6.4 Ethics Committees
Open Resources for Nursing (Open RN)
In addition to using established frameworks to resolve ethical dilemmas, nurses can also consult their organization’s ethics committee for ethical guidance in the workplace. Ethics committees are typically composed of interdisciplinary team members such as physicians, nurses, allied health professionals, administrators, social workers, and clergy to problem-solve ethical dilemmas. See Figure 6.8[1] for an illustration of an ethics committee. Hospital ethics committees were created in response to legal controversies regarding the refusal of life-sustaining treatment, such as the Karen Quinlan case.[2] Read more about the Karen Quinlan case and controversies surrounding life-sustaining treatment in the “Legal Implications” chapter.
After the passage of the Patient Self-Determination Act in 1991, all health care institutions receiving Medicare or Medicaid funding are required to form ethics committees. The Joint Commission (TJC) also requires organizations to have a formalized mechanism of dealing with ethical issues. Nurses should be aware of the process for requesting guidance and support from ethics committees at their workplace for ethical issues affecting patients or staff.[3]
Institutional Review Boards and Ethical Research
Other types of ethics committees have been formed to address the ethics of medical research on patients. Historically, there are examples of medical research causing harm to patients. For example, an infamous research study called the “Tuskegee Study” raised concern regarding ethical issues in research such as informed consent, paternalism, maleficence, truth-telling, and justice.
In 1932 the Tuskegee Study began a 40-year study looking at the long-term progression of syphilis. Over 600 Black men were told they were receiving free medical care, but researchers only treated men diagnosed with syphilis with aspirin, even after it was discovered that penicillin was a highly effective treatment for the disease. The institute allowed the study to go on, even when men developed long-stage neurological symptoms of the disease and some wives and children became infected with syphilis. In 1972 these consequences of the Tuskegee Study were leaked to the media and public outrage caused the study to shut down.[4]
Potential harm to patients participating in research studies like the Tuskegee Study was rationalized based on the utilitarian view that potential harm to individuals was outweighed by the benefit of new scientific knowledge resulting in greater good for society. As a result of public outrage over ethical concerns related to medical research, Congress recognized that an independent mechanism was needed to protect research subjects. In 1974 regulations were established requiring research with human subjects to undergo review by an institutional review board (IRB) to ensure it meets ethical criteria. An IRB is group that has been formally designated to review and monitor biomedical research involving human subjects.[5] The IRB review ensures the following criteria are met when research is performed:
- The benefits of the research study outweigh the potential risks.
- Individuals’ participation in the research is voluntary.
- Informed consent is obtained from research participants who have the ability to decline participation.
- Participants are aware of the potential risks of participating in the research.[6]
Media Attributions
- Ethics Committee
- “Ethics Committee.png” by Meredith Pomietlo for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
- Annas, G., & Grodin, M. (2016). Hospital ethics committees, consultants, and courts. AMA Journal of Ethics, 18(5), 554-559. https://journalofethics.ama-assn.org/article/hospital-ethics-committees-consultants-and-courts/2016-05 ↵
- Aulisio, M. (2016). Why did hospital ethics committees emerge in the US? AMA Journal of Ethics, 18(5), 546-553. https://journalofethics.ama-assn.org/article/why-did-hospital-ethics-committees-emerge-us/2016-05 ↵
- Centers for Disease Control and Prevention. (2021, April 22). The Tuskegee timeline. https://www.cdc.gov/tuskegee/timeline.htm ↵
- U.S. Food & Drug Administration. (2019, September 11). Institutional review boards (IRBs) and protection of human subjects in clinical trials. U.S. Department of Health & Human Services. https://www.fda.gov/about-fda/center-drug-evaluation-and-research-cder/institutional-review-boards-irbs-and-protection-human-subjects-clinical-trials ↵
- Annas, G., & Grodin, M. (2016). Hospital ethics committees, consultants, and courts. AMA Journal of Ethics, 18(5), 554-559. https://journalofethics.ama-assn.org/article/hospital-ethics-committees-consultants-and-courts/2016-05 ↵
- CrashCourse. (2018, April 18). Henrietta Lacks, the Tuskegee experiment, and ethical data collection: Crash course statistics #1 [Video]. YouTube. All rights reserved. https://youtu.be/CzNANZnoiRs ↵
To promote safety for clients of all ages, nurses should be knowledgeable about safety risks according to age and developmental stages because the types and frequencies of accidents vary among age groups. Information from the Centers for Disease Control (CDC) regarding safety tips for each age group is summarized in the following subsections.[1]
Infants and Preschoolers
Drowning is the leading cause of death in children aged 1-3 years. Motor vehicle accidents, falls, choking, and accidental poisoning are also safety concerns for this age group. Infants and toddlers are curious, but they lack the judgement to recognize the dangers of their actions, so childproofing the home and providing adult supervision are essential for this developmental age group.[2] See Figure 5.7[3] for an image of an infant car seat used to protect infants in the event of a motor vehicle accident. Nurses help educate parents about the proper use, positioning, and installation of car seats.
School-Aged Children
In children aged 4-11, motor vehicle injuries are a major cause of unintentional injury, along with drowning and poisoning. This age group is more aware of dangers and limitations, but adult supervision is still important. The nurse should educate parents of school-aged children about safety seats, booster seats, or shoulder seat belts while riding in the car.[4]
Bicycle accidents are also a common concern in this age group. Many bike accidents involve the head or face because of the lack of helmet use. Nurses provide health teaching to school-aged children regarding bicycle safety and helmet use. See Figure 5.8[5] for an image of a girl wearing a bike helmet.
Because this age group is beginning to enjoy more independence, basic instructions and education on how to recognize and respond to potentially dangerous situations with strangers should also be provided. Parents should also be educated about the AMBER alert system that can be activated if a child is missing and believed to be kidnapped or in danger. This AMBER alert system uses the resources of law enforcement and the media to notify the public about a possible abduction or a missing child in danger.[6]
Nurses must also be aware of signs of maltreatment and child abuse because millions of children are affected each year. Child abuse includes physical, sexual, emotional abuse, and neglect. According to the American Academy of Child and Adolescent Psychiatry (AACAP), after abuse or violence, many children develop mental health problems, including depression and post-traumatic stress disorder. These children may also have serious medical problems, learning problems, and problems getting along with friends and family members. Every state has laws that require health care professionals to report suspected child abuse no matter what form this abuse takes.[7]
Adolescents
Motor vehicle accidents are the number one cause of death for adolescents. Teens aged 16-19 are three times more likely to be in a fatal crash than drivers older than age 20. Adolescent males are twice as likely to die in a motor vehicle accident than females of the same age. Texting while driving is a common cause of distracted driving and accidents in adolescents. Because much of an adolescent’s time is spent away from the home, it is difficult for parents to control many of the decisions that adolescents make. Nurses educate teenagers to use seat belts, obey speed limits, and never use a cell phone or text while driving.[8] See Figure 5.9[9] for an image reminding teenage drivers to not text and drive.
Traumatic brain injuries (TBI) may occur in this age group due to participation in sports and recreation-related activities. TBI results from a blow, jolt, or hit to the head that causes a disruption in blood function or flow to the brain. Nurses should always be alert for indications of a concussion when a sports injury has occurred. Signs of a concussion requiring immediate medical attention include the following:
- Headache, vomiting, balance problems, fatigue, or drowsiness
- A dazed and confused appearance or difficulty concentrating or remembering; confusion
- Emotional irritability, nervousness, or a change in personality
The CDC has comprehensive information and education materials for parents, coaches, players, and health care providers as part of their “Heads Up” program.[10]
Substance abuse is another significant concern in the adolescent population and includes substances such as tobacco, alcohol, illicit drugs, prescription medication, over-the-counter medications, and bath salts. The National Institutes of Health provides many resources for educating teens and their parents about substance abuse.[11]
Adults
Intimate partner violence and substance abuse are common safety issues in the adult population.
Intimate Partner Violence
Intimate partner violence (IPV) is widespread in the United States and is the most prevalent adult safety issue. Intimate partner violence includes physical or sexual violence, stalking, and psychological or coercive aggression by current or former intimate partners. Victims can be female or male, and sexual orientation can be heterosexual or LGBTQ+. The nurse is often the initial health care professional in contact with a victim of IPV. Prompt recognition of a potential or actual threat to client and staff safety is crucial. It is often the nurse’s assessment that plays an important role in identifying a client experiencing IPV. Compassion and understanding are important to show to this vulnerable population. Effective communication is necessary to help victims come forward and share their experiences of abuse. IPV is a complex issue, and the client may not initially consider leaving the abuser as an option. See Figure 5.10[12] for an image of a sign in a community demonstrating support against domestic violence.
See the following tools and resources to share with clients experiencing IPV. For example, the Danger Assessment Tool is a self-administered survey that is free to use and is available in several languages.[13] Nurses can refer clients experiencing IPV to the National Center on Domestic Violence, the Trauma and Mental Health database for resources,[14] and the National Domestic Violence Hotline for free, confidential support.[15] Most importantly, nurses should assist clients experiencing IPV to create a safety plan.
View the tools and resources available at these hyperlinks to share with individuals experiencing intimate partner violence:
Substance Abuse
Substance abuse is defined by the World Health Organization (WHO) as a maladaptive pattern of using alcohol and/or drugs despite it causing persistent social, occupational, psychological, or physical problems that can be physically hazardous. Substance abuse continues to be a safety issue that affects adults across all socioeconomic levels. In America over 450,000 people died between 1999 and 2018 as a result of an opioid overdose.[16] The abuse of prescription pain medication (such as oxycontin and fentanyl) and heroin is a national crisis that plagues social and economic welfare. Substance abuse not only affects an individual, but also causes harm to their family members. Early identification of substance abuse, rehabilitation interventions, and continued support are key for helping the individual, as well as their family members, in the recovery process. See Figure 5.11[17] for an image of a heroin needle found in a community setting.
Older Adults
According to the Centers for Disease Control and Prevention, falls and motor vehicle accidents are leading causes of injury in older adults. However, several other issues pose significant hazards for this population, such as fires, accidental overdosing on medications (due to poor eyesight and confusion), elder abuse, and financial exploitation.[18] In most reported cases of elder abuse, a caregiver or a person in trusted relationship is the perpetrator. For various reasons such as fear and disappointment, most of these cases go unreported. Abuse, including neglect and exploitation, is experienced by about 1 in 10 people aged 60 and older who live at home. From 2002 to 2016, more than 643,000 older adults were treated in the emergency department for nonfatal assaults and over 19,000 homicides occurred.[19] Read an example of an older adult experiencing financial exploitation in the following box.
Consider the story of John, a 92-year-old male who lost his wife over a year ago and has been lonely ever since. He lives alone in a large home in the country. John hired a repairman to fix his roof. The repairman befriended John, bringing him homemade cookies and pies and even running errands for him. The repairman often stayed for coffee, and the two of them spent time talking about fishing and gardening. The repairman convinced John to take out a reverse mortgage to pay for additional improvements on his home. Then, knowing John’s bank account numbers and login information, the repairman stole $250,000 that John received for his reverse mortgage.
Most victims of elder abuse are frequently seen in the emergency department several times before they are admitted to the hospital. Nurses must be alert to any indications of elder abuse, such as suspicious injuries or behaviors, and report suspected incidents to local adult protective services agencies. Commons signs of elder abuse or maltreatment include the following[20]:
- Bruises, cuts, burns, or broken bones that are unexplainable or suspiciously explained
- Malnourishment or weight loss
- Poor hygiene, an unkempt appearance, unclean clothing, or dirty, matted hair
- Foul odor from clothing or body
- Anxiety, depression, or confusion
- Unexplained transactions or loss of money
- Withdrawal from family members or friends
View additional resources related to elder abuse in the following box.
Additional resources for older adults suspected as being victims of elder abuse:
After exploring a patient’s chief complaint, their current and past medical histories are reviewed to obtain a full understanding of their “human response” to medical conditions and life processes. While obtaining this information, it is also helpful to determine their understanding of the condition and its associated treatment. If a patient has a prior medical diagnosis, but is unaware of what it means or does not understand the recommended treatment, they may not be following instructions intended. For example, a patient diagnosed with “high blood pressure” may erroneously think they only need to take their medications when they feel as if their blood pressure is high, instead of daily at the recommended doses.
Categories included in past medical history include current health, medications, childhood illnesses, chronic illnesses, acute illnesses, accidents, injuries, and obstetrical health for females. Medication reconciliation is a comparison of a list of current medications with a previous list and is completed at every hospitalization and clinic visit. Not all categories of current and past health histories apply to every patient, so only ask questions that are relevant to the patient you are interviewing. See Table 2.6[22] for suggested focused interview questions related to current and past medical history.
Table 2.6 Sample Focused Questions for Current and Past Health History
| Category | Focused Questions |
|---|---|
| Current health | What are your current goals for your health?
Are there any other issues affecting your current health or the ability to complete your daily activities? Tell me more. |
| Medications | What are your current medications, including prescriptions, over-the-counter medications, vitamins, and herbal supplements and why are you taking them (to establish the patient's understanding of their medications)?
Do you take your medications as prescribed? Note: If the response is “no” or “sometimes,” follow up with an open-ended question such as, “Tell me more about the reasons for not taking the medications as prescribed.” |
| Allergies | Do you have any allergies to medications, food, latex, or other items?
If yes, what is your reaction? |
| Childhood illnesses | Tell me about any significant childhood illnesses that you had. Do you recall what childhood vaccines you received?
When did they occur? Were you hospitalized? Did you experience any complications? |
| Chronic illnesses | Tell me about any chronic illnesses you currently have or have experienced (such as cancer, cardiac or respiratory issues, diabetes, or arthritis).
When were you diagnosed? Do you see a specialist for this chronic illness? If so, what is their name and location? How is this condition currently being treated? How has the chronic illness affected you? How do you cope with the illness? Have you experienced any complications or disability from this chronic illness? |
| Acute illnesses, surgeries, accidents, or injuries | Tell me about any acute illnesses or surgeries that you have experienced.
Have you had any accidents or injuries? Did you experience any complications? |
| Reproductive health | For Females: When was your last menstrual period? Have you ever been pregnant?
Are you pregnant now or is there any chance of being pregnant now? Tell me about your pregnancies. Were there any issues or complications? |
| Immunizations | If a patient’s vaccination record is not included in their record:
|
