Nurses frequently face ethical dilemmas while caring for their patients. These dilemmas can take different forms, such as how best to respect a patient’s decision to refuse treatment due to cultural or personal beliefs, or what to do when conflicts arise between patients and their families in making end-of-life care decisions. These kinds of ethical dilemmas often challenge nurses to deliver optimal patient care while also adhering to professional boundaries.
Ethical values are so fundamental to nursing that the American Nurses Association (ANA) established a formal Code of Ethics for Nurses — often referred to simply as “The Code” — in the 1950s to set goals and values for the profession as a whole and to serve as a guide for nurses in their daily practice.
The Code is a living document, regularly updated to reflect modern-day advancements and challenges, and represents the social contract between nurses and the public. The Code and its accompanying provisions lay out the values and commitments nurses are expected to uphold, identify the boundaries of duty and loyalty, and describe the broader responsibilities nurses have outside of patient care.
An advanced degree, such as an online Master of Science in Nursing, can help aspiring nurses identify and address many ethical dilemmas in nursing. Below are some common dilemmas that nurses may face and how to navigate them.
Dilemma #1: Protecting Patients’ Rights
The first three provisions of the Code of Ethics for Nurses deal directly with the nurse’s relationship with their patient. The second and third provisions specifically address the nurse’s role in protecting patients’ rights and best interests. Patient autonomy — the right of patients to independently make decisions about their care based on their personal or cultural beliefs and values — is a paramount principle of nursing. This includes a patient’s right to refuse medications, treatments, or procedures. In some cases, a patient’s right to autonomy may directly conflict with what nurses or other health care workers believe is best.
Autonomy vs. Beneficence
Autonomy (respecting a patient’s wishes) and beneficence (doing good), two fundamental ethical principles in nursing, are sometimes in conflict. The nurse’s role is to strike a balance between the two through open discussion, sharing information with the patient, and negotiation. If addressed incorrectly, these situations can present not only ethical or moral issues, but legal ones as well.
The concept of patient autonomy goes beyond merely a philosophical or ethical consideration; it is considered a legal right throughout the Western world. Legal precedents have placed patient autonomy ahead of health care provider beneficence in many cases, arguably making patient autonomy the foremost principle affecting patients’ rights.
Typically, the only exceptions to the primacy of patient autonomy are if the patient is a minor or if they lack the ability to make informed decisions. In cases where a patient’s wishes conflict with the advice of medical professionals, nurses and other health care workers should make every effort to educate the patient about the implications of their decisions, but ultimately respect their wishes.
Advocacy
Nurses especially are expected to advocate on behalf of patients in these situations. These scenarios can present a quandary for nurses, where they must balance their duty to respect and promote the interests of their patient with their loyalty to their employer or colleagues. However, according to the Code of Ethics for Nurses, the nurse’s primary commitment is to the patient.
The Code’s corresponding interpretive statements explain: “Nurses address such conflicts in ways that ensure patient safety and that promote the patient’s best interests while preserving the professional integrity of the nurse and supporting interprofessional collaboration.”
Dilemma #2: Providing Informed Consent to Treatment
Another common ethical dilemma in nursing involves the concept of informed consent. Informed consent to treatment is a process wherein a patient, or their surrogate, grants their health care provider permission to administer treatment or perform a procedure after being advised of its potential benefits and risks, and informed of alternative treatments. Informed consent is required for many medical procedures, including anesthesia, blood transfusions, chemotherapy, and most surgeries. Informed consent typically requires written documentation, with a signature from the patient.
Exceptions to Informed Consent
Informed consent is not required in certain situations, including those where a patient is incapacitated or in a life-threatening emergency without time to properly obtain consent. Also, minors typically can’t provide informed consent. In such cases, a parent or guardian must authorize treatments or interventions, which is known as “informed permission.”
The Nurse’s Role
Though a nurse’s exact role in the informed consent process may vary by institution, in their capacity as patient advocates, nurses often participate in the process to ensure patient or caregiver comprehension. In some cases, patients and families may feel more comfortable speaking to a nurse than to their doctor because a nurse can explain complex medical terminology in layman’s terms.
According to the Agency for Healthcare Research and Quality, more than a third of the U.S. population possesses limited health literacy, and patients often sign consent forms even if they don’t fully understand a treatment or procedure, which courts have ruled does not constitute informed consent. Therefore, involving nurses in the informed consent process can be valuable.
Consent and the Law
Aside from its implicit ethical value, obtaining informed consent has legal implications as well. An effective informed consent process can prevent lawsuits. Failing to secure adequate informed consent is one of the top 10 leading causes of medical malpractice lawsuits, according to the Agency for Healthcare Research and Quality. Full disclosure is critical to the informed consent process.
To meet legal requirements, health care workers must explain what is involved with treatment, the anticipated benefits and potential risks, and alternatives to the proposed treatment, as well as the possible benefits and risks associated with the alternatives, including the option to forgo treatment.
Consent and Improved Patient Outcomes
Evidence also suggests that patients who are educated and feel empowered when it comes to their health care are more likely to follow a treatment plan and experience better outcomes. Additionally, ensuring that patients fully understand all the facets of a proposed treatment can help avoid delayed or cancelled surgeries, which can jeopardize patient health and be costly for hospitals. Nurses and other health care workers must make every effort to assure that patients understand a treatment or procedure and all the possible implications before obtaining informed consent.
Dilemma #3: Addressing Advanced Care Planning
Ethical dilemmas in nursing often arise during advanced care planning, particularly as it relates to end-of-life care scenarios. Advanced care planning is a process in which patients, often in collaboration with medical professionals, make decisions about their future health care in the event they become incapacitated. This process isn’t only for older patients. Due to the unpredictable nature of medical crises — a car accident or sudden illness, for example — advanced care planning is worthwhile for patients of any age, providing an opportunity to make sure they get the medical care they want if they’re unable to speak for themselves.
Advance Directives
During this process, patients often must make difficult decisions regarding the use of life-saving or life-extending treatments, such as the use of a ventilator or artificial nutrition and hydration (tube feeding, intravenous fluids). This plan is shared with family members, often in the form of an advance directive, a legal document that lays out a patient’s preferences for medical care if they become incapacitated.
The two primary elements of an advance directive are a living will and a power of attorney for health care, but it may also involve other documents such as a do not resuscitate order (DNR), which directs caregivers to forgo measures such as CPR. Patients may also choose more informal methods of conveying their wishes, such as a video message to loved ones, though this does not take the place of an advance directive.
The Nurse’s Role
As patient advocates, nurses play a critical role in assisting patients and their families with advanced care planning. Both the American Nurses Association and the Hospice and Palliative Nurses Association have issued position statements emphasizing the importance of nurse involvement in advanced care planning and end-of-life care, particularly for the purpose of educating patients and their families.
Nurses can help patients navigate the various decisions they may have to make related to emergency or end-of-life treatments and facilitate conversations between patients and families about these decisions, helping patients compare different treatment options and how they may affect the patient’s individual disease process. Nurses should be equipped to explain the implications of these decisions and mindful of the various elements that may influence a patient’s health care decisions, such as race or ethnicity, cultural beliefs, or religion.
Nurses and End-of-Life Care
Because of advances in medical technology, people are living longer and often making health care decisions alone. This reality underscores the important role of medical professionals, particularly nurses, in assisting patients with end-of-life care. Patients can choose from an array of life-saving and life-extending treatments, and nurses should be able to guide them through the decision-making process.
A nurse’s involvement is also vital to ensuring the preferences laid out in a patient’s advance directive are honored, especially in emergency situations where the patient is incapacitated. Ethical dilemmas can arise if, for example, a patient has requested not to be placed on a ventilator but members of their family object. As in other situations involving ethical dilemmas in nursing, patient autonomy is of utmost importance, and nurses are uniquely positioned to champion a patient’s interests in end-of-life care.
Dilemma #4: Shared Patient Decision-Making
Not that long ago, health care was characterized by a paternalistic mindset: medical professionals acted in what they thought was a patient’s best interests without considering the patient’s wishes. This outdated practice has now been replaced by a far more ethical approach. An extension of patient autonomy, the concept of shared patient decision-making empowers patients by providing the opportunity to work collaboratively with health care professionals to make important decisions regarding care. In shared decision-making, patient and provider work together to make decisions about tests, treatments, procedures, and overall care strategy. In a sense, shared patient decision-making is a form of informed consent, and vice versa. As with informed consent, nurses and others engaged in shared decision-making with patients are responsible for educating them about treatment and discussing various options with them.
Individualized Care
Shared decision-making goes beyond simple information-sharing. Health care providers should explore patients’ values, beliefs, and goals and build a relationship based on trust and respect. They should understand a patient’s background and how factors like age and race may influence their decision-making.
Patients who don’t have this kind of relationship with their provider may be more reluctant to communicate and less cooperative. On the other hand, when patients are actively involved in decision-making and have a respectful, compassionate connection with their provider, they are more satisfied with their care and more likely to follow prescribed treatment plans.
The Importance of Educating Patients
As with informed consent, medical professionals must take great care to ensure patients understand the information being shared with them and the implications of their decisions. Various methods exist for improving patient understanding, including the use of visual aids and teach-back, in which health care professionals have patients repeat back information shared with them.
Ethical dilemmas can arise if patients agree to a treatment plan but fail to comprehend its full scope, potentially leading to disputes with medical staff. Here again, nurses play a pivotal role in enhancing the shared decision-making process through their skills as gifted communicators and patient advocates.
Evolving Care
Shared patient decision-making is an ongoing process where both sides continually reflect on previous decisions. Situations may arise where patients are unable or unwilling to follow through on a care decision — either because it proved more challenging than anticipated or wasn’t what they expected — and seek to revisit the issue. A nurse’s job is to support the patient by facilitating ongoing discussion and collaboration.
Leading Ethically by Example
Nursing is consistently ranked as the most ethical profession, with 85% of Americans rating the honesty and ethical standards of nurses as “high” or “very high” in a recent Gallup survey, nearly 20 points higher than the rating of those in the second-most-trusted profession, engineers. That level of trust is a testament to the nursing profession’s strong ethical backbone, based in the ANA Code of Ethics, which helps nurses cope with the many ethical dilemmas in nursing. Applying ethical principles like patients’ rights, autonomy, and informed consent to health care empowers patients by involving them in their own care, which ultimately improves the patient experience.
Regis College’s online Master of Science in Nursing degree offers several specializations, including family care, women’s health, pediatrics, psychiatric mental health and primary and acute geriatric care. Coursework in these specializations gives nurses a deeper understanding of the ethical principles involved in each type of care. Aspiring nurses interested in the important role ethics plays in their field should explore Regis’s online nursing programs to learn more.
Recommended Readings
Ethics in Nursing: What Every Nurse Should Know
How to Develop and Maintain Social Justice in Nursing
5 Stress Management Techniques for Nurse Leaders
Sources:
Agency for Healthcare Research and Quality, “Making Informed Consent an Informed Choice: Training for Health Care Professionals”
American Nurses Association, Ethics and Human Rights
American Nurses Association, “Nurses’ Roles and Responsibilities in Providing Care and Support at the End of Life”
Gallup, “Nurses Continue to Rate Highest in Honesty, Ethics”
Healthline, “What You Need to Know About Informed Consent”
Journal of Hospice & Palliative Nursing, “HPNA Position Statement Advance Care Planning”
Medical Records Information, “Top 10 Most Prevalent Ethical Issues in Nursing”
National Institute on Aging, Advance Care Planning: Healthcare Directives
Oncology Nursing Society, “What You Need to Know About Obtaining Informed Consent”
The Open Nursing Journal, “Shared Decision-Making for Nursing Practice: An Integrative Review”
StatPearls, “Informed Consent”
StatPearls, “Nursing Ethical Considerations”
StatPearls, “Patient Rights”
Wolters Kluwer, “A Look at Shared Decision-Making with Patients”