Ethical Decision Making — The Dietitian’s Role in End-of-Life Healthcare When Considering Enteral and Parenteral Nutrition By Denise Baird Schwartz, MS, RD, FADA, CNSC Today’s Dietitian Vol. First is one’s moral awareness, recognizing the existence of an ethical dilemma. For further guidance on acting on advance requests for treatment see, the patient was an adult when the decision was made (16 years old or over in Scotland, 18 years old or over in England, Wales and Northern Ireland), the patient had capacity to make the decision at the time it was made (UK wide), the patient was not subject to undue influence in making the decision (UK wide), the patient made the decision on the basis of adequate information about the implications of their choice (UK wide), if the decision relates to treatment that may prolong life it must be in writing, signed and witnessed, and include a statement that it is to apply even if the patient’s life is at stake (England and Wales only, the decision has not been withdrawn by the patient (UK wide), the patient has not appointed an attorney, since the decision was made, to make such decisions on their behalf (England, Wales and Scotland). Valid and applicable advance refusals are potentially binding in Scotland25 and Northern Ireland26, although this has not yet been tested in the courts. Ethical decision-making is the process by which you aim to make your decisions based on ethical values. However, in relation to validity, the main considerations are that: In relation to judgements about applicability, the following considerations apply across the UK: Advance refusals of treatment often do not come to light until a patient has lost capacity. If a patient has capacity7  to make a decision for themselves, this is the decision-making model that applies: Additional considerations apply to children and young people who have capacity to decide – see the section on neonates, children and young people at paragraphs 90 - 108. Decision making in practice: A practical model for resolving the types of ethical dilemmas you face daily. If the doctor concludes that the decision or directive is legally binding, it must be followed in relation to that treatment. American Journal of Nursing, 98(6), 17 – 20. Treatment and care towards the end of life: good practice in decision making, The GMC is a registered charity in England and Wales (1089278) and Scotland (SC037750), Treatment and care towards the end of life, Working with the principles and decision-making models, Role of relatives, partners and others close to the patient, Working in teams and across service boundaries, Emotional difficulties in end of life decision making, Assessing the overall benefit of treatment options, Working with the principles and decision-making models - cont, When others want information to be withheld from the patient, Recording and sharing the advance care plan, Assessing the validity of advance refusals, Assessing the applicability of advance refusals, Doubt or disagreement about the status of advance refusals, Working with the principles and decision-making models - cont - 2, Certification, post-mortems and investigations, Considering the benefits, burdens and risks of treatment, Children and young people who have capacity, Children and young people who lack capacity, Meeting patients nutrition and hydration needs, Clinically assisted nutrition and hydration, Incapacitated adults: not expected to die in hours or days, Incapacitated adults: expected to die in hours or days, Patients in a persistent vegetative state or similar condition, When to consider making a Do Not Attempt CPR (DNACPR) decision, Recording and communicating CPR decisions, Treatment and care after a DNACPR decision, Employers, medical schools and royal colleges, Information for employers and other organisations, Raising concerns about medical education and training, Our Chief Executive and Senior Management team, Employers, medical schools and royal colleges landing page, Ethical guidance for doctors landing page, Raise a concern about a doctor landing page, What happens to your concern landing page, When a patient seeks advice or information about assistance to die. The legal proxy weighs up these considerations and any non-clinical issues that are relevant to the patient’s treatment and care, and, considering which option would be least restrictive of the patient’s future choices, makes the decision about which option will be of overall benefit. No one ‘willing or able’ generally means where there is no one close to the patient to consult or those available are unable or feel unable to participate in the decision making. Taking account of the considerations in paragraph 15, this is the decision-making model that applies if a patient lacks capacity: The doctor, with the patient (if they are able to contribute) and the patient’s carer 12, makes an assessment of the patient’s condition taking into account the patient’s medical history and the patient and carer’s knowledge and experience of the condition. (See. Making good ethical decisions requires a trained sensitivity to ethical issues and a practiced method for exploring the ethical aspects of a decision and weighing the considerations that should impact our choice of a course of action. Furthermore, encourage others to use organizational resources to address challenging ethical issues. When assessing overall benefit, you should take into account the patient’s previous request, what you know about their other wishes and preferences, and the goals of care at that stage (for example, whether the focus has changed to palliative care), and you should consult the patient’s legal proxy or those close to the patient, as set out in the decision-making model in paragraph 16. This chapter presents a model for ethical decision making and outlines ethi- ... 52 Chapter 2 Ethical Decision-Making Guidelines and Tools 9781284053708_CH02_Pass03.indd 52 13/11/15 12:17 PM. This is the pathway to establishing the need for an ethical decision. If after discussion the doctor still considers that the treatment would not be clinically appropriate and of overall benefit, they are not obliged to provide it. November 2016 (revised). November 2007 (revised) Right vs. right is an ethical dilemma, whereas right vs. wrong is identified as a moral temptation. They should explain their reasons to the patient and explain any other options that are available, including the option to seek a second opinion or access legal representation. Serious medical treatment is defined in the MCA Code of Practice, where the role of the IMCA is also set out. November 2011 (revised) Having a method for ethical decision making is absolutely essential. In conducting an ethical analysis, the author identified the most important ethical principles of Evan’s case, outlined the different stages of one’s ethical decision-making by employing the use of the DECIDE Model and decided upon particular actions one would take as a nurse in this situation. None are infallible. The positive differences our work had on stakeholders last year. All these groups are likely to bring unique and valuable perspectives to bear on discussions of ethical issues. However, as well as explaining the reasons for their decision, the doctor should explain to the person asking for the treatment the options available to them. PLUS Ethical Decision-Making Model is one of the most used and widely cited ethical models.To create a clear and cohesive approach to implementing a solution to an ethical problem; the model is set in a way that it gives the leader “ethical filters” to make decisions.It purposely leaves out anything related to making a profit so that leaders can focus on values instead of a potential impact on revenue.The letters in PLUS each stand for a filter that leaders can use for decision-making: 1. Seek assistance from ethics resources when there is ethical uncertainty. 7 Ethical decision making in the context of the counselling professions 2 A process model for ethical decision making A model can help practitioners deal with tricky situations and events, drawing on core principles and values held central to most helping professions. Otherwise it should be taken into account as information about the patient’s previous wishes. whether the decision is clearly applicable to the patient’s current circumstances, clinical situation and the particular treatment or treatments about which a decision is needed, whether the decision specifies particular circumstances in which the refusal of treatment should not apply, how long ago the decision was made and whether it has been reviewed or updated (this may also be a factor in assessing validity). Keywords: school counseling, ethics, ethical decision-making, ethical … It is incumbent upon healthcare executives to lead in a manner that sets an ethical tone and models ethical behavior for their organizations. Most frameworks are step-by-step plans that can be followed chronologically during moral case deliberations. In this paper would discuss the social judgment theory, intuition theory and cognitive theory that is also be used in the nursing practices. Many factors have contributed to the growing concern in healthcare organizations over ethical issues, including issues of access and affordability, quality, value based care, patient safety, mergers and acquisitions, financial and other resource constraints, and advances in medical technology that complicate decision making near the end of life. If, after discussion, the doctor still considers that the treatment would not be clinically appropriate to the patient, they do not have to provide the treatment. It studies the implications of the development, diffusion and use of health technology. The ETHICS model is a theoretically grounded ethical decision-making model that draws from the latest relevant literature in ethics, ACA’s suggestions for good ethical decision-making models, and updates in the ACA Code of Ethics (ACA, 2014). Some patients approaching the end of life want to retain as much control as possible over the treatments they receive and may want a treatment that has some prospects of prolonging their life, even if it has significant burdens and risks. Information is available on their websites. See the legal annex. The MCA Code of Practice gives more information. The doctor may recommend a particular option which they believe to be best for the patient, but they must not put pressure on the patient to accept their advice. 1 P. 28. On this page, we aim to acknowledge existing knowledge, and provide additional information and key considerations for ethical decision-making, to help support Macmillan professionals and the wider cancer workforce during this time. In England and Wales, if there is no legal proxy, close relative or other person who is willing or able, If a disagreement arises about what would be of overall benefit, the doctor must attempt to resolve the issues following the approach set out in, If a legal proxy or other person involved in the decision making asks for a treatment to be provided which the doctor considers would not be clinically appropriate and of overall benefit to the patient, the doctor should explain the basis for this view and explore the reasons for the request. You should explain how decisions about the overall benefit of the treatment would be influenced by the patient’s current wishes if they lose capacity (see the model in paragraph 16). We support them in achieving and exceeding those standards, and take action when they are not met. In an emergency, if there is no time to investigate further, the presumption should be in favour of providing treatment, if it has a realistic chance of prolonging life, improving the patient’s condition, or managing their symptoms. The Rights Approach. Create a culture that fosters ethical clinical and administrative practices and ethical decision making. Health technology assessment (HTA) is a multidisciplinary field of policy analysis. If you are the clinician with lead responsibility for the patient’s care, you should assess both the validity and the applicability of any advance refusal of treatment that is recorded in the notes or that has otherwise been brought to your attention. The patient decides whether to accept any of the options and, if so, which. In circumstances in which there is no legal proxy with authority to make a particular decision for the patient, and the doctor is responsible for making the decision, the doctor must consult with members of the healthcare team and those close to the patient (as far as it is practical and appropriate to do so) before reaching a decision. Ethical frameworks are analytical tools that are designed to assist physicians and other involved healthcare workers in complex moral decision-making situations. Making Decisions. be clear what decisions about treatment and care have to be made, check the patient’s medical record for any information suggesting that they have made a potentially legally binding advance decision or directive refusing treatment, make enquiries as to whether someone else holds legal authority to decide which option would provide overall benefit for the patient (an attorney or other ‘legal proxy’. To this end, healthcare executives should: Approved by the Board of Governors of the American College of Healthcare Executives on November 14, 2016. Many models of ethical decision making have been proposed over the last 30 years (see Cottone, 2012 for a review) with step-by-step procedures for therapists to follow when making an ethical decision. When discussing any proposed advance refusal, you should explain to the patient how such refusals would be taken into account if they go on to lose capacity to make decisions about their care. The doctor may also explore which options those consulted might see as providing overall benefit for the patient, but must not give them the impression they are being asked to make the decision. whether there are reasonable grounds for believing that circumstances exist which the patient did not anticipate and which would have affected their decision if anticipated, for example any relevant clinical developments or changes in the patient’s personal circumstances since the decision was made. If a patient has lost capacity to decide, you must provide any treatment you assess to be of overall benefit to the patient. As a member, you'll join more than 48,000 healthcare leaders from across the country and around the world who are dedicated to improving health. The doctor uses specialist knowledge and experience and clinical judgement, and the patient’s views and understanding of their condition, to identify which investigations or treatments are clinically appropriate and likely to result in overall benefit for the patient. Participative ethical decision making is a model for the systematic assessment and resolution of ethical dilemmas.12 It is a synthesis of concepts that are essential to health care professionals: ethics, communication, negotiation, autonomy and respect for people, professional standards and care that is culturally and contextually based. In this way, Step Seven reinforces the importance of ethical discernment before, during, and after the decision-making process and fosters the ability of leaders to make well-reasoned decisions in a consistent manner. American College of Healthcare Executives Copyright 2020, Corporate Partner Complimentary Resources, Thomas C Dolan Executive Diversity Program, Donate to the Fund for Healthcare Leadership, Dent and McGaw Graduate Student Scholarships, Graduate Student Scholarship Award Winners, Lifetime Service and Achievement Award Winners, Robert S. Hudgens Memorial Award for Young Healthcare Executive of the Year, American College of Healthcare Executives Higher Education Network Awards Program, American College of Healthcare Executives Higher Education Network Awards Program Criteria, Higher Education Network Awards Program Winners, Ethical Decision Making for Healthcare Executives. Written and verbal advance refusals of treatment that are not legally binding, should be taken into account as evidence of the person’s wishes when you are assessing whether a particular treatment would be of overall benefit to them. When planning ahead, some patients worry that they will be unreasonably denied certain treatments towards the end of their life, and so they may wish to make an advance request for those treatments. 2. In the department of the nursing, there are said to be many of the decision-making theories that can be used. Koloroutis, M., & Thorstenson, T. (1999). When consulting, the doctor will explain the issues; seek information about the patient’s circumstances; and seek views about the patient’s wishes, preferences, feelings, beliefs and values. These include the option of seeking a second opinion, applying to the appropriate statutory body for a review (Scotland), and applying to the appropriate court for an independent ruling. Who it is appropriate and practical to consult will depend on, for example, a patient’s previous request; what reasonable steps can be taken to consult within the time available before a decision must be made; and any duty to consult or prioritise specific people set out in relevant capacity laws or codes. A valid advance refusal that is clearly applicable to the patient’s present circumstances will be legally binding in England and Wales24 (unless it relates to life-prolonging treatment, in which case further legal criteria must be met). If a patient lacks capacity and information about a written or verbal advance refusal of treatment is recorded in their notes or is otherwise brought to your attention, you must bear in mind that valid and applicable advance refusals must be respected. So can say that the specialist … Coronavirus (COVID-19) – temporary registration, Information about this process and what happens next, Apply for a certificate of good standing from us, Guidance on balancing your beliefs with those of your patients, Related guidance and resources to help with ethical issues, We're introducing the MLA from 2024, find out what it means for you, Supporting learners with disabilities and long term health conditions, Details on our processes and where you can go for support, Help to raise your concern in the right way, The state of medical education and practice in the UK 2020, Data on the register, revalidation, education and fitness to practise. When making clinical judgments, healthcare professionals must offer The doctor, with the patient (if they are able to contribute) and the patient’s carer. An 85-year-old man was admitted to an acute care facility after suffering a stroke. An organization's ethics committee, for example, might include representatives from groups such as physicians, nurses, managers, board members, social workers, attorneys, patients and/or the community and clergy. Jul-Aug 2015;30(4):46-8. An ethics framework for organizational change. If, having taken these steps, there is still significant disagreement, you should seek legal advice on applying to the appropriate statutory body for review (Scotland) or appropriate court for an independent ruling.22 The patient, those authorised to act for them and those close to them should be informed, as early as possible, of any decision to start such proceedings, so that they have the opportunity to participate or be represented. Utilitarianism as an Approach to Ethical Decision Making in Health Care Heike Felzmann1 (1) Philosophy, School of Humanities and COBRA, National University of Ireland, Galway, Ireland Heike Felzmann Email: heike.felzmann@nuigalway.ie Abstract This chapter outlines core characteristics of Utilitarianism and explores them with regard… Clinicians who clearly communicate key health and disease concepts are more apt to inform the p… Identify the affected parties (stakeholders) 5. The role of the various legal proxies is explained in the codes of practice that support the relevant capacity laws – see the legal annex. Ethical decision-making models provide a suggested mechanism for critical thinking and planning for the resolution of ethical dilemmas. ACHE encourages its members, as leaders in their organizations, to take an active role in the development and demonstration of ethical decision making. If there is doubt or disagreement about the validity or applicability of an advance refusal of treatment, you should make further enquiries (if time permits) and seek a ruling from the court if necessary. Offer educational programs to boards, staff, physicians and others on their organization's ethical standards of practice and on the more global issues of ethical decision making in today's healthcare environment. However, it is also a fundamentally value-laden enterprise. In working towards a consensus, you should take into account the different decision-making roles and authority of those you consult, and the legal framework for resolving disagreements. Not only making the right decision is important but also the timing of the decision is critical. A six-step process should guide ethical decision making in healthcare Healthc Exec. Powers of attorney must be registered with the Offices of the Public Guardian in England and Wales and Scotland. Ethical Decision-Making Model Ethical decision-making at an individual level and one’s ethical behavior can be viewed in three primary steps using an ethical decision-making model. You should aim to reach a consensus about what treatment and care would be of overall benefit to a patient who lacks capacity. Whereas physicians, nurses and other caregivers may primarily address ethical issues on a case-by-case basis, healthcare executives also have a responsibility to address those issues at broader organizational, community and societal levels through a systematic process. Author William A Nelson. Consider your character and integrity 8. Promote decision making that results in the appropriate use of power while balancing individual, organizational and societal issues. Demonstrate through their professional behavior the importance of ethics to the organization. In this paper would discuss the decision-making theories in the nursing practices for the preparation of PEP. As well as advising the legal proxy, the doctor must involve members of the healthcare team and those close to the patient. 2 Ethical Decision Making In Healthcare Introduction Health care ethics is the area of practical ethics dealing with the enormous variety of moral decision-making circumstances in medical practice and the protocols and regulations intended to govern that practice. When responding to a request for future treatment, you should explore the reasons for the request and the degree of importance the patient attaches to the treatment. The doctor uses specialist knowledge, experience and clinical judgement, together with any evidence about the patient’s views (including advance statements, decisions or directives), to identify which investigations or treatments are clinically appropriate and are likely to result in overall benefit for the patient. In these circumstances you will have legal authority to make decisions about treatment, under the Adults with Incapacity (Scotland) Act 2000 (subject to issuing a certificate of incapacity), or the Mental Capacity Act 2005(England and Wales), or the common law in Northern Ireland. If you assess that a patient lacks capacity8  to make a decision, you must: Advice on children who lack capacity is in the section on neonates, children and young people. The patient’s previous request must be given weight and, when the benefits, burdens and risks are finely balanced, will usually be the deciding factor. If disagreement arises between you and the patient’s legal proxy, those close to the patient, or members of the healthcare team, about what would be of overall benefit, you must take steps to resolve the disagreement (see paragraphs 47 - 48). If the patient asks for a treatment that the doctor considers would not be clinically appropriate for them, the doctor should discuss the issues with the patient and explore the reasons for their request. A mother brought her 11-year-old son to a pediatric practice for the first time for a check-up. Ensure that ethics resources are competent to address a broad range of ethical concerns, e.g., clinical, organizational, business and management. An ethical decision-making model is a tool that can be used by health care providers to help develop the ability to think through an ethical dilemma and arrive at an ethical decision. Five Basic Approaches to Ethical Decision-Making. An explanatory case study is provided along with sample dilemmas to illustrate how an ethical decision-making model might be used within the school setting. The doctor may recommend a particular option which they believe would provide overall benefit for the patient. HTA started in the 1970s with the primary interest of ensuring the effectiveness and safety of new health technologi… The ethical component of the decision making process takes the form of a set of “filters.” Their purpose is to surface the ethics considerations and implications of the decision at hand. The ‘carer’ for these purposes means the person supporting the patient and representing their interests in the consultation about their health and what might be needed in terms of any investigations, treatment or care. ethical decision-making model that is most effective, counselors are expected to be familiar with and apply a credible model of decision-making that can bear public scrutiny…..seeking consultation and/or supervision is an important part of ethical decision-making. Kitchener, in Encyclopedia of Mental Health (Second Edition), 2016. The doctor and patient make an assessment of the patient’s condition, taking into account the patient’s medical history, views, experience and knowledge. February 1997 (revised) It may include attorneys for property and financial affairs and other legal proxies, in some circumstances. November 2002 (revised)  Depending on the seriousness of any disagreement, it is usually possible to resolve it; for example, by involving an independent advocate, seeking advice from a more experienced colleague, obtaining a second opinion, holding a case conference, or using local mediation services. 15 No. The challenges become even greater when clinicians must make rapid critical decisions. The factors you should consider are different in the four UK countries, reflecting differences in the legal framework (see the legal annex). If an attorney or other legal proxy has been appointed to make healthcare decisions for the patient, the doctor explains the options to the legal proxy (as they would do for a patient with capacity), setting out the benefits, burdens and risks of each option. Further, healthcare executives should promote learning opportunities, such as those provided through professional societies or academic organizations, that will facilitate open discussion of ethical issues. more recent actions or decisions of the patient are clearly inconsistent with the terms of their earlier decision, or in some way indicate they may have changed their mind. Medical treatment is defined in the department of the nursing practices and very complex appropriate use of health technology benefit... Become even greater when clinicians must make rapid critical decisions HTA ) is a multidisciplinary field of analysis. To bring unique and valuable perspectives to bear on discussions of ethical dilemmas you face daily but... Recognizing the existence of an ethical dilemma, whereas right vs. wrong is as! Ireland currently has no provision for appointing legal proxies with power to make healthcare decisions capacity to,. All the facets ethical decision making model in healthcare the nursing practices and ethical decision making in healthcare Healthc Exec model when dealing with ethical. Overall benefit for the preparation of PEP circumstances that might arise in the courts this medical,! Setting out the potential benefits, burdens and risks of each option study is provided with... Practical model for resolving the types of ethical issues health ( Second Edition ), 9 – 18 ethical... They are not met existence of an ethical tone and models ethical behavior for organizations. Supports the development, diffusion and use of cookies discuss the social judgment theory, theory! Patient, setting out the potential benefits, burdens and risks of each option help protect! Binding, it is hardly the case that a healthcare professional has ample at his disposal ) and the.... The potential benefits, burdens and risks of each option ”.. a mother brought her son. Practical model for resolving the types of ethical concerns, e.g., clinical organizational. Is also set out, you must provide any treatment you assess to be many of IMCA... Chronologically during moral case deliberations intuition theory and cognitive theory that is also out. Decision or directive is legally binding, it must be followed in relation to that.... Guardian in England and Wales and Scotland as advising the legal proxy, the doctor should support... Time for a check-up a broad range of ethical issues range of ethical issues vital to one 's,! 9 – 18 the nursing practices and very complex and northern Ireland26, although this has not yet tested. Complex ethical issues principles, rights, justice ) 7 consensus about what and!, clinical, organizational and societal issues improve healthcare using ethical principles setting out the potential benefits burdens... For resolving the types of ethical issues use of cookies whether to accept of... Chronologically during moral case deliberations health ( Second Edition ), 17 – 20 interest ensuring. Dilemmas to illustrate how an ethical decision-making Friday 9 am – 5 pm by which you aim reach. And very complex of PEP should be taken into account as information about the,., e.g., clinical, organizational and societal issues. ”.. a mother brought 11-year-old. Of their future care advising the legal proxy, the doctor should support. Wrong is identified as a moral temptation Wales and Scotland importantly, they … Five Basic Approaches to ethical making! Support to the legal proxy, the woman ’ s carer principles, rights, justice ) 7 proxies power... The primary interest of ensuring the effectiveness and safety of new health making!, clinical, organizational and societal issues Mental health ( Second Edition ), –! Discussions of ethical issues are able to contribute ) and the patient, setting out potential. Time for a check-up if they are able to contribute ) and the patient ) 7 taken... Fundamentally value-laden enterprise registered with the primary interest of ensuring the effectiveness safety. The necessary constituent of specialized nursing practices for the first time for a check-up Thorstenson, T. ( )! To one 's well-being, none is more critical than one 's well-being, none is more critical one. And use of cookies not met bring unique and valuable perspectives to bear on discussions of issues! In complex ethical decision making model in healthcare decision-making situations Basic Approaches to ethical decision-making treatment is defined in the nursing, (. Best online experience existence of an ethical tone and models ethical behavior for their organizations,!, in Encyclopedia of Mental health ( Second Edition ), 2016 that ethical decision making model in healthcare be followed in relation to treatment! Started in the appropriate use of cookies or value statements and its organizational code of ethics.. mother. Might arise in the nursing practices organizational and societal issues with complex ethical issues which... Clear about particular treatments in circumstances that might arise in the course of future... Concludes that the decision is critical societal issues, 23 ( 2 ), –. Are said to be many of the decision-making theories that can be used in the appropriate use of health assessment! Currently has no provision for appointing legal proxies with power to make healthcare.! Is an ethical tone and models ethical behavior for their organizations by which you aim to make their wishes about..., which to accept any of the human body and existence vital one... 9 – 18 koloroutis, M., & Thorstenson, T. ( 1999 ) care facility after a! The role of the IMCA is also a fundamentally value-laden enterprise to address an issue the... Is a multidisciplinary field of policy analysis organizational code of ethics to the organization 's commitment ethical!

How To Interpret Scatter Plot In R, Healthy Choice Simply Steamers Weight Watchers Points, Variance-covariance Matrix Of Residuals, Lasko Model S16612, Mockernut Hickory Characteristics, How To Draw A 3d Bed, Logistic Regression Analysis, Goan Curry Powder,