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Ethics in Perianesthesia Nursing
Alexander Tartaglia, MA, MDiv, DMin, BCC, ACPE Supervisor, Ken Faulkner, MA, MDiv, and Karen A. Kane, MSN, RN, CPAN
The concern for ethical practice in the care of patients has a long tradition. Since the times of Hammurabi and Hippocrates, clinicians have identified the need to develop superior technical skills and an understanding of the application of those skills using sound moral judgment. This chapter assists the perianesthesia nurse in developing a framework for understanding ethical obligations to patients, surrogates, and colleagues. Offering a historical review of landmark cases that contribute to the development of bioethics as a distinct discipline, the chapter describes and outlines the common principles used in the analysis and resolution of ethical concerns.
The chapter proceeds to examine ethical concerns most commonly encountered by perianesthesia professionals, including patient safety, privacy, and informed consent with particular attention to do not resuscitate (DNR) orders in the perioperative context. It offers practical guidance to assist clinicians in seeking strategies toward the resolution of ethical dilemmas.
Definitions
Autonomy The right to determine what happens to one’s own body, choosing treatment options consistent with one’s values.
Confidentiality Personal promise and trust that information about a patient’s health and treatment will be used only for the patient’s benefit and with care team members on a “need to know” basis.
Ethics Formal analysis, study, and reflection on questions of moral behavior; systematic reflection on the “ought.”
Informed Consent Detailed process of communication between a patient and physician regarding authorization for a particular medical intervention, including clear understanding of its benefits, risks, and alternatives.
Privacy Patient’s right to control access and distribution of personal information regarding his or her health and treatment; respect for patient’s personal space to ensure dignified care.
Required Reconsideration Comprehensive conversation between providers and patient/surrogate regarding a patient’s DNR status during the administration of anesthesia.
Understanding Ethics
Understanding the nature of ethical reflection requires the establishment of a common language and definition of terms. What do we mean when we use the terms ethics and morality? What is the nature of a moral dilemma? What is the goal of ethical reflection? How can we know which rules, principles, standards, or guidelines are best for determining appropriate ethical behavior in the resolution of everyday dilemmas?
The terms ethics and morality, although related, remain distinct. Ethics is derived from the Greek root ethos, meaning “character.”1 Morality or morals is derived from the Latin word mores or moralis, meaning “customs, character, or habit.”1 The ancient terms have a shared meaning. Today, persons engaged in the formal discipline of ethical reflection have a more distinct understanding. Beauchamp and Childress understand ethics as a “generic term for various ways of understanding and examining the moral life” and morality as “norms about right or wrong human conduct that are so widely shared that they form a stable (although usually incomplete) social consensus.”2 Morality informs persons in society as to what behavior or conduct may be considered good or right. Questions of morality include What is the right thing to do in this circumstance? How should I act in this situation?
Ethics is the formal analysis, study, and reflection on how individuals answer basic questions of moral behavior. As a method of reflection, ethics asks certain types of questions such as How do I determine what is good or bad? How do I justify my actions, and what reasons, rules, principles, standards, or guidelines should direct my decisions? Ethics is understood as a formal discipline engaged in the systematic assessment of the morals that exist in the lives of individuals and society. Ethics has a twofold task. One task is descriptive in nature, which means that ethics may simply describe in an orderly fashion the values or norms of good or bad behavior that are a part of the social context. The other task is normative, which means that ethics seeks to clarify, justify, and correct those values and norms as they apply in certain circumstances.
The goal of ethical reflection, particularly in health care, has the practical function of assisting individuals or groups in the resolution of moral dilemmas. A dilemma occurs when one is faced with a choice between two or more equally desirable but mutually exclusive options. A moral dilemma is present when a moral obligation exists on both sides of the choice—to either perform or refrain from performing an action—and ethical reasons can be found to support either of the alternatives.3 The essence of a moral dilemma is conflict. That is, a moral dilemma occurs when an individual or society experiences a conflict between competing values, duties, and obligations in a given situation.
A classic example of a moral dilemma in health care that continues to evade resolution in American society is abortion. Those who support reproductive choice argue on the basis of a woman’s right to decide what happens to her own body. Supporters of abortion rights give greater weight to the moral status of the mother, as an independent and autonomous agent, than to the developing fetus. Those who oppose abortion argue that the fetus is also a living human with its own independent moral status and, as a human life, deserves equal protection and the same right to a full life as the mother. The conflict is not so much between the mother and the fetus but rather the values and obligations owed to each party. Some value the autonomy of the mother more than the fetus. Others value the independent moral status of the developing fetus over the mother’s. One cannot equally honor both sets of values or obligations. Thus a moral dilemma exists along with a conflict about which obligation should prevail. This simplified version of the abortion debate illustrates the conflict of competing values inherent in any moral dilemma.
The Emergence of Bioethics
Ethical reflection can apply to any arena of life, but in the past few decades, a new term has come to signify ethical reflection in the health care field: bioethics, or more precisely biomedical ethics. Bioethics is the application of ethical study and reflection to the life sciences. More recently, the term clinical ethics has been used to define ethical reflection in the clinical context of the actual care of patients. Many of the ethical concerns that confront professionals in the perianesthesia context are, by nature, clinical ethics issues.
The emergence of bioethics as a field within health care responds to a series of emerging problems in the second half of the twentieth century. This period represents a time in American history of social fomentation related to developing individual and civil rights concerns, to the recognition that society has become increasingly pluralistic, and to the rapid development of technologic advances in medicine. Each of these concurrent historic forces led to novel moral challenges and the need for new ways to address the transformative dilemmas. For years, medical ethics remained under the purview of physicians who almost exclusively governed decision making for patients. Discussion or reflection on difficult moral problems encountered in the delivery of care or in medical research was kept private. After 1950, a number of noteworthy medical and legal cases emerged in the context of a rapidly changing society, which led to challenges to paternalism and gave rise to bioethics as a new interdisciplinary discipline. David Rothman describes this historic development as one in which physicians slowly became “strangers at the bedside” as other professions more frequently weighed in on the deliberations of medical decision making and recurring ethical dilemmas.4
Isolation occurred in part because paternalistic ways of governing health care by physicians began to break down in the face of increasing social challenges. Physicians no longer maintained sole discretion in addressing problems and shaping policy. Individuals from the fields of philosophy, religion, law, journalism, nursing, and the social sciences began to pay attention to issues in health care and began to organize to address their concerns. A more informed citizenry began to demand a more active voice in decision making and oversight in the delivery of medical care.
Paradigmatic Cases
The development of bioethics has been fueled by noteworthy medical and legal cases. These cases are significant for leading to profound changes in the way similar and future medical cases would be viewed. They reshaped health policy and law and reformed ethical practices in the way other patients in similar circumstances would be treated. The cases led to a different way of perceiving and valuing the moral obligations owed to patients by physicians, researchers, and other health care professionals.
Research With Human Subjects
Among the most sweeping reform in the second half of the twentieth century was in the arena of medical research with human subjects. For much of medicine’s history, the improvement of care for patients has been through the trial-and-error method of experimentation. Few therapies, when initially applied, had any guarantee of success, and some were fraught with the risk of further injury or debilitation to the patient. Early medical researchers were practicing physicians whose small-scale experiments were conducted solely for therapeutic benefit. The goal of experimentation was undertaken not as much to benefit future patients as to heal the very individual under the immediate care of the practicing physician.5 Most research was, at least in its intent, benevolent and humanistic, with the Hippocratic ideal of “doing no harm” providing the guiding norm of the experimenter’s conduct. Nonetheless, two key events revealed how flagrantly this norm can be ignored when the focus shifts to utilitarian goals rather than the safety and welfare of humans.
Nazi Germany, forever remembered for war crimes committed against the human race, was instrumental in perpetrating mass exterminations of innocent members of “undesirable” ethnic groups and other minorities. The techniques for these exterminations were perfected by Nazi physicians whose gruesome acts were later publicly revealed in the Nuremberg trials and documented by American observer Dr. Leo Alexander.6 The trials revealed how physicians and administrators conspired to engage in medical experiments such as forced sterilizations, poisonings, the infliction of simulated combat injuries, exposure to infections and extreme weather conditions, and ultimately the refinement of euthanasia techniques on those deemed mentally or physically “defective.” There were approximately 275,000 victims over a 10-year span of time. After these staggering revelations, an international tribunal of judges developed what is known as the Nuremberg Code, a statement of 10 principles that govern the ethical conduct of medical experimentation with human subjects. At the heart of the code is that the “voluntary consent of the human subject is absolutely essential” and that freedom from coercion, force, duress, or deception is a condition of participation in any form of experimentation. Expanding the moral framework for the conduct of medical research in the Nuremberg Code, the World Medical Association adopted the Helsinki Declaration in 1964.
Unfortunately, the efforts of Nuremberg and Helsinki did not end the problems with human research. Within the United States, these important principles did not filter into the consciousness or conduct of physician experimenters, which became all too apparent in the infamous research project known as the Tuskegee Syphilis Study. From 1932 to 1972, the U.S. Public Health Service (USPHS), later known as the Centers for Disease Control and Prevention (CDC), engaged in a research study that involved 400 African American men in Macon County, Alabama. What began as a small time-limited project to improve the treatment of syphilis among poor minorities expanded into a full-blown plan marked by deception and discrimination that yielded no new information about the disease and offered no bona fide treatment for subjects.7 Initiated with hopes of understanding the disease and finding the definitive cure, the study evolved into an observation of how the disease progressed through its various stages, culminating in death in many cases.
Participants in the study were led to believe they were being provided real treatment for what the physician researchers called bad blood, a euphemistic term for any kind of blood-related condition. Treatment amounted essentially to various placebos combined with painful nontherapeutic spinal taps. Subjects were induced to participate in the study through the offer of free treatment, meals, and transportation. Free burial insurance was promised on the condition the research subjects permit an autopsy upon their deaths for documentation of the effects of the end stages of the disease. Even when the curative antibiotic of penicillin became widely available, subjects of the study were prohibited from receiving it so researchers might continue to track the disease’s effects on the unsuspecting subjects’ bodies. The deception and coercion continued until USPHS investigator Peter Buxtun learned of the project from a colleague. Frustrated in his attempts to end the study by working within the USPHS, Buxtun turned to the press, and reporter Jean Heller broke the story in July 1972.8
The public and political outcry that followed the revelation of the study culminated in its immediate suspension and congressional passage of the Federal Research Act of 1974, which created two significant entities.9 First, the act established what is now known as the Office for Human Research Protections, which mandates that all institutions that receive federal funding for research with human subjects maintain institutional review boards with oversight for the safety and ethical treatment of research subjects. Second, the act established the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The multiprofession commission was assigned to craft guidelines that would serve as a moral foundation for future human research regulation.5 By 1979, the commission had arrived at a policy statement known as the Belmont Report.10 The report highlighted three basic ethical principles that guide all medical research involving humans in the United States. The principle of respect for persons requires that participation in research be based on the voluntary informed consent of the subject of the study. The principle of beneficence calls for a comprehensive risk and benefit assessment that weighs the potential harm against the potential benefit to the current subjects or future patients. The principle of justice requires that research subjects be chosen equitably (unlike Tuskegee) and that a fundamental fairness in both benefits gained and risks incurred be shared by research participants. Justice also requires that the more vulnerable members of society, such as children, prisoners, pregnant women, and the mentally challenged, be given added protection in research.
Reforms and regulations that emerged from Tuskegee and the Belmont Report now ensure that essential elements are present in every medical or behavioral research study that involves persons. These elements are voluntary participation, informed consent, comprehension by the subject of the nature and purpose of the study, full disclosure of risks and benefits, disclosure of alternatives to participation in research (as in the case of treatment associated with clinical trials), and the option to withdraw from the study without penalty.
Subsequently, President Barack Obama authorized the Presidential Commission for the Study of Bioethical Issues to conduct a thorough review of domestic and international regulations on human subject research to determine whether current rules still provide adequate protection. This directive occurred after the new revelations of unethical research in Guatemala from 1946 to 1948 in the USPHS Sexually Transmitted Diseases Inoculation Study.11
End-of-life Cases
Controversial patient care cases involving end-of-life decisions hold a prominent place in the development of the bioethics movement. Three cases are particularly noteworthy; all involved young women, each of whom was severely incapacitated and unable to participate in decisions regarding life-sustaining therapy. The first landmark case is that of Karen Ann Quinlan.12 Karen was a 21-year-old woman in New Jersey who, in 1975, suffered a severe anoxic brain injury after an accidental overdose of alcohol and drugs. Karen never regained consciousness and remained dependent on a ventilator for breathing and a feeding tube for nutrition and hydration. Eventually, she was given the diagnosis of a persistent vegetative state (PVS), a neurologic condition characterized by a “complete unawareness of the self and the environment, accompanied by sleep-wake cycles with either complete or partial preservation of the hypothalamic and brainstem autonomic functions.”13 Patients with PVS display “eyes open” unconsciousness and may have gross involuntary movements but do not respond to external stimuli or engage in any purposeful activity. After some months, Karen’s parents came to the realization that their daughter would likely never regain the ability to have any meaningful interaction. Following what they believed would be her own wishes, they asked physicians to remove the ventilator and allow Karen to die a natural death. Karen’s physicians adamantly opposed this idea, believing this to be an act of euthanasia, or worse, murder. Karen’s parents petitioned the courts, and her case eventually came before the New Jersey Supreme Court. The Supreme Court ruled in the parents’ favor on the basis that Karen had a fundamental right to privacy including the right not to receive treatment against her will. The court wrote that “the State’s interest (to preserve life) weakens and the individual’s right to privacy grows as the degree of bodily invasion increases and the prognosis grows dim. Ultimately there comes a point at which the individual’s rights overcome the State’s interest.”12 Physicians slowly weaned Karen from the ventilator while continuing her tube feedings and hydration (Karen’s parents never asked for the removal of the tube). Remarkably, Karen lived an additional 10 years before she died in a nursing home in 1986.
A second landmark case is that of Nancy Cruzan, a case sometimes referred to as the first “right to die” case to go before the United States Supreme Court.14 In 1983, Nancy was a 24-year-old woman who lost control of her vehicle on an icy road late one night in Missouri. She was found lying face down in a ditch after being ejected from her car. Nancy had stopped breathing and had no detectable heartbeat for a brief period of time. Rescue personnel intervened to restore her respiratory and cardiac function. Like Karen Ann Quinlan, Nancy had an anoxic brain injury that led to the eventual diagnosis of a PVS. Nancy was eventually transferred from an acute care setting to a rehabilitation facility where, despite years of effort, no improvements were seen in her condition. Unlike Karen Ann, Nancy was not dependent on a ventilator but was similarly sustained with a gastrostomy tube for feeding and hydration. Four years after her injury, Nancy’s parents asked physicians to remove the feeding tube with the understanding that Nancy would die. They contended that Nancy had remarked about never wanting to be artificially sustained if she could not be “at least halfway normal.”14 Physicians resisted, leading Nancy’s parents to turn to the courts for help. The Supreme Court of Missouri ruled against them with the argument that sufficient evidence of Nancy’s true wishes did not exist to justify the withdrawal of life support, particularly in light of the consequence of death. Denial of the Cruzans’ wishes on Nancy’s behalf led to an appeal to the U.S. Supreme Court and set the stage for one of the most famous medical legal cases in U.S. history.
The U.S. Supreme Court received the case in December 1989 and issued a ruling in June 1990. In somewhat of a split decision, the Court, on constitutional grounds, affirmed both certain rights and requirements for all parties in determining a course of action in cases like Cruzan’s. The Court acknowledged an individual’s right to refuse treatment, even such treatment as life-sustaining tube feeding and hydration. Yet the Court went on to say that the state of Missouri could require “clear and convincing evidence” that such refusal was made when that person was still competent. On these grounds, the Cruzan case was remanded to Missouri for further adjudication. The emergence of new evidence indicated that Nancy would not have wanted life-sustaining treatment in her current condition and led to a Missouri lower court permitting the withdrawal of the feeding tube. Nancy died in December 1990.
The Cruzan case and the memory of the Quinlan case before it propelled the creation of federal legislation designed for individuals to state their desire to refuse life-sustaining treatment under the conditions set forth by the Supreme Court even without capacity and the ability to communicate. The Patient Self-Determination Act of 1990 established on a national level the legitimacy of previously written advance directives as valid legal expressions of an individual’s desire to limit or refuse treatment in end-of-life circumstances.15 These advance directives, often referred to as living wills (and in many states includes durable power of attorney for health care decisions), in theory meet the “clear and convincing” evidence standard required by the U.S. Supreme Court. While all 50 states recognize and honor some form of written advance directives, problems persist in these difficult cases in both the interpretation of generalized written statements and the infrequency of their use among the public.16,17 Another attempt to assist patients, families, and clinicians in understanding a patient’s wishes for end-of-life care is found in the growing influence of the Physician Orders for Life-Sustaining Treatments (POLST) paradigm.18 POLST documents, intended for those with life-limiting or terminal disease processes, provide more specific guidance than generalized advance directives. POLST creates a specific set of medical orders by a physician based upon the expressed wishes and values of a patient. POLST is not a complete substitute for an advance directive. Rather, it builds upon and complements the wishes of the patient as expressed in an advance directive.
The case of Terri Schiavo is one of the more recent tragic end-of-life cases complicated by the absence of clear communication and understanding among family members over end-of-life wishes.19,20 Terri was a 26-year-old woman in 1990 when she had a cardiac arrest most likely as a result of an electrolyte imbalance from an ongoing eating disorder. Like Quinlan and Cruzan before her, she had a severe anoxic injury that rendered her a total care patient in a PVS for 15 years dependent on a percutaneous endoscopic gastrostomy tube for nutrition and hydration. Early on in her care, Terri’s husband, Michael, and her parents, Bob and Mary Schindler, were united in efforts to keep Terri alive and restore her to some level of conscious functioning. Within a few years, Michael came to the conclusion that Terri would not recover and sought to remove the feeding tube, allowing Terri to die. The Schindlers, deeply religious, vehemently opposed this request. They believed that removal of the tube was an act of murder and that continued aggressive effort could restore Terri to wakefulness. The Schindlers also questioned the diagnosis of PVS; they believed that Terri both recognized and communicated with them in her own limited way.
Fundamental disagreement between Michael and the Schindlers over Terri’s fate led to a bitter and international public dispute waged in the courts for more than a decade. The Schindlers petitioned to have Michael removed as Terri’s guardian and garnered the support of the Florida state legislature and Governor Jeb Bush, who signed a one-time stay forbidding the removal of the feeding tube pending further legal appeal. On three separate instances, the U.S. Supreme Court refused to hear the case, each time affirming the appropriateness of lower court findings in favor of Michael Schiavo. In the end, Michael’s position as Terri’s guardian was upheld, and the courts allowed the removal of the gastrostomy tube. Terri died on March 31, 2005, with her husband at her side. After her death, Michael permitted, at the request of the Schindlers, a neuropathologic autopsy that revealed severe atrophy of the brain. The official cause of death by the medical examiner was listed as “complications from anoxic encephalopathy.”21
The cases of Quinlan, Cruzan, and Schiavo reveal the ongoing struggle clinicians and families face in making decisions on behalf of patients with incapacitated conditions. The legacy of these cases highlights the continuing difficulties in withdrawing or withholding treatment in the care of patients with life-threatening conditions and little or no hope of recovery. A lack of public consensus has limited the development of social and institutional policy to guide clinicians. Even the closest of kin can sometimes be unclear about what their loved ones would desire in critical cases.22
Proponents of the principle of autonomy drive yet another option for end-of-life decision making, physician-assisted death (PAD) or physician-assisted suicide (PAS). Oregon was the first state to legalize this option through its Death with Dignity Act passed in 1997. The Death with Dignity Act “allows terminally ill Oregonians to end their lives through the voluntary self-administration of lethal medications, expressly prescribed by a physician for that purpose.”23 Since then, five other states have legalized PAD (Washington, Vermont, and California by legislation; Montana and New Mexico by court ruling), the most recent being California, whose law closely resembles Oregon’s. The passage of the California statute was significantly influenced by the case of Brittany Manyard, a young California woman diagnosed with terminal brain cancer who moved to Oregon to have the option for PAD that was not available in her home state.24 She died at the age of 29 years with her husband and mother by her side after ingesting a lethal medication provided to her by an Oregon physician. Her personal public appeal spurred California legislators and Governor Jerry Brown to enact the law.25
Guiding Principles
With insight gained from the history of research with human subjects and difficult end-of-life cases, the bioethics movement developed new ways of valuing and examining ethical dilemmas in patient care. A consensus has emerged on a set of guiding principles to assist health care professionals in the wide variety of clinical situations they may encounter. Beauchamp and Childress advance the clearest interpretation of these principles emerging over time from the common morality of society and the particular context of the clinical environment. These principles are respect for autonomy, nonmaleficence, beneficence, and justice.2
Respect for autonomy refers to the norm of respect for the decision-making capacity of autonomous individuals. Defined as self-rule or self-governance, autonomy means that competent adults have the fundamental right to determine what happens to their bodies and to make choices in treatment options consistent with their own beliefs and values.2 Autonomy is grounded in respect for persons and the inherent dignity and worth of each individual and is reflected in the Code of Ethics of the American Nurses Association.26 In the clinical setting, the autonomy of the patient is often challenged by the vulnerabilities created by pain, sedative effects, and severe illness as well as the anxiety produced by a lack of understanding of the complexities of the modern health care institution such as the medical language and jargon used by professionals. The obligation of clinical caregivers is to uphold autonomy by engaging in an ongoing process of informed consent, maintaining privacy and confidentiality, and enhancing, to the greatest degree possible, the mental and emotional capacity of the patient in his or her decision making. In the American context, autonomy is often thought of as the first and most important of the four principles.
Nonmaleficence refers to the obligation of clinicians to prevent harm to patients under their care or to minimize risks of harm to the fullest extent possible. This norm is often linked to the medical framework of the Hippocratic admonition primum non nocere, translated to mean “above all, do no harm.”2 The potential for harm to patients in health care can be understood in both broad and narrow terms. Nursing frames this understanding in the ethical obligation to advocate for processes that minimize harm and maximize comfort and support for patients.26 Nonmaleficence refers to the effort made by clinicians to limit physical pain, disability, or even death as a consequence of the treatment process itself. More broadly, the term refers to the duty to alleviate the emotional and spiritual suffering of the patient undergoing the traumatic experience of illness, institutionalization, isolation, and loss.
Beneficence is the principle that speaks to the duty of promoting the ultimate welfare of the patient above all other concerns. In common usage, beneficence speaks to acts of mercy, kindness, and charity.2 As such, beneficence and nonmaleficence may be thought of as two sides of the same coin. Nonmaleficence emphasizes not harming the patient in the effort to do good. Beneficence supports doing good for the patient. Again, the obligation to serve as a patient advocate in a manner that promotes health, well-being, and especially safety is a component of sound ethical practice for the nursing professional. In health care, beneficence speaks to the humanitarian values that should underlie decision making and treatments offered to vulnerable persons. It is no accident that the word hospital is associated with the term hospitality. Beneficence affirms that patients should be treated as valued guests in what can often be a foreboding institutional environment. It also suggests that, although clinicians often are tempted by interests in conflict with the patient’s welfare, they should seek to set aside those interests or minimize their effects as much as possible to maintain professional integrity.
The last and perhaps most elusive principle promoted is the principle of justice. The elusiveness of justice is the result of the wide variety of ways it is defined and understood in society. Within the context of health care, justice is best understood as the obligation of clinicians to fairly distribute the medical benefits, risks, and costs associated with the provision of health care.2 As such, persons in similar circumstances are to be treated similarly. The challenges to the fairness principle are immeasurable in the modern American health care system. Global challenges are most visible in the debates concerning universal health insurance, equity of access, and financing the health care industry. Clinical challenges to justice are more evident in the struggle to evenly allocate scarce resources such as organs for transplant and blood products as well as access to care, services, and beds in emergency and critical care areas. Justice for the practicing nurse might be understood again in terms of advocacy, this time in the promotion of equality in the provision of quality care through the use of appropriate standards of practice for all patients.26
Perianesthesia Ethics
Nursing professionals face a complex maze of ethical issues within the perioperative context. The intensity of a fast-paced environment with limited room for error demands not only clinical competence but critical thinking, quick judgment, and clear communication. Vigilance regarding professional functioning and ethical practice is essential for the achievement of positive clinical outcomes within a morally sound arena. Although many issues exist, the ethical issues faced by perianesthesia nurses can be captured within three general categories: (1) informed consent, (2) privacy and confidentiality, and (3) patient safety.
Informed Consent
Informed consent is the process of communication between a patient and physician that results in the authorization or understanding for a specific medical intervention.27 Informed consent is rooted in respect for persons, patient autonomy, and self-determination and formalizes a component of the covenant between the patient and the physician. It is built on the principles of trust and truth-telling regarding the use of a particular intervention or treatment to achieve a desired medical outcome.
Despite the clarity of definition for the informed consent process, multiple questions or potential ethical conflicts can arise for nursing staff within the perioperative period. A simple question such as “What were they going to do again?” asked by an anxious patient in the preoperative holding area can set off a series of internal alarms in the mind of a nurse. Does the patient need reassurance or more information? Is it a momentary failure of memory or a lack of adequate understanding of the procedure that prompted the question? Who secured the consent of the patient? How was the request approach conducted? How does the nurse understand the professional and ethical obligations in the face of a seemingly unsure patient and the pressure of a tight operating room (OR) schedule?
The nurse might begin by seeking verification of a signed written consent form. Whereas the presence of the form might satisfy the technical act of granting consent, it may or may not fulfill the ethical obligation. Informed consent is more than a means of securing a signature. Rather, it is a process of open two-way communication that implies full disclosure and provides detailed information on the nature of a specific procedure. A comprehensive informed consent process not only reviews the diagnosis and purpose of the intervention but also outlines its potential risks and benefits. It includes alternative treatment options, if any, and the risks and benefits of forgoing the treatment procedure. Informed consent assumes that the threshold elements of patient capacity and voluntary nature are met.28 Research conducted during the perianesthesia phase of care should likewise follow ethical, professional, and legal guidelines including the use of written informed consent documentation approved by the appropriate institutional review board.29,30
Questions may also arise regarding the duration and scope of a signed informed consent. The nurse in the previous scenario may have noticed that the signed consent was properly secured but completed in the surgeon’s office nearly 90 days ago. Should the consent still be valid for the patient who is now unsure about the nature of the procedure? Is the timing of the consent still valid? What is the nurse’s obligation to confirm that the patient understood the potential benefits, risks, and surgical outcomes?
Informed consent requires that the process be completed by a clinician able to provide the intervention and in a manner that allows time and space for patients to ask questions, seek clarification, and discuss potential options for care. This includes consents for anesthesia, which should include the type of anesthesia (e.g., general, monitored anesthesia care [MAC], regional, IV sedation, or other modality). All benefits, risks, and alternatives should be discussed, and a mutually agreeable plan of care should be documented and communicated to the care team. An adequate informed consent process is further challenged by potential language barriers such as complex medical terminology, cultural diversity, and functional limitations among populations with cognitive impairments.31,32 All these issues underscore the significance of effective communication in the patient-physician relationship and among members of the interdisciplinary team.
What, then, is the ethical responsibility of the nurse in the holding area faced with the patient’s question of uncertainty and the surgical team’s schedule? To what extent is the nurse’s ethical obligation to serve as a patient advocate in support of an informed decision? How might the nurse’s obligation be affected for the patient who adds the statement, “At least my surgeon promised to be there for the entire operation,” when the nurse knows of that particular surgeon’s tendency toward intermittent presence while residents perform most operations? What if the nurse understood from a colleague that the patient’s original consent was provided under pressure to comply? Specific questions such as these identify just a few of the immediate moral dilemmas that have implications for clinical practice and patient outcomes.
Resuscitation in the Perioperative Context
A special circumstance of informed consent in the perioperative context is the issue of resuscitation for patients with preexisting DNR orders. Cardiopulmonary resuscitation (CPR) is the only medical procedure routinely performed in a hospital without the expressed consent of a patient. Routine management of the patient under the influence of anesthesia shares some of the same interventions and characteristics of resuscitation. As such, the practice of routine suspension of DNR orders for patients during anesthesia care in the OR was commonly accepted through the 1980s.
By the mid-1990s, the evolution of increased respect for patient autonomy evolved from changes in medical practice and the Patient Self-Determination Act of 1990. Respect for patient autonomy and concern for adequate informed consent procedures challenged old practices and forced the issue onto the agendas of key professional organizations. Emerging from these conversations was support for the practice of required reconsideration. A comprehensive conversation regarding a patient’s DNR status during the administration of anesthesia is recommended between the physician and the patient or surrogate, with the result documented and communicated among health care team members. Anything less is a violation of a patient’s right to self-determination and fails adherence to the principle of patient autonomy.33–40 This position has obvious ethical implications for providers. It requires intentional dialogue with patients or surrogates regarding the options and implications of maintaining or suspending the DNR order during surgery. Required reconsideration has since become the predominant recommended approach supported by the American Society of PeriAnesthesia Nurses, the American College of Surgeons, the American Society of Anesthesiologists, the Association of periOperative Registered Nurses, the American Association of Nurse Anesthetists, and the American Academy of Nursing.41–46
Despite the consensus movement toward required reconsideration, change in culture regarding the application of this practice persists along with opinions among anesthesiologists, surgeons, nurse anesthetists, perianesthesia nurses, and patients.47 Variation in practice among providers is reflective of the complications associated with the delivery of anesthesia and the ability to differentiate between an arrest caused by sedation as opposed to the progression of disease.36,48,49 Additional complications are associated with inadequate familiarity with current guidelines on advance directives in the perioperative setting.50
Organizational policies can mandate such communication and documentation of the conversation, but the ethical challenge to informed consent remains in the details. Informed consent regarding the suspension of a DNR order implies that patients or surrogates are offered information about their procedures, including potential risks and benefits, alternative treatment, and the potential implications of foregoing the intervention. Careful consideration of the individuality of each patient is critical. Discussion of how resuscitation would be managed in the perioperative period is an essential but complicated discussion. Conversation within this context should be conducted without coercion in a language understandable to patients or surrogates and with sufficient time to allow questions and answering concerns to lead to an informed decision. The nature of the preoperative conversation is particularly critical to avoid assumed contractual buy-in to postoperative life support especially for DNR patients facing high-risk surgery.51,52
Clear and consistent communication alone does not readily resolve the complexities of management of a DNR order in the perioperative period. Discussion in the literature on the pragmatics of managing the DNR order in the perioperative period is reflected in two approaches, both supporting the ethical obligation to respect patient autonomy. One position suggests a means or procedure-directed approach that examines routine resuscitative actions and determines which interventions would be offered in the perioperative period. The second position supports an ends-oriented approach that examines the goals of the patient relative to the present procedure. Both options suggest a limited resuscitation approach during the perioperative period as distinct from the two extreme options of suspension of DNR orders with unrestrained resuscitative efforts or maintenance of current DNR orders limiting all interventions not immediately associated with routine anesthesia care.
The procedure-directed approach provides a checklist of specific provider interventions.46,48 The application of this approach requires consideration of each optional intervention (i.e., those not associated with routine anesthesia care) individually between the patient or surrogate and the surgeon or anesthesia provider. The advantages of procedure-directed orders are the reduction of ambiguity and the consistency of application from one clinician to another throughout intraoperative resuscitation management. The limitations to procedure-directed orders include an expectation that anything but the most likely problems would be anticipated in advance and the lack of flexibility offered the clinician in response to a temporary and readily reversible event.
The goal-oriented approach seeks to incorporate the patient’s values as the primary consideration in determination of the extent of resuscitation.46 Patients offer guidance regarding preferred outcomes but leave specific interventions to the discretion of the provider. Although this approach supports patient autonomy, it also provides a larger role for the provider. The advantage to this approach is that it offers flexibility to the clinician to act in accordance with a broad understanding of patient preferences should an unanticipated event occur in the OR setting. The limiting argument for this position has been that it risks putting unanticipated decision-making power back in the hands of the physician.
Keys to success for either of these approaches are communication and documentation. The complexity of this issue underscores the significant ethical obligations of the perioperative nurse. The obligation to act in the patient’s best interest demands that the nurse be knowledgeable and informed beginning with having a clear understanding of the organization’s DNR policy and its specific application to the perianesthesia period. Equally important is that the nurse has knowledge of the DNR status of the patient during that period, including any documentation regarding limited resuscitation and knowledge of the timeframe in the case of temporarily suspended DNR orders.
Privacy and Confidentiality
Maintaining the privacy and confidentiality of patients remains a challenge for health care organizations and clinicians. Privacy and confidentiality are complementary rather than synonymous concepts.53 Privacy suggests that a patient has the right to control general access and distribution of personal information about his or her health and implies that boundaries that protect a patient’s personal space are respected within a clinical setting. Confidentiality relates to the personal trust that intimate information shared by a patient with a clinician is used only for the patient’s medical benefit. As such, information is shared with those members of the interdisciplinary team on a need-to-know basis. Information should be shared with third parties only with permission of the patient except in the cases of an identified surrogate for the patient who lacks decision-making capacity. Discussion and consent regarding release of information in this situation should be managed in the preoperative phase. The ethical responsibility to maintain privacy and confidentiality proceeds from the principle of respect for persons that promotes human dignity and maximized patient control.54 This responsibility applies to the preoperative setting when marking surgical sites to ensure minimal exposure. It also applies to treatment of patients under the effects of anesthesia by eliminating and addressing derogatory or disrespectful behaviors or communications.54,55
One of the most significant challenges to patient privacy during the perioperative period is the physical setting of the postanesthesia care unit (PACU). More often than not, the PACU is configured as a multipatient care area with only curtains for privacy. Private communications between patients and clinicians are subject to being overheard by other patients or even visitors. The literature continues to support increased visitation for patients in the PACU as a means of decreasing family anxiety.56–59 Family-centered care responds to visitation preferences of families and significant others yet increases the potential to compromise privacy obligated to other patients. This potential ethical compromise can be mitigated through consistent policy and practice.60,61
Respect for confidentiality has been given renewed attention as a result of health care reform for nurses who care for young adults who are not minors yet remain on parental health insurance plans. Another conflict that may emerge stems from the rights of parents who wish to be present when a minor child awakens from surgery. Staff members not directly involved in the care of specific patients may encounter neighbors and friends recovering from surgery and who would have preferred to remain unnoticed. In addition, the changing world of social media creates new challenges that can blur the line between personal and professional boundaries. What constitutes responsible use of social networks?62,63 Can nurses, for example, “friend” patients on Facebook or talk about a patient scenario even without identifying factors?
How does the PACU nurse observe multiple patients while ensuring privacy? The typical PACU nurse monitors more than one patient, thus exposing patients to potential violations of personal space in the interest of patient safety. An additional challenge to the nurse can be finding the appropriate way to respond to the physician who performs examinations without properly drawing the curtain or who engages in intimate conversations with patients without proper discretion as to volume and content.
Teaching hospitals carry additional potential dilemmas in maintenance of patient privacy. The parameters of what is ethically permissible or appropriate relative to observation or examination by students or others in training of patients who are anesthetized remains ethically ambiguous. Should examination itself, the type of examination, the number of students observing, the nature and extent of the consent process, or some combination of these factors drive the parameters of ethical appropriateness? Should informed consent include details regarding these parameters? What is the extent of ethical obligation on the perianesthesia nurse to speak up as a patient advocate?
The professional responsibility to maintain confidentiality and privacy is clearly required from the perianesthesia nurse. The exchange of privileged patient information should follow the organization’s policies on confidentiality and the code of ethical conduct of the appropriate professional organization, which would include at a minimum the sharing of information on a need-to-know basis and the proper collection of patient data for research purposes.
Patient Safety
The ethical responsibility for all clinicians and health care providers to act in the best interest of patients is no more evident than in the obligation to ensure patient safety. The significance of this obligation on perianesthesia nurses is both organizational and personal. Minimally, this obligation stems from the ethical principle of nonmaleficence. Organizational obligation includes responsibility to ensure that the environment is safe for patients. Critical to patient safety is the requirement that a clinician at any given point in the treatment process demonstrate appropriate competencies for the level of provided care. Competency implies possession of the knowledge, skills, attitudes, and behavior to deliver the appropriate level of care on a consistent basis.64 Clinicians are obligated to know and to function within the standard of care of their professional role and the professional standards of practice within their discipline.65 This responsibility can be particularly challenging for nurses in the PACU, an environment frequently characterized by overcrowding because of limited intensive care unit beds and staffing shortages and where nurses might be asked to provide care outside the unit’s scope.66
The principle of beneficence speaks to the perianesthesia nurse’s responsibility to a wide range of ethical obligations. Ethical dilemmas faced by clinicians can include how to respond to a colleague who appears impaired in some way, what to do regarding the reporting of a medical error, or how to respond to a situation in which a colleague is engaged in deceptive practice or illegal behavior—all situations that affect maintenance of a safe environment and adherence to ethical practice and organizational guidelines. The nurse is obligated to follow best practice processes and be proactive about eliminating errors. One example of proactive practice is calling a “time-out” prior to any procedure. If guidelines for anything from a nerve block to correct site surgery are not followed properly during the procedure, the nurse calls a time-out and stops the procedure until it is corrected.67,68 Time-out is the opportunity to adhere to safety. As the advocate for patients at a vulnerable time, the nurse should be empowered to speak up, and organizations should support those efforts.
The transfer of the patient from the OR to the PACU has the potential to introduce a number of ethical dilemmas related to patient safety. One common dilemma faced by the perianesthesia nurse in the PACU setting is the obligation to determine unintended intraoperative awareness. The responsibilities of the nurse in this instance can be multiple. The nurse must make an initial assessment with an interview of the patient who emerges from the influence of anesthesia to determine whether any recollection of events exists or whether the patient experienced pain during the surgical procedure. If the finding is affirmative, the nurse must then determine how to communicate the information. Clear documentation of the patient’s response and notification of the surgeon and the anesthesia provider are critical. Equally important is communication of the patient’s experience to the intensive care unit or floor nurse who will assume care for the patient and who can identify resource personnel who could be available to support the patient who has experienced such trauma. The ethical dilemma becomes more complicated should the perianesthesia nurse discover a pattern of unintended intraoperative awareness emerges as the result of care by a specific anesthesia provider or surgeon.
The hand-off from the OR to the PACU can be complicated by the pressure of time. What essential information needs to be passed from the OR nurse or the nurse anesthetist to the PACU nurse? How should the transfer of a patient whose condition is marginally stable or one whose condition is hemodynamically stable but in pain be handled between the nurse anesthetist and the PACU nurse? How could this situation be compromised by a demanding OR schedule that anticipates a speedy return to the OR by the anesthetist? Current literature supports the use of a structured process for hand-offs to ensure all essential information is communicated. Many PACUs use the same structured process from anesthesia to PACU nurse and then PACU nurse to receiving nurse, allowing for consistency and safer continuity of care.69,70
Minimal responsibility in this instance includes documentation of the patient’s status on arrival, information on the surgical and anesthesia course, and collaboration in the care of the patient until the PACU nurse accepts responsibilities. The proper medication management, particularly as it applies to pain in the postoperative period, remains a critical ethical obligation and can be a source of tension between the transferring anesthesia provider and the receiving PACU nurse. This process can be particularly complicated for the pediatric patient or the geriatric patient with cognitive impairment because clinicians may need knowledge and specialized training for such populations. Again, standardization of procedures and proper communication skills are key factors in successful patient transfers and outcomes.71
A corollary of the ethical principle of respect for persons and the obligation to ensure patient safety is truth-telling. The ethical responsibility to tell the truth in medicine exists at both organizational and individual patient levels. Organizationally, the perianesthesia nurse needs to determine the ethical course of action in disclosing potential safety problems under the pressure to move patients efficiently through the system. At an individual patient level, the perianesthesia nurse is challenged to determine the ethical course of action in facilitating disclosure of a medical error, even one seemingly inconsequential.72,73
At one point or another, all health care professionals encounter a case that conflicts with their own personal value system or that creates significant emotional discomfort. Perianesthesia nurses are no different. Nursing professionals should make every effort to anticipate such potential conflicts in advance and reference any organizational personnel policies that address this conflict. Generally speaking, refusal of anticipated conflicts of moral conscience is ethical provided no compromise to patient safety exists.
Resources for Resolving Ethical Dilemmas
Clear and consistent communication between clinicians and patients as well as among clinicians continues to be the backbone of good ethical practice. Despite the most diligent practice, ethical dilemmas continue to challenge clinicians. The ethical responsibility for the perianesthesia nurse can become particularly burdensome in the perioperative environment where issues of power and politics are never far away. Identification of resources to support staff seeking resolution of ethical conflicts can relieve the burden. Managers and supervisors should not be overlooked as resources for assistance. Supervisors should be dependable sources for accessing organizational policies or for support in dealing with colleagues in other disciplines. Staff access to organizational and departmental policies has been enhanced with the use of an institution’s intranet postings. In addition, the ethics codes for nearly all relevant professional nursing organizations are available through Internet websites. Questions regarding ethical practices related to release of patient information, business practices, or even professional behavior can be referred to ever-expanding corporate compliance programs.
Ethics Committees and Consultation Services
The Standards of The Joint Commission require that hospitals have an identifiable process for the resolution of ethical dilemmas. Subsequently, most hospital-established ethics committees are charged with three functions: the development of policies to address recurrent difficult situations such as DNR or withdrawal of care orders; education to the organization that addresses issues faced by the organization or its specialty disciplines; and consultation to patients, families, and staff for the mediation of conflicts or exploration of treatment options. Although guidelines to determine the functioning of ethics committees can vary by organization, generally speaking, access to the ethics committee is available to any individual with standing in a case. This access includes patients or surrogates and staff involved in the care of the patient. Consultation services are generally provided by a subcommittee of the membership that possesses some training in clinical ethics. Consultations, whether by the committee as a whole or by subcommittee, serve as nonbinding recommendations that identify the ethically appropriate options of care available to the physician and patient.
Consultation provided by members of the ethics committee can be a critical resource for the perianesthesia nurse uncertain about the appropriate ethical course in a given clinical situation. The goal of ethics consultation is the improvement of patient outcomes through a process of reasoned decision making. Consultation typically takes the form of facilitation and dialogue to ensure that the key ethical issues and the essential perspectives of persons with standing in a case are provided adequate voice. The value of ethics consultation is the availability and timely response of a neutral resource to assist staff in the exploration of ethically appropriate alternatives to a situation that lacks consensus. Like a medical consultation, an ethics consultation is a resource, not a final decision, that may disappoint clinicians who seek a quick resolution for a complex situation or an ally to advance a particular position.
Ethics Case Review Methodology
The use of a pragmatic tool to examine a moral problem is a valuable resource for both the novice and the experienced clinician. Thoughtful case analysis requires a reasoned methodology ensuring that a systematic approach is followed and that influential factors are given appropriate consideration. The use of a case-based methodology can facilitate responsible reflection with an objective theoretic framework while attending to the specifics of a particular situation. The following adaptation offers a pragmatic approach to moral problem solving.74,75
Assessment: What are the facts? What are the patient’s medical condition and prognosis? What are the needs of the patient (e.g., relief from suffering)? What are the current goals of treatment or care? What are the patient’s preferences? What is the patient’s capacity for decision making? For the patient who lacks capacity, have any care preferences been previously expressed or documented? If not, does the family/surrogate have an understanding of the patient’s values or what the patient would have wanted given the current medical condition? If not known, what are the family/surrogate preferences?
Moral Diagnosis: How are the ethical questions in the situation being framed by the participants who hold moral standing? Have all relevant persons been heard? Is the ethical dilemma clearly articulated? Separate facts from feelings. Clarify the points of disagreement or uncertainty. Identify and rank all relevant moral considerations. What ethical guidelines apply? Consider laws that may apply while carefully separating ethical from legal options during discussion. Are there similar cases in the literature that might be instructive? Identify and list the full range of morally acceptable options for resolving the case.
Goal Setting, Decision Making, and Plan Implementation: What options for resolution of the dilemma seem most appropriate and why? Do the goals of treatment or plan of care need to be revised? What resources can be brought to the situation for assistance? How would you negotiate a plan among the affected parties and achieve consensus on a plan? What would help resolve the conflict? Is consultation with the institutional ethics committee indicated? Is judicial review indicated, and, if so, consider consultation with risk management.
Evaluation: The implementation of any medical decision includes an element of ongoing evaluation. Consideration of the benefit of any intervention and the goals of treatment should be subject to periodic and regular review. Evaluation should include consideration of what could have been done to prevent the problem from occurring. Retrospective review might consider a range of issues from communication between providers and patient/family to assessment of institutional policy and practice.
Summary
Clinical ethics continues to develop into a mature field with established acceptance among health care professionals. Codes of professional ethics are the norm for nursing organizations, and there is a growing literature of ethical issues in perianesthesia nursing. Evolving technology and increased emphasis on patients’ rights presents ever-increasing options for care and considerations for decision making within the medical community. In addressing these issues, the perianesthesia nursing professional has much to contribute. It is crucial to develop the competencies and skills required to be effective clinicians who possess the critical assessment tools necessary to negotiate difficult situations in an environment of culturally diverse values.
