What are the behaviors that will almost always be viewed 2.
2. Looking at all the relevant facts and developing valid
as unethical?
What are the behaviors that will almost always be viewed as
unethical?
- Sexual intimacy with clients
- Libeling slandering a client
- Sharing confidences without compelling professional
reason
- Assaulting causing physical injuries or placing clients
in danger
- Discriminatory practices
- Withdrawing services precipitously (abandoning
client)
- Failure to warn and protect the victim of a violent
crime
- Failure to exercise reasonable precautions with a
potentially suicidal client
- Promising “cures” for problems
How do I avoid rushing into ethical dilemmas?
- Develop a working knowledge of the Code of
Practice (By necessity they cannot be specific to
every possible ethics violation)
- By anticipating likely trouble spots before they
occur.
How do I resolve ethical dilemmas?
- The first step is recognizing the problem and
identifying the source of the conflict.
- You also must keep all parties informed of your legal
and ethical obligations.
- Engage clients or involved parties in dialogue and
brainstorm the “best” course of action.
- Make sure you are constantly keeping in mind the
mission of the profession observing the clients self-
determination.
- If you are still unclear about what to do discuss the
situation with your field instructor.
- Protect the identity of the clients if necessary and
present the situation as a “hypothetical” case if you
need external help.
How do I know whether I am doing the right thing?
- It is not always possible to know but there is a
greater chance that we can feel good about the
decision we have to make if we go through
deliberate process, where we examine our values,
seek additional information and consult others.
A decision-Making Model: 5 steps (M.V. Joseph, 1983)
1. Definition of the Dilemma
arguments for various courses of action
3. Consideration of practice wisdom, personal beliefs,
and values, and how these might influence the final
decision
4. A developing options, exploring compromises,
evaluating alternatives in an attempt to find a course
of action with the least negative effects.
5. Choosing a position that you can defend
Important Elements in Making Moral decisions
Making moral decisions involves different elements to guide
us.
- These elements are very important if we are to
understood our moral situation and arrive at a good
moral decision to we are called
Important Elements in Making Moral Decisions
1. Investigate the facts. – we need to discern
accurately three elements of every moral acts:
-Nature of the Act.
-Intention of the person
-Circumstances of the Act
2. Inquire about moral norms affecting you decisions
3, Imagine consequences and alternatives
4. Introspect. – we need to understand the value of our
emotions or affectivity in making moral decisions; listen to
your emotions.
5. Implore Gods help in prayer – we ought to seek God’s
guidance in prayer before, during and after and making our
moral decisions.
6. Implement one’s decisions. – One must have the courage
and resolve to do what has decides upon.
7. Conclusion – making actual moral decisions is grounded on
both our human nature and God’s grace.
- By human nature, we possess intellect and free will and by
grace, we are strengthened, empowered by the Holy Spirit.
Moral Decision Making: Other Approaches
EGOISM/EGOTISM
- An ethical theory that treats self-interest as the
foundation of morality.
Two Types of Egoism:
Descriptive
- Claims that individuals always act selfishly
Ethical
 - Claims that everyone out to act selfishly
Moral Decision Making: Other Approaches
Psychological Egoism
- We ‘do’ act in our own self-interest.
Ethical Egoism
- We ‘should’ act in our own self-interest.
Utilitarianism
- Is an ethical theory that determines right from
wrong by focusing on outcomes. It is a form of
consequentialism.
- Holds that the most ethical choice is the one that will
produce the greatest good for the greatest number.
Naturalism
- Naturalism is the belief that nothing exists beyond
the natural world.
- Instead of using supernatural or spiritual
explanations, naturalism focuses on explanations
that come form the laws of nature.
Cultural Relativism
- Is the idea that a person’s beliefs, values, and
practices should be understood based on that
person’s own culture, rather than be judged against
the criteria of another.
Ethnocentrism
- Is insensitive to other cultures, while cultural
relativism shows high cultural sensitivity.
Emotivism
- An ethical theory that regards ethical and value
judgments as expressions of feeling or attitude and
prescriptions of action, rather than assertions or
reports of anything.
Theism
- Belief of the existence of God or Gods
- Other words for theism: faith, religion, piety, creed,
worship, conviction, denomination, sect, doctrine,
church
MORAL DISCERNMENT
- It is the process by which a person or community of
faith attempts to discover God’s will for
understanding and responding to the dilemmas and
questions that human beings face when seeking the
“right” and the “good”.
- Maybe thru prayer, meditation, or supplication
before God, but it INVOLVES two additional
elements – the turning to various sources and the
use of critical thinking to animate and guide the
discernment process.
Discernment
- It is prayerful pondering or mulling over the choices
a person wishes to consider.
- It is a process that should move inexorably toward a
decision.
- It is both to understand and to decide.
Six Principles of Discernment
Principle 1 – Stage of Life.
- There are many different stages in life, some
permanent, some lone-lasting, some only
temporary.
- We may be single, married, a priest, a religious,
young, old, healthy, or fragile in health.
- We may be a student, a parent, rich or poor.
- Being clear about our state in life can help us discern
if a call is from God or not.
Principle 2 – Gifts and Talents
- It is a clear fact that people have different
combinations of virtues and talents, gifts, and skills.
- In discerning the will of God, regarding a course of
action, or of accepting an offer or opportunity, we
ought to carefully ponder if it will make good sense
based on our skills and talents
Principle 3 – Desire
- We are often suspicious of our desires, and not
without reason.
- When it comes to most things regarding the Moral
Law and Doctrine, our feelings and desires are
largely irrelevant, and should not be determinative
of understanding God’s will.
Principle 4 – Organic Development
- This principle simply articulates that God most often
moves us in stages rather than in sudden and
dramatic ways.
- While it is true, in most lives, there are times of
dramatic change, loss, and gain, it is more usual for
 God to lead us gently and in stages toward what he
wills for us.
Principle 5 – Serenity
- When God leads us, the usual result is serenity
(peace) and joy.
- And yet, when it is God’s will that the time has come
for moving on, in spite of the sadness, I also feel an
inner peace, a serenity.
Principle 6 – Conformity to Scripture and Tradition
- This principle should be at the top of the list, and
you are free to put it there.
- The Word of God and the teachings of the Church
has the last word in any decision.
James Rest (Rest and Narvaez 1994), a development
psychologist who studied moral and ethical development,
identified four components of moral development:
Moral sensitivity
- The ability to interpret a situation in moral and
ethical terms
Moral judgment
- The ability to determine a course of action in the
context of what is just
Moral motivation
- The ability to select an appropriate course of action
among multiple good alternatives
Moral character
- The courage and skills to follow a course of action in
response to a situation
“CONSCIENCE is a judgement of practical reason that helps us
to recognize and seek what is good and to reject what is evil”
(Catechism of the Catholic Church, no. 1778,1796)
A well-formed conscience is an ongoing exercise. The Church
offers the following process in forming one’s conscience:
When examining any issue or situation, we must begin by
being open to the truth and what is right.
We must study Sacred Scripture and the teachings of the
Church.
We must examine the facts and background informaiton
about various choices.
We must prayerfully reflect to discern the will of God.
Advance Directives
Living wills and other advance directives are written, legal
instructions regarding your preferences for medical care if
you are unable to make decisions for yourself.
Advance directives guide choices for doctors and caregivers if
you’re terminally ill, seriously injured, in a coma, in the late
stages of dementia or near the end of life.
Require someone to make a judgment about your likely care
wishes.
- Meets your state’s requirements for a health care
agent
- Is not your doctor or a part of your medical care
team
- Is willing and able to discuss medical care and end-
of-life issues with you
- Can be trusted to make desiciosn that adhere to
your wishes and values
- Can be trusted to be your advocate if there are
disagreements about your care
The person you name may be a spouse, other family member,
friend or member of a faith community. You may also choose
one or more alternates in case the person you chose is unable
to fulfill the role.
Advanced Directives: when our wished are not always what
happens.
- You can get the medical care you want,
- Avoid unnecessary suffering and
- Relieve caregivers of decision-making during
moments of crisis or grief.
Advanced Directives (a simple guide to making your end-of-
life wishes known)
- Interventions for futile care which provides people’s
preferences wishes in the event that they aren’t
capable of wishing them anymore through a will or
proxy.
- A general term used to describe the documents that
give instructions about future medical care and
treatments
- Advance Directives include:
Living Will
 Do Not Resuscitate Order
Withholding or Withdrawing Treatments
Living Will
- Was the first advance directive
- The lay term used frequently to describe any
number of documents that give instructions about
future medical care and treatments or the wish to be
allowed to die without heroic or extraordinary
measures should the patient be unable to
community for self
- Is a written, legal document that spells out medical
treatments you would and would not want to be
used to keep you alive, as well as your preferences
for other medical decisions, such as pain
management or organ donation.
- Most states have replaced the idea of living wills
with the natural death acts
- These include:
Directive to Physicians (DTP)
Durable Power of Attorney for Health Care (DPAHC)
Medical Power of Attorney
Directive to Physicians (DTP)
- A written document specifying the patient’s wish to
be allowed to die without heroic or extraordinary
measures.
Durable Power of Attorney for Health Care (DPAHC)
- A term used by some states to describe a document
used for listing the person or persons to make health
care decision should a patient become unable to
make informed decisions for self.
Medical Power of Attorney (MPOA)
- Same as durable power of attorney for health
(depends on state)
- Person appointed may be called a health care agent,
surrogate, attorney-in-fact, or proxy
A medical or health care POWER OF ATTORNEY is a type of
advance directive in which you name a person to make
decisions for you when you are unable to do so.
DURABLE POWER OF ATTORNEY FOR HEALTH CARE or a
HEALTH CARE PROXY.
You should address a number of possible end-of-life care
decisions in your living will.
- CardioPulmonary Resuscitation (CPR)
- Mechanical ventilation
- Tube feeding
- Dialysis
- Antibiotics or antiviral medications
- Comfort care (palliative care)
- Organ and tissue donations
- Donating your body
Do Not Resuscitate
- A written physician’s order instructing
- Often requested by family
- Must be signed by a physician to be valid
- Several types of CPR decisions can be made,
including:
Full Code
Chemical Code
DNR or “no code”
Out-of-hospital DNR
Do Not Resuscitate (DNR) and Do Not Intubate (DNI) orders
- You don’t need to have an advance directive or living
will to have DNR and DNI orders.
- To establish DNR or DNI orders, tell your doctor
about your preferences.
- He or she will write the orders and put them in your
medical record.
Full Code:
- Complete and total heroic measures, which may
include CPR, drugs, and mechanical ventilation.
Chemical Code:
- The use of drugs for resuscitation without the use of
CPR.
DNR or “no code”
- Allows the person to die with comfort measures only
and without the interference of technology.
- Becoming known as allow natural death (AND) or
comfort code.
OUT-OF-HOSPITAL DNR
- For use by terminally ill patients who wish to have
no heroic measures used to prolong life after they
leave an acute care facility.
Withholding or Withdrawing Treatments
- What is to be done and what is not to be done must
be included in clear terms
- Honoring the refusal of treatments that a patient
does not desire, are disproportionately burdensome
to the patient, or will not benefit the patient can be
ethically and legally permissible
 - The decision to withhold artificial nutrition and
hydration should be made by the patient or
surrogate with the health care team
THE NURSE’S RESPONSIBILITIES
- Be aware of legal issues and the wishes of the
patient
- Nursing care of dying patients is holistic and
encompasses all aspects of psychosocial (grieving
process) and physical needs (physical changes that
are associated with dying)
- Focus on patient and family; respect, dignity, and
comfort
- Recognize own needs when dealing with grief and
dying
Consider reviewing your directions and creating new ones in
the following situations:
- New diagnosis
- Change of marital status
- About every 10 years
Even if you already have a living will that includes your
preferences regarding resuscitation and intubation, it is still a
good idea to establish DNR or DNI orders each time you are
admitted to a new hospital or health care facility.
Advance Directives and POLST
PHYSICIAN ORDERS for LIFE-SUSTAINING TREATMENT
- A POLST is intended for people who have already
been diagnosed with a serious illness
- This form does not replace your other directives.
Instead, it serves as doctor-ordered instructions –
not unlike a prescription – to ensure that, in case of
an emergency, you receive the treatment your
prefer.
PHYSICIAN ORDERS for LIFE-SUSTAINING TREATMENT
- Signed by both the client or health care decision
maker and the primary care provider, and specifies
current preferences for resuscitation; medical
interventions such as comfort measures, intravenous
medications, and noninvasive airway support; and
artificial nutrition.
- For individuals already diagnosed with serious,
progressive, or chronic illnesses.
- This document remains with the client when
transferred to different levels of care.
The elements and components of end-of-life choices and
advance directives can include:
- An election to donate some or all bodily organs
according to the US Uniform Anatomical Gift Act
- A living will
- A health care proxy
- A durable power of attorney for health care (DPAHC)
which is separate and distinct from a durable power
of attorney relating to financial and monetary
decisions
Three values relevant to the nurse in assisting client/patient
with the end-of-life decision-making
Value: health and well-being
Description of value
- Nurses value health and well-being and assist
persons to achieve their optimum level of health in
situations of normal health, illness, injury, or in the
process of dying.
Associated responsibility statements
- “… nurses are accountable for addressing
institutional, social and political factors influencing
health and health care.”
- “Nurses foster well-being when life can no longer be
sustained, by alleviating suffering and supporting a
dignified and peaceful death.”
Value: Choice
Description of value
- Nurses respect and promote the autonomy of clients
and help them to express their health needs, and
values and to obtain appropriate information and
services.
Associated responsibility statements
- “Nurses seek to involve clients in health planning
and health care decision-making.”
- Nurses are sufficiently clear about personal values to
recognize and deal appropriately with potential
value conflicts.”
- Nurses respect decisions and lawful directives,
written or verbal, about present and future health
care choices affirmed by a client prior to becoming
incompetent.”
 - “Nurses seek to obtain consent for nursing care from
a substitute decision-maker when clients lack the
capacity to make decisions about their care…”

Value: Dignity

Description of value

- Nurses value and advocate the dignity and self-

respect of human beings.

Associated responsibility statements

- “Nurses exhibit sensitivity to the client’s individual

needs, values, and choices.”
- “Nurses treat human life as precious and worthy of
respect. Respect includes seeking out and honouring
clients’ wishes regarding quality of life.”
- “Nurses advocate the dignity of clients in the use of
technology in the health care setting.”
- The priority ranking of ethical principles
(Lowenberg and Dolgoff, 1992) an approach for
ordering social work values that might help you get
off the “horns of a dilemma.”
1. Protection of life
2. Equality
3. Autonomy and freedom
4. Least harm
5. Quality of life
6. Privacy and confidentiality
7. Truthfulness and full disclosure