Fundamentals of Nursing and Midwifery 2e

Chapter 11 Values, ethics and advocacy

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ethics and some on organisational ethics. These committees are uniquely equipped to deal with the complexities of modern healthcare because they are interdisciplinary and provide a forum in which radically divergent views can be aired without fear of repercussion. Nurses and midwives bring an important voice to the ethics committee. When clinical issues are being reviewed, they can help to ensure that the technical facts are under- stood, that the appropriate decision makers have been identified, that the person’s medical and overall best interests have been identified, and that the course of action selected from the alternatives is justified by sound ethical principles. Nurses’ and midwives’ strong backgrounds in interpersonal communication allow them to contribute unique knowledge about the person and their family to the discussion and to facilitate the ethics committee’s group dynamics. Nurses and midwives also play an important role in policy making. They are frequently able to identify what policies are needed to address recurring ethical concerns and to suggest needed modifications of existing policies. See Chapter 10 for further discussion of the role of ethics com- mittees in healthcare research. ADVOCACY IN CLINICAL PRACTICE By bridging vulnerable people with the resources they need to secure health outcomes, nurses and midwives have always been strong patient advocates. Advocacy is the protec- tion and support of another’s rights. This role is increasingly important because of people’s changing expectations and demands, and because the public has learned that in our increasingly market-driven healthcare economy, there are no guarantees that the healthcare system will work to secure their safety and health. Nurses and midwives who value patient advocacy: • Make sure their loyalty to an employing institution or colleague does not compromise their primary commitment to the person • Give priority to the good of the individual rather than to the good of society in general • Carefully evaluate the competing claims of the person’s autonomy (self-determination) and patient well-being. Woods (1999) describes how a nurse may become an advocate though a nurse’s story of a 7-year-old Ma – ori boy who was terminally ill. He requested that the nurse support him in refusing any more blood transfusions; he understood that without the transfusions he would die within the next week or two rather than in a few months. The nurse tried to coax and cajole him to accept the transfusions but he was adamant; he needed her support to confront his family and doctors with his decision. A meeting was convened and the nurse advocated on behalf of the boy, helping him to present his point of view. Despite intense emotions and pressure, the boy and nurse convinced all concerned that stopping treat- ment was in his best interests. Woods suggested that the

nurse’s strong moral conviction could have resulted in a breakdown of relations between her and the doctors. However, she sensitively navigated a complex moral situa- tion and in doing so upheld Article 12 of the United Nations Convention on the Rights of the Child (UNCROC, 1990), which conveys the right of a child to have an opinion and for that opinion to be heard in all contexts. When respecting autonomy, you respect and support the person’s right to make decisions. Informed consent is described in Chapter 10. When promoting patient well- being, you must act in the best interests of the person. Ideally, both autonomy and patient well-being are promoted in every interaction between you and your patient; however, conflicts sometimes arise. Representing patients Most nurses and midwives would agree that a great deal of time is spent representing patients’ interests or guiding people in protecting their own rights. They are often involved as an intermediary between the person and the family, espe- cially when the person and family have conflicting ideas about the management of healthcare situations. For example, a person with terminal cancer may want to go home to die. He tells this to his nurse. The person’s family, however, tells the nurse they cannot care for him at home. As an advocate, the nurse recognises the rights of both the person and his family. The nurse then works to assist them in finding a solution that benefits both the person and his family. By informing the family of the availability of home care and hospice care, the nurse gives them knowledge that may help satisfy the person’s right to a dignified death. Working alone, most people would be unable to get the financial help needed for such care. Nurses have the resources available to help them and can arrange referrals from other healthcare workers, such as social workers, to achieve the desired out- comes. Patients with special advocacy needs include those who are uninformed concerning their rights and opportunities, those with sensory impairment, those who do not speak English well or at all, the very young and older people, those who are seriously ill, those who are mentally or emotionally impaired, those with physical disabilities, and those who lack adequate financial or human resources. Promoting self-determination Advocacy is linked to the belief that making choices about health is a fundamental human right that promotes the indi- vidual’s dignity and well-being. Ethical dilemmas may arise when people are unable or unwilling to make choices, or when they are not given the opportunity to do so. Faulty communication among patients, family members and carers frequently contributes to these dilemmas. Nurses have an important advocacy role in educating the public about the value of written advance directives (ADs) (described in Chapter 26), and midwives provide a powerful voice in