CARDIO ETHICAL LEGAL ISSUE. power presentation ptx

ETHICAL AND LEGAL ISSUES EVIDENCE
BASED NURSING AND ITS APPLICATION IN
CARDIOVASCULAR AND THORACIC NURSING
SHABANA. N
M.SC NURSING II YEAR
COLLEGE OF NURSING
MADRAS MEDICAL COLLEGE
CHENNAI 03

INTRODUCTION
Extended technologies and developments in cardiac nursing result in nurses having to
increasingly explore ethical issues. The need for contextual analysis is crucial as legal,
professional or local service delivery requirements may supersede an ethical view and in fact
determine the approach a clinician may take. Indeed, cardiac nurses need to examine their own
knowledge and reflect on the situations they face within clinical practice in order to explore the
process itself in conjunction with the specific analysis of an individual case.

ETHICS
DEFINITION:
Ethics is a study of what is right or what people ought to do in a specific
situation.
-Donna.D.Ignatavicius
Ethics refers to the moral code for nursing and is based on obligation to service
and respect for human life. Ethics are the rules or principles that govern right
conduct and are designed to protect the rights of human beings.

ETHICS VERSUS MORALITY:
• The terms ethics and morality are used to describe beliefs about right and
wrong and to suggest appropriate guidelines for action.
• In essence, ethics is the formal, systematic study of moral beliefs,
whereas morality is the adherence to informal personal values. Because
the distinction between ethics and morality is slight, the two terms are
often used interchangeably.

ETHICS THEORIES
1.The teleologic theory or consequentialism focuses on the ends or consequences of actions. the best-
known form of this theory, utilitarianism, is based on the concept of “the greatest good for the greatest
number.”
2.The deontological or formalist theory, which argues that ethical standards or principles exist
independently of the ends or consequences. in a given situation, one or more ethical principles may apply.
nurses have a duty to act based on the one relevant principle, or the most relevant of several ethical
principles. problems arise with this theory when personal and cultural biases influence the choice of the
most primary ethical principle.

APPROACHES TO ETHICS:
TWO APPROACHES TO ETHICS ARE
1.META-ETHICS
2.APPLIED ETHICS
• An example of meta-ethics (understanding the concepts and linguistic terminology used in ethics) in the
health care environment is analysis of the concept of informed consent. delving more deeply into the
concept of informed consent would be a meta ethical inquiry.
• Applied ethics refers to identification of ethical problems relevant to specific disciplines. various
disciplines use the frameworks of general ethical theories and principles and apply them to specific
problems within their domain.
• Nursing ethics may be considered a form of applied ethics because it addresses moral situations that are
specific to the nursing profession and patient care. nursing has its own professional code of ethics.

LEGAL ISSUES
The Law Constitutes Body Of Principles Recognized Or Enforced By Public And
Regular Tribunals Has The Administration Of Justice.
• SOURCES OF LAW:
• COMMON LAW
• CONSTITUTIONAL LAW
• ADMINISTRATIVE LAW.

CLASSIFICATION OF LAW
• CRIMINAL LAW
• CIVIL LAW
TORTS:
Torts are civil wrongs committed by one person against another.the wrong may be physical
harm ,psychological harm.
CLASSIFICATION OF TORTS:
INTENTIONAL TORTS- ASSAULT , BATTERY , FALSE IMPRISONMENT.
QUASI INTENTIONAL TORTS: INVASION OF PRIVACY.
UNINTENTIONAL TORTS: NEGLIGENCE , MALPRACTICE
LICENSURE:
STANDING OF CARE
STANDING ORDERS.

LIST OF DO’S AND DON’TS AS GUIDELINES FOR SAFE PRACTICE
DO’S
 DOCUMENTATION OF ALL UNUSUAL INCIDENCES.
 REPORT ALL UNUSUAL INCIDENCE
 KNOW YOUR JOB DESCRIPTION
 FOLLOW POLICIES AND PROCEDURE
 KEEP YOUR REGISTRATION UPDATE
 PROTECT PATIENT FROM INJURIES THEMSELVES

CONT….
• REMAIN ALERT AND FOCUSED
• ESTABLISH AND MAINTAIN RAPPORT WITH PATIENTS AND FAMILY
• SEEK AND CLARIFY ORDERS WHEN THE PATIENTS MEDICAL CONDITIONS CHANGES
• PRACTICE SAFETY WITH PHYSICIAN’S VERBAL ORDERS.

DON’TS:
• ALLOW PATIENT TO LEAVE THE HOSPITAL WITHOUT ORDER OR A SIGNED RELEASE
• ACCEPT MONEY OR GIFT FROM PATIENTS
• GIVE ADVICE THAT IS CONTRARY TO PHYSICIAN ORDERS OR THE NURSING CARE PLAN
• GIVE MEDICAL ADVICE TO FRIENDS AND NEIGHBORS
• ATTEMPT TO PRACTICE MEDICINE
• WITNESS A PATIENT’S WILL
• TAKE MEDICATION THAT BELONG TO PATIENTS.

COMMON ETHICAL PRINCIPLES
• AUTONOMY
• BENEFICENCE
• CONFIDENTIALITY
• DOUBLE EFFECT
• FIDELITY
• JUSTICE
• NON MALEFICENCE
• PATERNALISM
• RESPECT FOR PERSON
• SANCTITY
• VERACITY

COMMON ETHICAL PRINCIPLES:
THE FOLLOWING COMMON ETHICAL PRINCIPLES BE USED TO VALIDATE MORAL CLAIMS.
AUTONOMY:
The word is derived from the Greek word autos (self) and nomos (“rule or law”) and therefore refers to
self-rule. in contemporary disclosure it has broad meaning, including individual rights, privacy and
choice of obtaining informed consent for treatment, facilitating and supporting patients choices regarding
treatment options , allowing patients to refuse treatment. autonomy entails the ability to make a choice
free from external constraint.
BENEFICENCE:
Beneficence is the duty to do good and the active promotion of benevolence acts (eg.goodness, kindness,
charity)
example: a nurse is acting beneficently when he/she relaxes visitation rules in a hospital to allow a family
member to spend the night with a confused elderly client.

CONT..
NONMALEFICENCE:
The principle of non maleficence regulates that no matter what other outcomes are achieved during
an ethical issue, the nurse must prevent harm. "do not harm” is the minimal standard of behaviour for
health care professionals.
Example: nurse following the rights of medication administration or helps a postoperative client to
turn, cough and deep breathe.
CONFIDENTIALITY:
This refers to the concept of privacy. information obtained from an individual will not be disclosed to
another clients it will benefit the person or there is a direct threat to social good.
DOUBLE EFFECT:
This is a principle that may morally justify some actions that produce both good and evil effects.

CONT..
FIDELITY:
Fidelity is promise keeping. The duty to be facilitated upon ones commitments. It includes both
explicit and implicit promise to another person.
JUSTICE:
Justice states that like cases should be treated alike. A more restricted version of justice is
distributive justice and retributive justice.
PATERNALISM:
Paternalism is the intentional limitation of another autonomy, justified by an appeal to beneficiaries
or needs of another under the principle, the prevention of evil or harm takes precedence over any
potential evil caused by interference with the individual autonomy or liberty.
RESPECT FOR PERSONS:
Respect for persons is frequently used synonymously with autonomy. However, it goes beyond
accepting the no turn or attitude that people have autonomous choices, to treating other in such a
way that enables them to make choice.

CONT..
SANCTITY OF LIFE:
This is the perspective that life is the highest good.
VERACITY:
Veracity is the obligation to tell the truth and not to lie or
deceive others.

MORAL SITUATIONS
Many Situations Exist In Which Ethical Analysis Needed.
1.MORAL DILEMMAS
Situations in which a clear conflict exists between two or more principles and nurses must
choose the lesser of two evils.
2.MORAL PROBLEMS
Competing moral claims or principles although one claim or principle is clearly dominant.
3.MORAL UNCERTAINTY
When one cannot accurately define what the moral situation is or what moral principles
apply but has a strong feeling that something is right.
4.MORAL DISTRESS
One is aware of the correct course of action but constraints stand in the way of pursuing the

ETHICAL RESOURCES
Various ethical resources exist that may facilitate a nurse’s ethical decision
making.
• Code of ethics for nurses
• Policies and procedures
• Nursing administrator
• Institutional ethic committee
• Ethic consultants

SOLUTION OF ETHICAL AND LEGAL ISSUES
1. Promoting beneficence
2. Preventing and avoiding harm to patients
3. Ensuring informed consent and informed refusal
4. Handling medical errors
5. Addressing refusals of and requests for withdrawal of life-sustaining treatment
6. Fostering advance care planning
7. Ensuring appropriate surrogate decision making
8. Addressing requests for interventions
9. Maintaining patient confidentiality
10. Bedside allocation of health care resources

PROMOTING BENEFICENCE
Beneficence requires that nurse promote the interests of patients, which take
precedence over the nurse s’ self-interests.
Beneficent nurse maintain clinical competence and strive for quality, safety, and
continuous improvement in nursing practice.
Beneficence requires that, nurse completely and clearly share their assessments
and recommendations with patients and ensure that patients understand them.
 Recommendations should not be presented as a menu of choices, but as a
hierarchy of options based on efficacy, safety, and patients’ health care–related
values, preferences and goals.

PREVENTING AND AVOIDING HARM TO PATIENTS
The principle of non maleficence is closely coupled with the principle of
beneficence.
Weighing the potential benefits versus the potential harms of a diagnostic or
therapeutic intervention is common in nursing practice.
Nurses should prevent or minimize harms associated with any intervention.
Conflicts of interests should not compromise nurses’ nonmaleficence duties

ENSURING INFORMED CONSENT AND
INFORMED REFUSAL
Consent problems arises because patients experiencing acute, life threatening illness
that interfere with their ability to make decisions on treatment.
The informed consent is based on the principle of autonomy.
Consent denotes voluntary agreement, permission or compliance. It implies to
permission by the patient to perform an act on his body either for diagnosis or
therapeutic procedure.
The four elements of consent are;
 Voluntariness
 Capacity
 Knowledge
 Decision making.

CONT..
If patient is not mentally capable (critical patients) informed consent
should be obtained from surrogate or legal next of kin.
It should be given by a person of sound mind & above the age of 18 years.
Requires the disclosure of basic information considered necessary for
decision making.
 Patients providing consent should be free from pain & depression.

CONT..
Informed consent, therefore, can be described as:
A voluntary, uncoerced decision
Made by a sufficiently competent or autonomous person
On the basis of adequate information and deliberation to accept rather than reject
some proposed course of action that will affect them.

CONT..
 Expressed either verbally or in writing, or implied through compliant actions,
example: a patient rolling up a sleeve when a practitioner approaches to take a
sample of blood.
 Obtaining written consent is normal practice for invasive and surgical procedures;
verbal or implied consent is generally acceptable for non-invasive and non-surgical
procedures (dimond, 2005).
No one may give consent on behalf of an adult unless they have lasting power of
attorney (mental capacity act, 2005).
If the patient is incompetent, the clinician/health professional (as all are bound to act
in best interests) can act in the best interests of the patient, or out of necessity, and
therefore ignore refusal of consent by a relative.
 Any proposed treatment is lawful if it is in the best interests of the patient and
unlawful if it is not.

HANDLING MEDICAL ERRORS
The ethical rationale for disclosing errors to patients is strong.
First, nurse should act in the best interests of the patient. Nondisclosure does not serve
the patient and damages trust because many patients eventually learn of errors.
Second, respect for patient autonomy requires that nurse disclose errors to patients to
allow for informed decision-making.
Third, justice requires that patients be given what is due to them, including
information about their medical condition and compensation if appropriate (e.g., For
injury).
Finally, nurses should participate in efforts to prevent errors.

ADDRESSING REFUSALS AND REQUESTS FOR
WITHDRAWAL OF LIFE-SUSTAINING TREATMENT
 Based on patient’s principle of autonomy
 a patient also has the right to refuse previously consented treatments if their health care–related
values, preferences, and goals have changed.
Dying patients or their surrogates may refuse or request the withdrawal of life-sustaining
treatments (e.g., Mechanical ventilation, hemodialysis, artificially administered hydration and
nutrition, device therapies) that are perceived by the patients.
Withdrawal of life-sustaining treatments from dying patients who no longer want the treatment is
widely practiced.

FOSTERING ADVANCE CARE PLANNING
Advance care planning is a process in which patients, working with their nurse and loved ones,
articulate their values, preferences, and goals regarding future health care decisions
One form of advance care planning is the do not resuscitate (DNR) order.
Cardiopulmonary resuscitation (CPR) is the default standard of care for cardiac arrest unless a DNR
order has been written for the patient. Advance care planning also includes completion of an
advance directive.

ENSURING APPROPRIATE SURROGATE DECISION
MAKING
Patients who lack decision-making capacity are incapable of being autonomous.
For these patients, the nurse must rely on surrogate decision-makers to make decisions for
patients.
If the patient’s inform names a surrogate, this choice should be honored.
If the patient does not have any believing person than the ideal surrogate is one who best
understands the patient's health care values, preferences, and goals.

DNAR
• “Do not attempt resuscitation” (DNAR) is a medical order to provide no resuscitation to individuals for
whom resuscitation is futile and therefore inappropriate (or who have refused life-saving treatment).
• The important concept here is that of medical futility and refers to interventions that are unlikely to
produce any significant benefit for the patient. This can be in terms of either the likelihood that an
intervention will benefit the patient or the quality of any benefit that does occur. A treatment that merely
produces a physiological effect on a patient’s body does not necessarily confer any benefit that the
patient can appreciate. The question is “does the intervention have any reasonable prospect of helping
the patient?” (Jecker, 2000).

ADDRESSING REQUESTS FOR INTERVENTIONS
Many patients or their surrogates make requests for specific diagnostic and
therapeutic interventions.
Many requests are reasonable and within standards of care. The nurse generally
should grant these requests.
However, clinicians or nurse are not obligated to grant requests for interventions
that are ineffective or violate their consciences

MAINTAINING PATIENT CONFIDENTIALITY
The ethics principle of respect for patient autonomy requires that the nurse to
maintain patient confidentiality.
The nurse need access to patients’ medical information, ask sensitive questions
and conduct thorough physical examinations to assess and treat patients properly.
Patients should trust that their personal and medical information will be kept
confidential.

BEDSIDE ALLOCATION OF HEALTH CARE RESOURCES
The ethics principle of justice requires that the nurse treat patients fairly.
Injustice occurs when health care–related decisions are based on patient-specific
factors such as gender, ethnicity, and religion, not on medical need

PATIENTS’ RIGHTS AND RESPONSIBILITIES
• The NHS was established in 1948 to afford people the right to receive healthcare free at the point of
delivery. Since then the concept of patients’ rights has continued to develop to not only include having
access to free care, but also to having a say in the way that care is actually provided.
• Respect and promotion of patient autonomy is now a central component of department of health
guidance relating to consent to treatment and professional body codes of practice. Thompson et al.
(2006) identify different types of rights that outline what is to occur or to whom it occurs:
• Positive – implies a right to an action
• Negative – implies a lack of action
• Particular – to an individual
• Universal – can be seen as a general rule.

CONT
• In addition to this, leathered and McLaren (2007) discuss that rights can be
considered as concrete/fundamental; those that are based in law,
• For example: International human rights and those that are aspirational – what we
would strive for with ever-increasing advances in medicine, technologies and
therapeutic interventions, questions are being raised relating to patients’ rights to
specific types of treatment and care.
• The NHS has devolved the commissioning of patient services to primary care trusts
(PCTS) which must consider the best way of allocating its resources. High-profile
cases relating to the refusal of pcts to permit the use of drugs for the treatment of
cancer or degenerative neurological disorders have fueled the debate both within the
professional and political area.

WITHHOLDING AND WITHDRAWING CPR (TERMINATION OF
RESUSCITATIVE EFFORTS) RELATED TO OUT-OF-
HOSPITAL CARDIAC ARREST
CRITERIA FOR NOT STARTING CPR
While the general rule is to provide emergency treatment to a victim of cardiac
arrest, there are a few exceptions where withholding cpr would be considered
appropriate:
 situations where attempts to perform cpr would place the rescuer at risk of
serious injury or mortal peril (eg, exposure to infectious diseases).
Obvious clinical signs of irreversible death (eg, rigor mortis, dependent lividity,
decapitation, transection, decomposition).

CONT..
TERMINATING RESUSCITATIVE EFFORTS IN ADULT OUT-OF-HOSPITAL CARDIAC
ARREST:
• In the absence of clinical decision rules for out-of-hospital cardiac arrest (OHCA) victim, CPR and
advanced life support protocols are used by responsible pre hospital providers in consultation with medical
direction in real-time or as the victim is transported to the most appropriate facility per local directives.
• The impact of the availability of advanced hospital-based interventions, including extracorporeal
membrane oxygenation (ECMO during refractory CPR and the use of targeted temperature management
(TTM), is now being considered in the local evaluation for continuing resuscitation and transport in some
emergency medical service systems.
USE OF EXTRACORPOREAL CPR FOR ADULTS WITH OHCA—UPDATED
• The use of extracorporeal CPR (ECPR) may allow providers additional time to treat reversible underlying
causes of cardiac arrest (eg, acute coronary artery occlusion, pulmonary embolism, refractory ventricular
fibrillation, profound hypothermia, cardiac injury, myocarditis, cardiomyopathy, congestive heart failure,
drug intoxication) or serve as A bridge for left ventricular assist device implantation or cardiac transplant.

WITHHOLDING AND WITHDRAWING CPR
(TERMINATION OF RESUSCITATIVE
EFFORTS) RELATED TO IN-HOSPITAL
CARDIAC ARREST
LIMITATION OF INTERVENTIONS AND WITHDRAWAL OF LIFE
SUSTAINING THERAPIES
It was noted that not initiating resuscitation and discontinuing life-sustaining
treatment of in-hospital cardiac arrest (IHCA) during or after resuscitation are
ethically equivalent, should not hesitate to withdraw support on ethical grounds
when functional survival is highly unlikely.

ETHICS OF ORGAN AND TISSUE
DONATION
• Updated situations that offer the opportunity for organ donation include donation after neurologic
determination of death, controlled donation after circulatory determination of death, and uncontrolled
donation after circulatory determination of death.
• CONTROLLED DONATION AFTER CIRCULATORY DEATH usually takes place in the hospital
after a patient whose advanced directives or surrogate, family, and medical team agree to allow natural
death and withdraw life support.
• UNCONTROLLED DONATION usually takes place in an emergency department after exhaustive
efforts at resuscitation have failed to achieve return of spontaneous circulation.
• In 2015, the advanced life support task force reviewed the evidence that might address the question of
whether an organ retrieved from a donor who has had CPR that was initially successful (controlled
donation) or unsuccessful (uncontrolled donation) would impact survival or complications compared with
an organ from a donor who did not require CPR (controlled donation).

CONT..
2015 RECOMMENDATIONS—UPDATED
All patients who are resuscitated from cardiac arrest but who subsequently
progress to death or brain death be evaluated for organ donation .
patients who do not have ROSC after resuscitation efforts and who would
otherwise have termination of efforts may be considered candidates for kidney
or liver donation in settings where programs exist.

ETHICAL QUESTION
• How long after loss of circulation can A practitioner declare death?
• Between 2 and 10 minutes, based on current literature documenting length of time
that autoresuscitation (unassisted return of spontaneous circulation) has occurred,
as long as the decision to allow natural death has been made.
• Between 7 and 10 minutes after resuscitative efforts have stopped in uncontrolled
donation after circulatory determination of death.
• Not until the point in time that resuscitative efforts could not restore spontaneous
circulation. Currently we do not have evidence to support how long this would.

ICMR CONSENSUS GUIDELINES ON ‘DO NOT ATTEMPT
RESUSCITATION
• In India there is no formal process of discussion and documentation of ‘not for resuscitation.
• Patient autonomy still remains a weak concept and surrogate decision making by the next of kin
or the financial provider usually overrides patient wishes.
• Do not attempt resuscitation (DNAR) as an option has been practiced in many countries for such
cases to avoid futile CPR and maintain dignity of the patient. The guidelines were finalized
through A national web-based and in-person consultative meeting with A wider representative
audience. 2020 ICMR releases new guidelines on CPR, says emergency
‘procedure’ may deteriorate quality of life in some cases.

STORAGE OF DNAR FORMS
The resuscitation plans and completed DNAR forms should be easily accessible to
all the medical professionals to respond appropriately in the event of
cardiorespiratory arrest of the patient concerned.
• It is recommended to attach a copy of THE DNAR form to the patient’s case records
and to be integrated with the electronic health records, if available.
• All the case reports along with the DNAR forms should be archived for future
reference.

EVIDENCED BASED NURSING
Evidence based nursing is the conscientious, explicit, and
judicious use of current best evidence in making decisions about the
care of individual patients.
The practice of evidence based nursing means integrating
individual clinical expertise with the best available external evidence
from systematic research

EVIDENCE BASED PRACTICE PROCESS

THE NEED FOR CHANGE
THE CHANGING NATURE OF MODERN SOCIETY HAS PLACED
ADDITIONAL EXPECTATIONS ON HEALTH SYSTEMS STRUGGLING TO KEEP
PACE WITH DEMAND. THE PRESSURE FROM MANY INTERRELATED FACTORS
HAS INCREASED THE COMPLEXITY OF HEALTH CARE DECISION-MAKING, AND
FUELLED INTEREST IN EBP.
 Consumer factors
 Health service delivery factors
 Public scrutiny
 Increased complexity of health care
 Volume of literature
 Poor quality research
 Internet
 Research literacy
 Implementing change

BARRIERS OF EBNP
 Lack Of Knowledge About EBP.
 Lack Of Knowledge About Library And Online Resources.
 Inconvenient/Inaccessible Library/Internet.
 Misperceptions Or Negative Views Of Research.
 Devotion To Traditional Care
 Overwhelming Patient Care Load.
 Voluminous Amounts Of Literature.
 Difficult Patient Care Situations.
 Organizational Constraints.
 Inadequate Information In Nursing Program.
 Laziness/Lack Of Motivation/ Burnout.

2015 EVIDENCE SUMMARY
The 2015 ILCOR systematic review evaluated the use of ECPR techniques (including ECMO or
cardiopulmonary bypass) compared with manual CPR or mechanical CPR. One post hoc analysis of
data from A prospective, observational cohort of 162 OHCA patients who did not achieve return of
spontaneous circulation (ROSC) with more than 20 minutes of conventional CPR, including
propensity score matching, showed that at 3-month follow-up ECPR was associated with A higher
rate of neurologically intact survival than continued conventional CPR.
2015 RECOMMENDATION—REVISED
There is insufficient evidence to recommend the routine use of ECPR for patients with cardiac
arrest.
In settings where it can be rapidly implemented, ECPR may be considered for select cardiac arrest
patients for whom the suspected etiology of the cardiac arrest is potentially reversible during a
limited period of mechanical cardiorespiratory support

CONCLUSION
 The ethical & legal responsibility of nurse working in cardiovascular and
thoracic nursing care areas has increasing.
 Nurses must maintain & continually update their knowledge base & clinical
competence.
 Failure to do so could not only cause harm to patients but could also put
nurses & their employer at risk for allegations & professional negligence.
 As a registered nurse working within the health care industry it is important to
consider all sides of the ethical debate & to always act within the law & with
the best interests of the client in mind.

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