Chapter 2
Thoughtful practice
23
decision making. The Commonwealth of Australia has no
legislation regarding living wills, which can be regarded as a
form of advance directive. Recognition of advance directives
depends on individual State or Territory legislation. In most
situations advance directives are limited to situations in which
the patient’s medical condition is deemed terminal; they are
frequently written while the person is in good health. They
are not always honoured. It is not unusual for people to change
their minds as their illness progresses. Therefore, the patient
retains the option to nullify the document.
Another type of advance directive is the enduring power of
attorney for medical treatment, in which the patient identifies
another individual to make healthcare decisions on his or her
behalf. In this type of directive, the patient may have clarified
his or her wishes concerning a variety of medical situations.
As such, the power of attorney for medical treatment is a less-
restrictive type of advance directive. Laws concerning advance
directives vary among State jurisdictions. Even in States
where these documents are not legally binding, however, they
provide helpful information and assist healthcare providers to
determine the patient’s prior expressed wishes in situations
where this information can no longer be obtained directly.
CLINICAL REASONING CHALLENGE
You are at the bedside of a 93-year-old patient who has
no advance directive. The patient has been comatose for
3 days and the doctor has not prescribed any feedings.
When you ask the doctor about an enteral nutritional
supplement (tube feeding), he responds: ‘No, I don’t think
so.’ What actions should be taken in this situation? What
ethical and legal dilemmas exist? What other health profes-
sionals could be helpful in resolving any issues?
Institutional ethics committees, which exist in many hos-
pitals to assist practitioners with ethical dilemmas, also aid in
preventive ethics. The approach to ethical decision making
can follow the steps of the nursing process. Chart 2-4 outlines
the steps of an ethical analysis. This analysis can be used in
reflection on an ethical experience.
Self-awareness
not only requires a moral compass so we are
in tune with our own moral values and ethical reasoning, it
requires nurses to be intensely aware of their own biases and
prejudices when dealing with people from diverse cultural
backgrounds in order to provide culturally safe care.
Cultural safety
In the healthcare system, as in society, nurses interact with
people of similar and different cultural backgrounds. People
may have similar or different frames of reference and varied
preferences regarding their health and healthcare needs.
Acknowledging and adapting to the cultural needs of people
are important components of nursing care in thoughtful
practice. To plan and deliver culturally safe and competent
care, the nurse must understand the definitions of culture,
cultural competence, and cultural safety and the various
aspects of culture that should be explored for each patient.
Leininger (2001) developed a model of nursing known as
transcultural nursing
to guide nurses in providing culturally
competent care.
Definitions of culture
The concept of culture and its relationship to the healthcare
beliefs and practices of patients and their families and friends is
central to the exploration of cross-cultural nursing. Awareness
of culture in the delivery of nursing care has been described in
different ways, including respect for cultural diversity (Kruske,
Hikuroa & Bradford, 2008) and the need for the provision of
Ethics and related matters
Steps of an ethical analysis
The following guidelines will assist nurses in ethical decision
making. These guidelines reflect an active process in decision
making, similar to the nursing process detailed in this chapter.
Assessment
1. Assess the ethical/moral dimensions of the problem. This
step entails recognition of the ethical, legal and professional
dimensions involved.
a. Does the situation entail substantive moral problems
(conflicts among ethical principles or professional
obligations)?
b. Are there procedural conflicts? (For example, who
should make the decisions? Any conflicts among the
patient, healthcare providers, family and guardians?)
c. Identify the significant people involved and those
affected by the decision.
Planning
2. Collect information.
a. Include the following data: medical facts, treatment
options, nursing diagnoses, legal data, and the cultural
(values, beliefs) and religious components.
b. Make a distinction between the factual information and
the values/beliefs.
c. Validate the patient’s capacity, or lack of capacity, to
make decisions.
d. Identify other relevant information that should be elicited.
e. Identify the ethical/moral issues and competing
claims.
Implementation
3. List the alternatives. Compare alternatives with applicable
ethical principles and professional codes of ethics. Choose
either of the frameworks below, or other frameworks, and
compare outcomes.
a. Utilitarian approach: Predict the consequences of the
alternatives; assign a positive or negative value to each
consequence; choose the consequence that predicts
the highest positive value or ‘the greatest good for the
greatest number.’
b. Deontological approach: Identify the relevant moral
principles, compare alternatives with moral principles,
appeal to the ‘higher-level’ moral principle if there is a
conflict.
c. Implement the plan of action. This stage could involve
a range of actions, including reporting the matter to a
supervisor or consulting the Ethics Committee.
Evaluation
4. Decide and evaluate the decision.
a. What is the best or morally correct action?
b. Give the ethical reasons for your decision.
c. What are the ethical reasons against your decision?
d. How do you respond to the reasons against your decision?
CHART
2-4
