Ethical issues and advance directives in nursing: who decides?
Ethical concerns, dilemmas, competence, advance directives and care planning: the rule for each, for practical nurses in Canada.
- Don't lie to a capable client, and don't decide alone.
- If a rule answers it, follow the rule. If two values pull apart, name both.
- Get a client's wishes into the plan before the day they are needed.
Ethical issues and advance directives in nursing come back to one question: who decides? A capable client decides, the nurse never decides alone, and the client's written wishes speak when the client can't. This guide follows one client from her diagnosis to her last wishes, and links to a lesson on each part.
Five parts of ethical practice and advance directives
| Part | The rule |
|---|---|
| Ethical concern | Facts, conflict, talk, act, review. Don't lie, and don't decide alone. |
| Advance directives | A capable client's words today come first. If the client can't decide, their wishes still lead. |
| Ethical dilemma | If a rule answers it, follow the rule. If two values pull apart, name them both. |
| Continuing competence | When you find a gap, your client comes first. Then make a learning plan, every year. |
| Advance care planning | Ask, get the paper, tell the team, and match the plan. When a family disagrees, escalate. |
Act on an ethical concern
A daughter asks you not to tell her mother that it is cancer. Your client is capable, and that afternoon she asks you, “Is it cancer?” You don't lie, and you don't give the diagnosis yourself. You tell the physician and the nurse in charge what she asked, and you ask the physician to come today. Later, you check that the conversation happened.
Read the full lesson: facts, conflict, talk, act, review.
Know whose words come first
After the diagnosis, she puts her wishes on paper. She names her daughter to decide for her, and she writes: no feeding tube. While she can decide, her own words today come first, ahead of anything she wrote. A client who can't decide and has no paper still has a decision-maker, because the law lists who speaks.
Read the full lesson: whose words the team follows.
Spot the ethical dilemma
Most hard moments are not dilemmas. A colleague who asks you to chart vital signs that you did not take is answered by a rule. A dilemma is two values that pull apart, like a capable client's choice to walk alone and his safety after two falls. Name both values, and take them to the client and the team.
Read the full lesson: three questions for anything that troubles you.
Keep yourself competent
Ethical practice is also about you. When you meet a pump that you have never used, your client comes first: tell the nurse in charge, and set it up with a colleague who knows it. Then name the gap, set a goal with a date, choose the activities and check the result.
Read the full lesson: what to do when you find a gap.
Put the client's wishes into the plan
Months later, she comes back with pneumonia, and her papers are at home. You get a copy into the record, tell the team, and check that the orders match her wishes. When her son asks for a feeding tube, you listen, promise nothing, and escalate to the charge nurse and the prescriber.
Read the full lesson: get the client's wishes into the plan.