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The Nursing Code of Ethics and Patient Advocacy

By Currents Editor posted 01-26-2023 14:47

Michelle Schober, MD, MS
Audrey Paulson, DNP, FNP-BC, CCRN, CNRN, SCRN

Ethical principles common to the various health care professions include the concepts of justice, nonmaleficence, beneficence, and autonomy. The American Nurses Association (ANA) Code contains these concepts and cites three additional principles: veracity, accountability, and fidelity. The ANA Code outlines “the fundamental values and commitments as a nurse,” identifies “the boundaries of duty and loyalty,” and describes “the duties of the nurse that extend beyond individual patient encounters.”

The first provision states: “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.” The second provision states that the nurse’s commitment is to the patient, no matter whether the patient is a person, family, group, community, or population. The third provision states that the nurse promotes, advocates for, and protects the rights, health, and safety of the patient. This applies to everyone: patient, community, and population.

The next three provisions state that nurses are responsible for their practice, to practice safely, and to promote good health and care for themselves and their patients. Nurses must maintain competencies and are responsible for delivery of care. The last three provisions state nurses are responsible for the profession, and that nurses “advance the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.” Nurses are to maintain their professional organization and work with others in the field to share best practices and information.

The primary difference between the nursing and physician code of ethics lies in the focus, which in nursing is not as much on the professional aspects of practice, but on the patient or population served.

Nowhere is this difference in focus more apparent than on the matter of prognostication after cardiac arrest. As noted in the 2020 Lancet Neurology publication by Cronberg, T.  et al titled, Brain injury after cardiac arrest: from prognostication of comatose patients to rehabilitation “One of the most challenging, but also most common, situations for patients after cardiac arrest is decision making around withdrawal of life sustaining therapy (WLST)…A forecasted poor outcome typically leads to [...] WLST […] and death. Hence the prediction precision, usually reported as specificity, should be maximal.”

Bedside nurses often witness how difficult it is for family or other surrogate decision-makers to act on the patient’s behalf when the patient’s wishes are unknown. The ANA nursing code of ethics, enshrined in principles that emphasize patient and family-centered care, suggests instead that increasing public awareness of advance directives and of POLST (Physician Orders for Life-Sustaining Treatment) would enhance providers’ ability to advocate for the patient’s best interest.

The nursing code of ethics suggests that focusing on the patient’s wishes rather than on the physician’s ability to determine outcome may serve the public better. The NCS guidelines note that WLST remains the most common cause of death for comatose survivors of cardiac arrest. Families commonly encounter medical situations in which predictions of poor outcome are more readily supported while little evidence is available to estimate the odds of a positive outcome. When negative prognosticating factors are absent, families tend to translate that information as predictive of a good outcome.

In the face of rapidly changing science, technology, and social norms, educating the public about tools everyone can use to clarify their care goals should they become comatose or otherwise unable to communicate will likely have the most impact on these difficult bedside decisions.

Education may be the best medicine. A lesson may be taken from California procedures regarding organ and tissue donation (which were modeled after motor-voter provisions regarding voter registration). In California, every individual who obtains a driver’s license is asked to indicate if they choose to be an organ, eye, and/or tissue donor. Their choice is indicated on the license and entered in a registry. Adults make donor decisions independently and give final consent to be a donor by making that selection long before a decision is needed. Drivers under the age of eighteen may state their intent regarding donation while leaving the final decision with the parent or guardian. The consent (or intent, for minors) to donate lessens the burden on families at a highly emotional and stressful period.

With the provisions of the nursing code of ethics and the methodologies of the California Donor Network in mind, nurses can focus on the patient and their decision-making capacity. No one plans on becoming incapacitated, yet we all know the likelihood of that occurring increases with older age. The Physicians Order of Life Sustaining Treatment, or POLST form, is available to prevent life sustaining treatment when it is not desired. While it is a simple form that allows one to state, in advance, their desires and preferences for medical treatments if they are ever incapacitated, it is estimated that only approximately one-third of adults in the United States have executed a POLST or equivalent advanced directive. Many adults believe they have many years of life ahead of them, and while most of them do, catastrophe is often unpredictable.

Education must come first. A campaign to inform the public about such advance planning, with an explanation of the form and the different options available, must occur prior to implementation of any new process. This campaign and process could be modeled on the Donor Network’s methodology. The POLST form itself starts the conversation: What would you want done? How aggressive should we be? It would also make clear the options available by informing individuals about life support, feeding tubes, and long-term care. As one’s life and health change, personal wishes may change. This form could be updated with each license renewal or more often if necessary. Instead of the physician having to determine what degree of survival is considered an acceptable quality of life for each patient, patients themselves would determine what quality they are willing to accept, what treatments they wish to have, and for how long. They may want to have “everything” done, including a tracheostomy, feeding tube, skilled nursing home placement, and so on, while others may choose not to continue long-term life sustaining measures like a ventilator and/or feeding tube. In this way, the decision-making process would be more likely to support the patient’s choice. The nursing code of ethics, and indeed the nursing profession, urges health care providers to advocate for increasing the voice each patient has in decisions about WLST.

The existence of a reliable database with easy POLST accessibility could provide important directives for a comatose patient’s medical team and family to use in conjunction with the usual care and prognostication tools available at the time. On its own, a physician’s foreboding prognosis may not provide sufficient guidance to meet the patient’s true wishes and may not align with the families’ vision of the patient’s will.  

The widespread use of the POLST could save families, physicians, and nurses from the struggle associated with such critical decision making. The Donor Network already has in place the means and the method for requesting and sharing information. The addition of POLST questions to the Donor Network form would be an efficient and effective method of memorializing patient wishes. This could be done while protecting and advocating for our patients and promoting the advance of our practice. As nurses, we owe it to our patients to reduce disparities in care and to promote the health and well-being of all individuals.


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