At some stage in their career, nurses are likely to be faced with a dilemma of sorts, where there is no correct answer, or where the correct answer goes against the wishes of the patient and their family. Perhaps a colleague (and good friend) has shown incompetence or just been overworked and made a mistake. Should it be kept quiet or brought to the attention of superiors?

With the onset of COVID-19 in early 2020, confusion reigned. Medical experts were faced with a disease that was spreading rapidly and taking lives at an unprecedented rate in this modern age. There was no real cure, and the symptoms presented were varied. Makeshift hospital wards were set up, patients were isolated and they often died alone. 

Nurses are taught that the patient’s needs take priority over everything else. But here they were, faced with multiple dilemmas. Nurses were putting themselves and their families at risk. In many cases, there was not enough protective equipment to go around, so they were not permitted to spend too much time with patients as the risks were too high. 

They administered the necessary treatment and then removed themselves very quickly, leaving seriously ill patients alone to fear the worst. There was often a shortage of equipment, and this presented yet another dilemma: who to treat first? Non-malfeasance is about causing no harm to a patient, however, exhausted after long hours of work under stressful circumstances, nurses were at risk of making mistakes.

Fortunately, the early horrors of COVID-19 are now behind us. However, the extreme stress levels of those early days have had long-term effects on many nurses. Having had to deal with constant ethical dilemmas and the ensuing guilt of not being able to give the patients the necessary care has resulted in nurses battling with mental issues such as depression, anxiety and self-doubt. 

What are the ethics of nursing? 

The Code of Ethics for Nurses was developed as a guideline for nursing practice consistent with the quality care of patients and the ethical obligations of nursing.

With greater nurse autonomy, a nurse practitioner is in a better position to face ethical dilemmas, whether they be in a hospital situation or in private practice. With their long-term experience and additional education, nurse practitioners are more likely to anticipate the needs of patients and their families and are better placed to deal with ethical dilemmas. Courses such as the online program offered by Marymount University teach these skills to their students.

How do ethical dilemmas arise, and what should nurses do?

Nurses are taught that the patient’s wishes, values and preferences come first, and this is where many of the dilemmas arise. Here are some rules to keep in mind:

• A nurse’s top priority is always the patients’ health and safety.
• A nurse is duty-bound to provide patients and their families with as much detail about the illness as possible.
• A nurse may not give personal advice at any stage.
• If in doubt, the dilemma should be discussed with a senior colleague, hospital management or an ethics committee.

Patients have the right to autonomy — to determine their preferred course of treatment without interference. However, in practicing beneficence, which includes removing conditions that can cause harm, the nurse may be going against the patient’s wishes and inadvertently causing harm to the patient. In this case, the nurse should first explain the code of ethics to the patient and what the implications of his or her wishes for autonomy would be on the health outcome. 

Family matters

Abortion is a controversial life vs. death dilemma. If a mother’s life is at risk because of her pregnancy, the doctor will advise that the fetus be removed. This may go against the moral or religious beliefs of one or both parents-to-be, and they can choose whether to continue with the pregnancy. An abortion may also go against the nurse’s beliefs, and while nurses are not permitted to give an opinion on the matter, they can refuse take part in the procedure. If the parents are in a dilemma, the nurse should give as much information as possible about the health risks and possible outcomes without voicing an opinion. 

Patients have the right to know 

When a patient is gravely ill, the doctor will discuss the matter with the family, usually giving them the details of the illness. If the patient is unlikely to recover, the doctor will also discuss details on further care, for example hospice, and how long the patient is likely to live. Often, the family does not want the patient to know how ill they are, as they feel it would not do them any good. 

Patients usually have more contact with their nurses and are likely to ask the nurse for details of their illness. Although the responsibility lies with the physician, the nurse should explain as thoroughly as possible. If the nurse is unable to articulate the details, then the physician should be called in.

Disagreements over treatment 

If a patient has told the medical staff to go ahead with a treatment, for example, chemotherapy, but certain family members would prefer that he or she try an alternate method first, the nurse will give priority to the patient’s wishes. However, if the family members become difficult and verbalize their unhappiness, the nurse should point out that medical staff are trained to always put the patient’s wishes first and it would be unethical for them to change this. The nurse could report the conversations to a superior if necessary.

If, however, the patient is in cognitive decline and unable to give consent, then the family members’ wishes can be taken into account.

Advanced directive and end of life choices 

An advanced directive (AD), also known as a living will, medical directive or advance decision, is a document that is signed by the patient, specifying what treatment they would, or would not, prefer in the event of a terminal illness or if they are on life support and no longer able to speak for themselves. 

If a patient is seriously ill, the nurse should endeavor to find out whether there is an advanced directive in place, and if not, try and persuade the patient to sign one. This should obviously be done tactfully and with sensitivity by explaining the consequences of not having one. Having an AD relieves the family from having to make a very tough decision one day.

If a patient has not signed an advanced directive or a do not resuscitate order (DNR) and is no longer capable of making their wishes known, then the family is entitled to make the decision to stop life support or treatment if it is no longer going to be of any value. This is known as an ‘end-of-life’ choice. In this case, the nurse can give the family support and help them understand the medical side of things, but that is where it ends. Nurses may not give their personal advice or opinion on the matter.

If there is no family and no advanced directive, hospitals have ethics committees and can make decisions based on the law in their particular state.

Duty and compassion do not always align with facility protocols. If a nurse has been working long hours and is tired, he or she is unlikely to deliver their best quality care and could even make mistakes. For example, a nurse may have promised family members that she will stay with a patient who is dying so that they do not die alone. The rules in the hospital state that she should not work longer than 12 hours at a time. This places the nurse in a dilemma. She could discuss the matter with her superior, but this situation could have been avoided.

Nurses should not make promises they are unable to keep. 

Spiritual and religious beliefs vs. science 

If the patient is in a sound frame of mind, he or she can refuse treatment based on religious beliefs. Provided the nurse or doctor has supplied sufficient information for the patient to fully understand the implications if treatment is refused, the only thing left to do is document the situation and get the patient to sign it to avoid lawsuits at a later stage. Once again, the nurse can inform but not divulge personal feelings on the matter.

On the other hand, if a patient is terminally ill and the doctor has suggested that life support be removed as it is not serving any purpose, the family may refuse based on grounds of spirituality. If they have been informed of the hopelessness of the situation but still believe that the patient’s religion will save him and they are happy to continue with the treatment, the treatment must continue. The nurse can help treat the patient and can inform the family of the situation, but she cannot give advice.

Children and adolescents 

When parents refuse to allow children to be vaccinated as part of the school immunization program on grounds of philosophical or religious beliefs, the nurse needs to inform the parents of the reasons for the vaccination and the risks of going without.

The state’s rules regarding vaccination can be of guidance here to both nurses and parents. If the parents persist, they should sign a form containing the details of the vaccination, reasons for refusal and an acknowledgement of the risks.

Suspicion of abuse or maltreatment of a child poses another ethical dilemma. The nurse may suspect this is happening and be duty-bound to report it, however, proving it may be difficult and could result in the nurse being sued if incorrect. 

Adolescents may choose not to disclose certain ‘delicate’ health issues to their parents, while the nurse feels duty-bound to do so. Before taking any action, however, it is important for the nurse to be familiar with the state laws regarding minor consent, as a violation of the patient’s privacy can result in the loss of a job and even having a nursing license revoked. 

Personal and professional boundaries 

Nurses should keep their professional boundaries intact by avoiding personal involvement with patients. Nurses should avoid at all costs developing a relationship with a patient.

Healthcare organizations should have social media policies in place, and these must be adhered to. Befriending a patient on social media can inadvertently lead to disclosure of personal healthcare issues and result in legal action. Any involvement with a patient, or their family or friends on social media needs to be kept private.

Lack of comprehension when signing medical forms 

If a nurse picks up that the patient does not understand the consent they are signing, this should be brought to the attention of the medical practitioner, even if it means a delay in the treatment, such as disrupting a theater schedule.

Questioning physician’s orders 

Patient comfort and safety are the nurse’s top priorities. However, going against a doctor’s wishes may create bad feelings in a working relationship and could affect the quality of successful patient care in the future.

It may be something simple, like the discovery that the patient has an allergy to an ingredient in the medicine just prescribed by the doctor. The nurse should bring the allergy to the doctor’s attention, and if the medication is not rectified, the nurse may withdraw the medication until the matter has been reported to a superior and investigated. 

If a doctor refuses to prescribe medication on the grounds that the patient has an addiction to certain medication, this goes against the nurse’s priority of seeing to it that the patient gets the best possible care. The matter should be reported to a superintendent for further investigation or clarification.

Lack of training or incompetence 

An untrained or incompetent nurse is a danger to patient safety. If a nurse is moved to a different section within the organization, but not given sufficient training to be able to treat the patients effectively, this should be reported to the superintendent. Likewise, if a nurse realizes that a colleague is incompetent and poses a threat to patient safety, the nurse should discuss the issue with a superior as a matter of urgency, regardless of the fact that the colleague may also be a good friend.

Be aware

As with most things in life, being aware of problems that may arise, having an understanding of the implications and having an idea of how to deal with them is half the battle. A sound knowledge of nursing ethics and state laws applicable to health and welfare is a good place to start.