratic Oath and as current as the dilemmas posed by the unique clinical practice of today[i].
In the past decade, changes in society and within health care have increased the impact of ethical and legal issues upon practice. The pressures derived from ethical conflicts have become so great that they are often portrayed in the media. As practice continues to become more high-tech and high-cost and continues to be affected by the advent of managed care, ethical and legal issues will rapidly become even more complex. Now more than ever, healthcare professionals must be prepared to face situations that demand ethical consideration.
Ethics are an expression of our values. In practice, ethics are rules, often legally prescribed, that help us decide whether a decision or action is right or wrong[ii]. Ultimately however, ethical decisions and concepts of morality are based on fundamental notions about protecting and maintaining human dignity.
Moral reasoning is the thought process that attempts to resolve ethical dilemmas; ethical practice is the result of decisions made and actions taken. Unfortunately for many people, moral reasoning and ethical practice are not clearly defined. Home care team members, however, must develop ethical thought and practical guidelines because they routinely face ethical questions and increasingly shoulder a large measure of decision-making responsibility.
Healthcare providers in home care will often find themselves facing questions of fairness or of right and wrong. Much more than hospital staff, home care providers must assert themselves and assume an expanded role as the patient advocates[iii]. As a result, we must be able to make clear decisions and act with assurance. It is of the utmost importance that we develop an awareness of ethics and practice morally, according to the established standards of the profession, making sure that our ethical practice is based on thought and reflection, not on intuition, self-interest, or pragmatic considerations.
Home care delivery continues to grow. In part, this is due to an increasing number of elderly individuals, especially those over age 85, and to the continued cost-containment policies of hospitals and other healthcare organizations. Primarily, home health care is growing because it is the care option that many people desire and value for themselves. As home care continues to expand, home care professionals will face even more ethical dilemmas.
Home care has an underlying generic mission – to support patients in their own environment without the loss of their autonomy and within their own community. In addition, constraints from regulatory bodies such as Medicare and Medicaid, third party insurance payers, and hospitals often place the home care provider in a position of having to make very dif.cult ethical decisions.
For instance, a nurse or a physical therapist in home care practice may have to discontinue services to patients who no longer meet the criteria for payer reimbursement, even though the patient may still have healthcare needs within these areas of practice. The American Nurses Association (ANA) document entitled A Statement of the Scope of Home Health Nursing Practice and the Code of Ethics for home care nurses outline some of the ethical considerations that nurses should understand practicing in the home setting: the importance of ethics, ethical guidelines, the home care concept, and typical ethical dilemmas[iv].
Professionals in the home care setting are also confronted with legal and liability issues. Although many ethical practices such as con.dentiality of patient information are also grounded in law, there are a multitude of laws that healthcare-related professions do not addressed ethically. For example, the mandatory reporting of child abuse is required by law in most, if not all, states; however, it is the law rather than an ethical code of conduct that provides the impetus for this reporting. Additionally, liability issues may or may not be addressed in ethical codes and legal statutes. For example, a healthcare provider can be held civilly liable and responsible for punitive, monetary awards to clients when they have not practiced according to a professional standard and the geographic norm, an issue not directly addressed in ethic codes nor dictated by law.
Healthcare resources are increasingly allocated especially in advanced technologies. Advances in research and development have greatly enhanced the tools for extending a patient’s life, often without regard to the quality of life and patient choices. Although decisions concerning the rationing of medicines are a focus for debate by the general public, home care providers already face difficult decisions concerning appropriate use of resources on a daily basis. On top of these allocation issues, nurses also encounter conflicts concerning autonomy, benecence, justice, con.dentiality, and truth. In this modern era (where scientists can now clone sheep)[v], a nurse in home care can only wonder what lies ahead. With each scientific advance, there is the potential for entirely new ethical problems.
Healthcare providers in home care must be familiar with the codes of ethics and anhere to them. The Code for Nurses with Interpretive Statements by the American Nurses Association (ANA), established in 1995, is a guide for dealing with the ethical issues that confront the home care nurse in practice. The guide outlines a forum in which nurses, patients, and caregivers can best identify and clarify ethical dilemmas. After identification and clari.cation, the process of negotiation can begin. Negotiating treatment solutions and options must be an ongoing process because conflicting needs and goals will emerge as care and treatment progress. In home care, the nurse and other healthcare professionals are in the center of these types of discussions, thus they need to understand the relevant ethical and legal issues.
Home care, along the continuum of care, utilises the services provided by virtually all the same providers that a patient encounters in other settings such as the hospital, a longterm care facility, and a primary care setting. This course will address the ethical, legal, and liability issues for all home health care providers. Some of these issues are specific to Home Care Ethical and Legal Issues. Home care is not merely a change in the healthcare delivery site, nor is it a version of acute care delivered at home. Home care has its own definitions, limits, and structures for care. The in-home care provider must know the nature and range of services available at home and how to allocate them to patients. A broad array of services and caregivers may be required for a single patient, or care may include enduring frailty or addressing multidimensional problems and services outside the realm of typical medical treatment.
Due to the complex nature of home care services and the predominately elderly population that home care serves, many individual ethical issues arise, posing dilemmas that must be discussed, reflected upon, and resolved[vi]:
1) Premature discharge of clients based on exhausted or diminished reimbursement sources affects the decision to provide home care;
2) Patients who are underserved and families unable to successfully meet the demands of home care can pose difficult problems;
3) Patients and families may demand services that are not required, and others may reject treatment even though it is reasonable and would be beneficial;
4) There may be a demand for services not covered by the payer sources;
5) Families or caregivers may refuse to improve environmental conditions that are essential for a healthy outcome for the patient;
6) There may be patients who are unwilling to allow a mandated reporter to report abuse or neglect.
Negotiating treatment solutions and options must be an ongoing process because conflicting needs and goals will emerge as care and treatment progress. It particularly concerns the disciplines and specific certain professions, which provide insightful guidance to other home health care professionals. These professionals are all a part of the team – directly, indirectly, some involved on a short-term intermittent basis and others on a continuous ongoing basis.
Professionals and technical support professionals in such disciplines as nursing, social work, physical, occupational, and speech therapy, dietetics, and respiratory therapy are specifically mentioned. However, others including those that coordinate care including case managers, home care administrators and discharge planners, risk managers, and those involved in quality improvement are not specifically mentioned in the readings or this course[vii]. They nonetheless play an integral role in home care coordination, one that requires an integrative knowledge of all disciplines, a necessary competency to ensure the effectiveness of an ethical, lawful, and liability – free home care delivery system.
One organisation that umbrellas all home care providers is the National Association of Home Care. This organization represents the interests of all home care agencies and their staff. The Association has a Code of Ethics that all home care agencies can and should adopt to guide practice and personnel, although other bodies specific to a discipline or profession such as nursing, social work, dietetics, physical, occupational and speech therapy have their own as well.
The Code of Ethics, upheld by the National Association of Home Care and its members since 1982, provides ethical guidelines relating to patient rights and responsibilities such as those relating to decision making, self-determination, informed consent, privacy, con.dentiality, the right to refuse treatments, the rights to professional care and voicing grievances. It also provides guidance in terms of relationships with other provider agencies to ensure comprehensive services and referrals, the responsibilities of individual and member agencies to the National Association of Home Care, fiscal ethics and patient charges, ethical marketing and public relations, personnel guidelines including those associated with equal opportunity employment, competency of staff, supervision, continuing education and inservice education, and lastly, legislative efforts and the disciplinary process for professional misconduct[viii].
An example of ethical guidelines for a specific professional discipline is found in the Code of Ethics for those who practice in the area of dietetics and nutrition. In addition to its nineteen principles, the American Dietetic Association’s Code of Ethics details how ethical issues and concerns within the profession will be addressed. It details the membership of its Ethics Committee, how it will generate ethical opinions, and how ethical practice issues will be resolved in order to uphold the Code of Ethics and promote ethical practice. The steps of this process include:
1) List of a written and sworn complaint that details the alleged violation of the Code of Ethics by a member of the American Dietetic Association;
2) Review of the complaint by the Ethics Committee chairperson and others to initially determine whether or not there is a basis for the complaint, that is, the determination of whether or not a breech of ethics could possibly have occurred;
3) Notifying the individual under scrutiny about the complaint if it is determined through this preliminary review that there was a possible breech of the Code of Ethics, and the procedural steps that the Committee will follow in response to the complaint;
4) Response of the individual to the allegation with a written and sworn statement to the Committee within 30 days after notification;
5) Decision by the Ethics Committee, in collaboration with legal counsel on how best to proceed. Some of the options include continuing education, supervision in practice, a formal hearing of the case, or another course of action;
6) Appeal and final decision should the respondent choose to .le an appeal in writing to the Ethics Committee[ix]
Among the Main pronciples that all the medical workers must follow are th autonomy and confidentiality The principle of autonomy signifies that choices decrease and autonomy often diminishes as a patient becomes increasingly frail. Eventually, a patient may have very little ability to make decisions about healthcare settings and healthcare issues. In many cases, the patient is still competent to make these decisions, but soon notices that his or her choices are limited by increasing dependency on others. The patient’s health care may not be provided in the same way the patient handled it, and the patient may not be comfortable with the new method. Maintaining the patient’s desired quality of life and choices often requires accommodating and negotiating the competing interests of the patient and the caregiver or family in an ethical and legal manner.
The principle of confidentiality foresees that information disclosed to or observed by a formal caregiver must remain undisclosed to unauthorized individuals. At times, several parties may be entrusting the home care staff with con.dential information. care providers often become the recipients of the most intimate and private information about the patient, the family, and other caregivers[x]. Ethical conflicts may occur when several parties request information from the nurse, sometimes demanding disclosure when it is not appropriate. Even in the informal environment of home care however, the confidentiality of the patient must be protected without compromise. Advance directives in 1990, the federal government passed the patient self-determination act which requires hospitals, skilled nursing facilities, home health agencies, health maintenance organizations, and hospices to provide written information to all patients about the option to accept or refuse medical treatment as well as how to formulate advance directives about those decisions in compliance with state law[xi]. This legislation also mandates that all healthcare providers document in the medical record whether or not a patient has an advance directive. There are two types of advance directives: the living will and the durable powerof-attorney (also called a healthcare proxy). Either type of advance directive is valid when the patient becomes incapacitated and is unable to make his own decisions in situations such as irreversible brain damage, permanent coma, or terminal illness, for instance. these directives can be changed at any time, whenever the patient so desires. Living wills are typically used to record a decision to decline any or all life-prolonging treatments. Whatever their purpose, living wills should be in writing, explaining the patient’s wishes regarding health care. They should also indicate the circumstances in which they would be implemented and the medical care desired in the event certain circumstances occur. the durable power-ofattorney or healthcare proxy, on the other hand, names a decision-maker who makes healthcare decisions for another person should he or she become unable to do so hisor herself. A living will can make a patient’s feelings known about treatments such as cardiopulmonary resuscitation (CPR), intravenous therapy, feeding tubes, ventilators, dialysis, and pain relief with terminal illness[xii]. It is important that these issues are discussed and that the home care provider understands that the acceptance or refusal of medical care is the patient’s right alone. Whether it is a living will or a durable power-of-attorney, advance directives allow the patient to give directions to the health care provider about his or her wishes. As a consequence of the patient self-determination act, home care agencies and other healthcare systems have started to include advance directives into the routine admission process, asking patients if they have completed an advance directive. If a patient is transferred from one healthcare agency to another, the home care professional should inform the new agency that the patient has an advance medical directive, so the patient does not have to repeat the same information again.
Among the most famous, effective leading organisations, which are occupied by ethical aspects of medical care, is the Joint Commission on Accreditation of Healthcare Organisations (JCAHO). It worked out the main principles of medical activity linked to ethics and morality. The JCAHO is one of the preeminent organizations in health care quality, of which credentialing and privileging are important elements. One must be familiar with the JCAHO’s standards and policies to fully understand and be effective in the credentialing and privileging of healthcare professionals. Statements such as “the JCAHO requires”[xiii] are based on careful readings of the JCAHO standards, exposure to the JCAHO’s surveyor training, and frequent observation of the JCAHO survey teams at work. Federal and state law can differ from those of the JCAHO or other accrediting organizations. These requirements can be stated in licensing laws or regulations or in a contract or contract-like document (e.g., Medicare Conditions of Participation).
JCAHO standarts are adopted by all American medical centres and services, because they (principles) include the experience of national medical care, so they effective and they merit attention. Leadership of the organisation is responsible for:
1) Consumer protection, rights, and assisted living community ethics;
2) Continuity of services as they relate to assisted living;
3) Assessment and reassessment of resident care;
4) Providing resident services, including medication;
5) Providing resident education regarding services, rights, and responsibilities;
6) Managing human resources;
7) Health and wellness promotion, including nutrition and therapy;
8) Improving performance of provider service and resident status;
9) Leadership within all facets of assisted living;
10) Managing the environment to reflect and serve the needs of residents;
11) Managing information to ensure that residents are informed about their care;
12) Prevention and control of infections[xiv].
There is also another list, created in 1997 by JCAHO, these are properly the rights of patients. The Patients Rights Standards continue to emphasize access to care, treatment of patients and respect for patients and their families. While these Standards are requirements, various strategies may be utilized to achieve compliance. Hospital Ethics Committees, while not required, have been effective in addressing many of the issues outlined in these Standards[xv]:
1) The hospital addresses ethical issues in providing patient care;
2) The patient’s right to treatment or service is respected and supported;
3) Patients are involved in all aspects of their care;
4) Informed consent is obtained;
5) The family participates in care decisions;
6) The hospital addresses advance directives;
7) The hospital addresses withholding resuscitative services;
8) The hospital addresses forgoing or withdrawing life-sustaining treatment;
9) The hospital addresses care a the end of life;
10) The hospital demonstrates respect for the following patient needs: confidentiality, privacy, security, resolution of complaints, pastoral counseling and communication;
11) Each patient receives a written statement of his or her rights;
12) The hospital supports the patient’s right to access protective services;
13) The hospital has a policy and procedures, developed with medical staffs’ participation, for the procuring and donation of organs and other tissues;
14) The hospital protects patients and respects their rights during research, investigation, and clinical trials involving human subjects;
15) The hospital operates according to a code of ethical behavior This code addresses ethical practices regarding marketing, admission, transfer, discharge and billing, and resolution of conflicts associated with patient billing;
16) In hospitals with longer lengths of stay, the code addresses a patient’s rights to perform or refuse to perform tasks in or for the hospital.
With the emergence of new technologies for health care and the greater use of technology in home care, home care’s future will likely be fraught with change. The path leading to updated information systems for patient assessment has already been cleared. These systems will be used to predict physiological needs and projected care for in-home patients. They will also be used to establish goals for safe and palliative care. Although life-promoting technologies will be available for patients who have a chance for recovery, there will be more emphasis on informed decision-making by patients and their families about prolonging life that is without quality and terminal.
Many individuals do not execute an advance directive because they “do not feel their present perceived state of affairs urgently call for advance directives, and there is widespread confidence that they can rely on others”[xvi]. Healthcare providers often do not have enough regular ongoing contact with patients, thus patients do not feel comfortable discussing end of life issues or completing advance directives.
The evidence to date indicates that simply providing information encourages patients to talk about their preferences with family members and friends who are the people that will be making decisions in the event the patient loses decision-making capacity.
Medical workers need to engage in a process of ethical discernment, discourse and decision making. The application of ethical principles can assist in a search for the best solutions to complex ethical dilemmas at the end of life. An ethical process is a way to seek balance in decision making by addressing values and understanding the needs of those involved[xvii]. Medical workers have a responsibility to patients and families to advocate for their rights to pursue choices and make informed decisions. Medical workers should work very closely with other disciplines to address ethical issues in end of life care, as end of life decision making will continue to raise difficult issues for healthcare professionals, patients, and patients’ families.
[i] “Home Care Ethical and Legal Issues” – by Naomi F. Miller-Schlabach, 2003.
[ii] The same source.
[iii] “An Ethical Assessment Framework for Nursing Practice” – by Cassells, J. & Gaul, A., 1998.
[iv] “Standards of Practice and Code of Ethics” – by American Occupational Therapy Association, 2000.
[v] The same source.
[vi] “Home Care Ethical and Legal Issues” – by Naomi F. Miller-Schlabach, 2003.
[vii] The same source.
[viii] The same source.
[ix] «Code of Ethics” – by American Physical Therapy Association, 1998.
[x] “Care of the Hopelessly Ill: Proposed Clinical Criteria for Physician-assisted Suicide” – by Quill, T.E., Cassell, C.K. & Meier, D.E., 1992.
[xi] “New JCAHO Standards for Pain Management: Carpe Diem!” – by C. Richard Chapman, PhD, 1998.
[xii] The same source.
[xiii] “Home Care Ethical and Legal Issues” – by Naomi F. Miller-Schlabach, 2003.
[xiv] The same sourse.
[xv] “Legal, Ethical, and Regulatory Issues” – by Gingerich, B. & D. Ondeck., 1995.
[xvi] “Concepts and Cases in Nursing Ethics” – by Yeo, M., Moorhouse, A., & Donner, G. Justice., 1996.
[xvii] “Home Care Ethical and Legal Issues” – by Naomi F. Miller-Schlabach, 2003.