Bioethics for clinicians: 11. Euthanasia and assisted suicide

Euthanasia and assisted suicide involve taking deliberate action to end or assist in ending the life of another person on compassionate grounds. There is considerable disagreement about the acceptability of these acts and about whether they are ethically distinct from decisions to forgo life-sustaining treatment. Euthanasia and assisted suicide are punishable offences under Canadian criminal law, despite increasing public pressure for a more permissive policy. Some Canadian physicians would be willing to practise euthanasia and assisted suicide if these acts were legal. In practice, physicians must differentiate between respecting competent decisions to forgo treatment, providing appropriate palliative care, and acceeding to a request for euthanasia or assisted suicide. Physicians who believe that euthanasia and assisted suicide should be legally accepted in Canada should pursue their convictions only through legal and democratic means.     

Nursing practice in Canada: the influence of current and proposed legislation

Nursing practice in Canada is regulated by separate acts in each of the 10 provinces and two territories. These acts grant self-governance to the nursing profession, define a scope of practice, and establish mechanisms for registration and quality assurance. The Canada Health Act 1984, the Agreement on Internal Trade (1994) between provinces, and the North American Free Trade Agreement have potentially great effects on Canadian nursing by altering the regulation of professionals within the various jurisdictions.     

Usefulness of ultrasound in Sudeck''s atrophy of the foot

A study was carried out to evaluate burn nurses' attitudes toward do-not-resuscitate (DNR) orders. Questionnaires were submitted to 57 staff members, 52 of whom responded. Seventy-five percent of those responding ranged in age from 30 to 49 years. Seventy-one percent were registered nurses or licensed practical nurses. Sixty-five percent of the respondents had been in health care for more than 10 years; 25% had been in burn care for more than 10 years. Fifty percent were Protestants. Thirty-seven percent of the total described themselves as very religious. Ninety-four percent of respondents felt that DNR orders are sometimes appropriate. Eighty-eight percent felt that DNR decisions should not be made solely by the physician. Ninety-five percent felt that input from patients, family members, or both is essential. Having formal ethics committees make such decisions was opposed by 75% of the respondents. Fifty-six percent felt nurses should be involved in such decisions and 21% opposed such involvement. There was considerable uncertainty, disagreement, or both about whether a DNR order should include stopping all medical treatment, ventilators, intravenous fluids, gastric feedings, and medication. The study indicated statistically significant support for the view that DNR orders are appropriate in some cases. Which patients should be given DNR status and who should make the decision about writing DNR orders were more controversial questions.     

Private practice: a choice, but what challenges!

Recent changes in the Canadian health care system are having an impact on the way health care services are delivered. As a result, opportunities are opening up for a whole new generation of autonomous and independent nurses who choose to work directly with clients in a private practice setting. In part one of this two-part article, the author describes the main responsibilities of the nurse entrepreneur. Stressed are the areas of competency and the entrepreneurial spirit required. Administrative, professional, legal and fiscal aspects of independent practice are also outlined. Part two of the article focuses on the ethical responsibilities of the nurse entrepreneur and the regulations concerning fees, publicity, insurance, and office and file management. The author recommends keeping current on new developments and establishing a process whereby clients can evaluate the quality of care they receive.     

Advance directives and advocacy in end-of-life decisions

This article examines the issue of advocacy for all adults in end-of-life decisions to help enhance the role of health care providers as partners in decision making. The ethical issues of death and dying are of particular concern for the elderly. Conflicts may prevent providers and nurses from creating a good dying experience for patients and family. Among the many issues associated with end-of-life decision making are futility, autonomy, and quality of life, a "good death," advance directives, family distress, and the culture of medicine. To overcome related barriers, involved health care providers can promote advocacy by offering choices in end-of-life care and providing an environment of listening and communication. Initiating and maintaining dialogue on this difficult subject will provide better care to patients and families.     

Health nurses: attitudes towards treating AIDS patients

Many nurses working in hospitals, especially in the wards, as well as nurses in community clinics have been involved in treating AIDS sufferers. In spite of clear and widespread information available to professionals, strong apprehensions still exist as to the contagious nature of the disease. A survey was carried out in order to assess the attitudes of nurses in this regard. Participants were drawn from the nursing profession, all were Registered Nurses (R.N.) The survey was carried out in the centre of the country and involved 137 participants, 69 of whom were hospital nurses and 68 community health nurses. Their average age was 43 years with an average professional experience of 10 years. A questionnaire was issued containing 24 closed questions, based on professional knowledge, clinical experience, professional literature, and attitudes towards treatment, as well as obligations involving information to family members and other institutions and commitment to HIV patients.     

The disaster preparedness concerning personnel at the hospitals in the Disaster Preparedness Region II: Viborg, Ringkj?bing and Aarhus counties

The aim of this investigation was to describe the disaster preparedness concerning hospital staff members in Viborg, Ringkj?bing and Arhus county, and to describe the outcome of the disaster medicine-courses given in the region--in theory as well as practice. In the region a questionnaire was sent to the chief doctor and chief nurse for the involved departments, and a personal questionnaire was sent to all the doctors and nurses in the region, who had participated in one or more courses in disaster medicine during the period 1990-1995. Of the total number of doctors at the involved departments, 7% of the residents, 29% of the senior residents and 56% of the consultants had taken a course in disaster medicine, as had 33% of the nurses. Only 15% had taken more than one course, and as few as 2% had had a follow-up course to the primary one given in the region. Forty-one percent had used their acquired knowledge either in theory or practice: 55% for educational purposes, 11% for disaster planning and 12% for buying equipment for the hospital. In general an easier access to follow-up is desired, and there seems to be a need to give more consideration to the priorities of the individual departments concerning the selection of participants to the courses in disaster medicine.     

Differentiated levels of nursing work force demand

In addition to reviewing the literature about the extent to which basic nursing education is related to actual nursing practice, this article investigates the extent to which the relationship between nursing practice, education, and experience varies across specific health care settings. The literature presented no consistent or systematic association between type and amount of previous nursing experience and current nursing practice. However, the literature generally provided evidence of a consistent and systematic association between baccalaureate preparation and level of registered nurse (RN) practice. The review of practice and organizational differences across the hospital, nursing home, and ambulatory care sectors suggests that baccalaureate-prepared RNs in hospitals may have a more strongly differentiated role relative to those in nursing homes and ambulatory settings. If baccalaureate-prepared nurses continue to be perceived as capable of more complex and independent practice, and if employers believe that they can increase revenues by increasing the quality of nursing care or can save money by shifting to RNs some responsibilities now held by more costly personnel (such as physicians), then demand for baccalaureate-prepared nurses may increase.     

Chiral separations by capillary electrophoresis in process chemistry

BACKGROUND: Conducting research in clinical settings can be problematic for many nurses in practice due to lack of experience and support. METHOD: Research collaboration between clinical nurse specialists and staff nurses in clinical settings can promote development of their research process skills. RESULTS: Strategies identified can be applied by clinical nurse specialists involved in continuing education and staff development in clinical practice through further research development. CONCLUSION: Collaboration among clinical nurse specialists and staff nurses provides a unique and strong link that transcends degrees and roles to make substantial contributions to professional nursing practice.     

Déontologie et éthique: La pertinence pour le Québec du code Canadien d'éthique pour les psychologues.

The duties and responsibilities of psychologists practicing in Quebec are defined by the province's Deontology Code for Psychologists (Code de déontologie des psychologues). This article examines the differences between the Canadian Code of Ethics for Psychologists and the provincial code, and considers whether the Canadian Code could play an important role in the training of future psychologists in Quebec, while serving as an essential tool for the practice of the profession in the province. A comparison of the two codes shows certain limitations in the Quebec Code concerning the professional conduct of psychologists, especially in complex situations involving conflicts of principles, values, standards, rights or responsibilities. Closer examination also indicates that the Canadian Code of Ethics for Psychologists represents a reference framework that could overcome these difficulties. The author discusses the implications of this conclusion for the training of future psychologists and the practice of the profession in Quebec and offers recommendations. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

New technology, old issues: Demonstrating the relevance of the Canadian Code of Ethics for Psychologists to the ever-sharper cutting edge of technology.

New technology brings with it new opportunities for the practice of our profession. However, this technology is also a double-edged sword in that it can also cause problems for our profession and those we serve. The Canadian Code of Ethics for Psychologists (3rd edition) provides a foundation for approaching the issues that can arise in its use. It is argued that psychologists need not wait for specific rules and guidelines regarding the ethical use of new technologies; rather, psychologists can utilize the Canadian Code of Ethics for Psychologists immediately to address many of the issues involved. There is a wide range of areas in which ethical issues can arise. The focus in this paper is on three specific examples (online personal information accessibility, web-based advertising, and electronic data storage). These examples illustrate both the ethical issues involved and demonstrate the potential for how the Code can be used to think through and manage or resolve the issues. After a discussion of the three examples, the ongoing relevance of the Code to meeting the ethical challenges of continuously evolving technologies is discussed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Co-amplification of nuclear pseudogenes and assessment of heteroplasmy of mitochondrial DNA mutations

As nurses begin to develop the sensitivities and skills necessary to preserve the integrity of clinical care and professional life, they must recognize the legitimacy of their perspectives and the value and consequences they have for the well-being of patient and family care. Nurses have much to contribute to the development of ethical practice environments for patients, families, multidisciplinary team members, and themselves. The frenzied, and at times anesthetized, culture of clinical settings can mitigate against the kind of deliberate reflection that is necessary if nurses are to act with ethical integrity. Knowing the rules of the road for end-of-life care and being attentive to common warning signs and addressing them proactively, enables nurses to provide patients and families with the highest quality care at the end of life.     

Managing occupational HIV exposures: a Canadian study

The findings reported in this paper are part of a larger study that explored how nurses cope with the risk of acquiring HIV infection while caring for persons with AIDS (PWAs). The data were collected through in-depth interviews with 13 nurses who cared for PWAs in a large Western Canadian hospital. Seven of these nurses perceived that they had been exposed to HIV-infected blood or body fluids. This paper describes how these seven nurses coped with actual exposures to HIV-infected blood or body fluids. Data were analyzed using the methodology of grounded theory. Nurses' coping efforts after exposure were grouped into four categories: minimizing the effect of exposures, reducing a sense of vulnerability, selective disclosure to others, and assigning meaning. Nurses minimized the physical effects of exposure through measures such as 'bleeding' the needlestick injury and immersing the affected area in bleach solution. Nurses reduced their sense of vulnerability by assessing the possibility of harm, avoiding situations that aroused fear, and confronting the decision for HIV testing. Nurses limited their disclosures to co-workers to avoid rejection and to preserve professional self-esteem. Disclousre to significant others was influenced primarily by the support nurses perceived they would receive. Finally, nurses attempted to assign meaning to the exposure by determining why the event occurred and by evaluating the implications it has had on their lives. The article concludes with implications for nursing practice.     

Bioethics and Canadian dentistry

Formal ethical reflection and analysis have become expected components of clinical decision making for all health professionals. The implicit acceptance of professional ethics as the sole determinant of "the right and the good" has been replaced by an expectation for more broadly-based understanding of ethical issues. Dentists, like physicians, must be clear about professional ethics and competent in interdisciplinary and interprofessional discussions of the right and good. Modern bioethics is providing approaches to these issues to help practitioners make ethical clinical decisions. These approaches may not be appropriate for dentistry, especially as practised in Canada. Clearly, there are fundamental questions concerning dentistry as a profession, patient-dentist interactions and dental health that must be addressed to form a basis for an ethic relevant to professional practice. The answers to these questions have profound implications for the initial and continuing education of Canadian dentists and for dentistry itself. Some possible starting points for a truly Canadian ethic for dentistry are suggested from a non-dentist, physician ethicist.     

Clinical nurse specialists in California: who claims the title?

State nursing practice acts granting legal authority to advanced practice nurses vary widely, with many states not recognizing clinical nurse specialists (CNSs). This survey identified characteristics of registered nurses claiming the CNS title in California. A literature-based survey tool was designed, piloted, and distributed to 209,846 nurses in California, with instructions to return the survey if the recipient self-identified as a CNS. Among the 1061 respondents, 65% were prepared with a Master's in Nursing. Most CNSs practiced in hospitals, and patients were the most frequently listed clients. CNSs overwhelmingly identified their primary role as clinical expert. Major barriers to practice included lack of public recognition and legal recognition in nursing practice acts. Significant differences were found in most characteristics between graduate-prepared and nongraduate-prepared CNSs. Variability in practice and educational preparation is not only potentially confusing to other healthcare providers and the public, but it may not serve the best interests of CNS clients.     

Information retrieval patterns and needs among practicing general surgeons: a statewide experience

Information retrieval has progressed from a reliance on traditional print sources to the modern era of computer databases and online networks. Surgeons, many from remote areas not served by professional medical libraries, must develop and maintain skills in information retrieval and management in both electronic and standard formats. One hundred thirty-three New Mexico general surgeons were surveyed to identify their information-seeking patterns in five areas: retrieval purposes, retrieval sources, barriers to access, techniques used, and continuing education needs. Ninety-nine (74.4%) surgeons responded to the survey. Ninety-five percent utilize professional meetings, the medical literature, and physician colleagues as information sources. Only 17% utilize the outreach services of the state's only medical school library. Common retrieval barriers were practice demands (71%), isolation from medical schools (30%), computer illiteracy (28%), and rural environment (25%). Continuing education topics related to information management would be valuable to 61% of the surgeons. Sixty-nine percent believe their current ability to access biomedical information is adequate, despite most frequently accessing their personal libraries for information related to decision-making or patient management. These data suggest that, despite significant information needs, surgeons have not embraced newer forms of information retrieval. It is imperative that surgeons acquire and maintain modern information retrieval skills as a means of remaining up-to-date in their profession. Professional surgical organizations and medical librarians should collaborate on these continuing education ventures.     

Ethics training in Canadian graduate schools of psychology.

Evaluated the extent and nature of ethics training in 27 Canadian graduate schools of psychology by means of a questionnaire sent to the schools that asked questions on the nature of graduate programs, the nature of graduate programs and of graduate employment, the content areas, and views on whether and how ethics should be taught. It was found that many graduates from nonclinical programs obtain clinical employment, and that clinical students are more likely to receive some ethics training than are nonclinical. In view of the variable and often minimal approaches to ethics in some institutions, it is unsafe to assume that graduates generally have knowledge and practice in dealing with ethical issues. In order to avoid potential harm to the public and to the profession of psychology, it is recommended that professional associations promote continuing education programs and that graduate schools increase their commitment to teaching ethics and developing effective teaching models. (20 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Exploring the potential of problem-based learning in nurse education

Despite the increased attention that problem-based learning has received as an appropriate pedagogical technique for educating adults for professional practice, reports that evaluate the process are rare and usually relate to professions other than nursing. A study was undertaken in order to discover the graduates' own perceptions of a problem-based learning programme and its effectiveness in preparing them for the reality of their chosen profession. Twelve practising graduate nurses who had completed the programme were interviewed according to the ethnographic method. Three categories were identified from the data: 'and all of a sudden...', which describes the transition from PBL student to staff nurse; 'not an unthinking assistant', where the characteristics that the PBL graduates believe make them different from traditionally trained nurses are described; and 'the buck stops here', which describes the sense of personal responsibility that the graduates experience in terms of their learning and actions.     

Caring

Many nurse scientists consider caring to be the core concept of nursing practice. This article describes the caring process that occurs when a nurse and a client interact in a nursing care situation. This interactional process has five integrating phases: co-presence, experience-sharing, caring acts, caring-perception, and mutual care-receiving. The authors provide a specific example that illustrates this caring process. The difficulties inherent in the caring process relate to one, or a combination of, three factors: the nurse, the client, and/or the circumstances. Nurses must be cognizant of the client's expression of subtle clues that indicate the need for caring. They also need to learn to recognize their own personal signals that might prevent them from engaging in the caring process. For caring, in its full context, can only occur when nurses know how to care for themselves. Nurses face unpredictability and challenges in their practice on a daily basis. In order to promote caring they must learn to promote an environment that nurtures this process. The authors discuss the essential characteristics of a favorable caring environment and present the conditions that can enhance quality nursing. The challenges that caring nurses face are counterbalanced by the value they attribute to this basic human need and the profound human benefits that caring brings.