Teaching ethics: It starts with solid family values
Five tips for conflict resolution
A patient treated by a Michigan home care agency wanted to die and was refusing treatment. The patient, who was under age 21, was a quadriplegic who was ventilator dependent, and he refused to allow the agency’s staff to clean the ventilator.
So how could the home care agency resolve this ethical conflict?
Those kinds of issues arise daily across the country as home care nurses and staff find that their moral and legal obligations to provide the best possible health care often collide with patients’ rights.
Several education managers and other experts on home care ethics say you can begin resolving these conflicts through education and then by forming an ethics committee that regularly addresses ethical dilemmas.
Here are five steps to handling ethical problems:
1. Define the four basic areas of ethical val- ues: autonomy, beneficence, non-maleficence, and justice.
These four values cover most ethical problems, says Mary Robert, RN, C, director of education for Mercy Medical of Daphne, AL. Mercy Medical is a Catholic-run health care organization that has facilities for acute rehabilitation, long-term care, hospice, home health, and residential care. The agency serves all of lower Alabama.
• Autonomy.
"This is my right to choose what’s happening to me," Robert explains. "That’s a good all-American, you-can’t-tell-me-what-to-do right."
The case of the ventilator-dependent young man falls under this category. And like many in this category, there was no easy solution.
The patient was taken to a psychiatrist for evaluation to see if he was mentally competent to make his own decisions, and it was determined he was competent, says Susan Johnson, acting director of quality management and director of advancement and special programs for Huron Valley Visiting Nurses of Ann Arbor, MI. The private nonprofit agency serves southeast Michigan and parts of Ohio.
The agency soon discovered that the patient’s refusal to have his ventilator cleaned was a control issue between him and his father. The son wanted to move out into his own apartment, and the father didn’t want him to, Johnson says.
Patients who are paralyzed can exert only so much control over their lives, and refusing treatment is something within their control, she adds.
The patient continued to refuse care for 14 hours, and then he agreed to allow the nurse to provide services, Johnson says. The agency helped him gain more control over his life by working with him through counseling.
• Beneficence.
This concept means that home care workers are there to do good for patients, Robert says.
When working with the elderly, the sick, and people who are at the end of their lives, it’s especially important to be kind and charitable, she adds.
Mercy Medical, like many home care agencies, has a budget for charity work, and that’s one example of beneficence.
The home care service itself could be considered a good or beneficent activity. But an ethical conflict could develop if the agency discovers that by having its staff visit a particular patient, it has placed its staff at risk for injury.
A patient with a gun
A Birmingham, AL, home care agency once had a case where a patient kept a gun under his pillow.
The agency discussed it with the patient’s family and with the staff and told them the gun couldn’t be there when the staff were attending the patient, says Martha Loveland, RN, MSN, MSHHA, CHE, chief clinical officer of Alacare Home Health Services of Birmingham, AL, a full-service agency that serves central and north Alabama with 19 branch offices.
• Non-maleficence.
"The first priority in health care is one should do no evil or harm, and one should prevent evil or harm," Robert says.
Under this concept, the home care professional avoids taking harmful actions. It differs from beneficence, which is the idea that a home care professional would take good or kind actions to help a patient.
"One example I use that seems to make sense to people is that if you’re standing at a swimming pool with someone who can’t swim, it’s more important to not push them into the deep end, knowing they can’t swim than it is to rescue them in the deep end after they’re pushed in," Robert says.
• Justice.
"These are conflicts between what’s best for an individual and what’s best for the community," Robert explains.
This type of issue could arise when an agency is using its charity budget to help patients. Robert says there could be cases when a particular patient wants to receive a great deal of aggressive treatment even though the physician says it’s futile treatment.
"Do we use a big hunk of our budget for one person rather than use it for more people?" Robert asks.
"This is one of the hardest issues," she adds. (See human values exercise, p. 124.)
2. Before home care administrators or an ethics committee hears about a particular ethical problem, they should gather all the facts.
Loveland says the first step before a committee reaches this point is for its members to conduct a literature review and talk with other home care agencies to find out how they set up their ethics programs.
Then, Loveland adds, the agency should hold extensive staff inservices to show employees how ethics is a major responsibility.
Ethical problems need attention
Robert says each ethical problem presented to a committee needs to be studied carefully so the committee can make sure it has not overlooked an obvious solution.
"Are there other issues from family members to consider?" or "Are there family or clergy or whoever who knows something we don’t know?" Robert offers as suggestions.
"We’ve had a [long-term care] case before where the day staff never saw anyone come to visit a patient, and the staff thought the patient was being neglected by the family," Robert says.
"But the day staff didn’t know that the patient’s family was coming in at night because only the night staff knew about it," Robert adds.
This communication problem can be similar in the home health setting where there are professionals in various disciplines who need to share information with each other, experts say.
3. Identify what the ethical issues are.
"Ethical issues are when there are two right things that don’t seem to go together," Robert says.
A common issue facing home care agencies is when a patient, who is very ill, insists on staying in his or her home even though the home care nurses think the home isn’t safe enough.
"Who will win in the end?" Robert says. "Does his autonomy count more than safety?"
When Mercy Medical’s ethics committee was faced with a similar situation, the staff was split down the middle on whether the patient should be allowed to stay home or be removed from the home.
The committee’s review of this case was in retrospect because the patient in question had already died at home before the case came before the committee, Robert says.
4. Brainstorm and look at all alternatives to resolving a conflict.
Robert advises home care professionals to avoid making "a hard and fast rule" regarding an ethical dilemma. Instead, they should brainstorm with everyone involved, including the caregivers, case managers, nurses, social workers, pastoral care, administrators, dietitians, and anyone else involved in the patient’s home care.
Mercy Medical’s policy is that anyone can contact the committee and arrange for a meeting to discuss an ethical conflict.
"We sit down and try to talk with the patient if we can and talk with the family members," Robert says.
5. Make recommendations for resolving the conflict, but make sure these are only recommendations.
"Part of what we do is try to figure out who would be the best person to carry out the recommendations," Robert says.
"We might recommend a particular course of action and talk with the caregiver and family members, and then maybe it’s the pastor who talks with them, or maybe the physician carries it out," she explains.
So far, most of Mercy Medical’s ethical cases were brought to the committee after they’ve been resolved through the patient’s death or discharge. "There have been a few that have happened while the conflict is going on," Robert says.
If a particular case could involve a resolution that conflicts with Mercy Medical’s institutional policy, then the committee will state that it cannot participate in that ethical dilemma. "We’re a Catholic organization, so we can’t participate in assisted suicide," Robert says.
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