ETHICAL ISSUES IN NURSING HOME

Ethical issues in nursing home

Ethical issues in nursing home

Introduction

Although the ethics that apply to the treatment of patients in other settings apply to patients in the nursing home, some issues are brought more acutely into focus because of the setting and the concentration of patients with chronic and end-stage disease.

Discussions

The medical care of nursing home residents is demanding and challenging. Many nursing home patients are physically and psychologically frail, which makes treatment more complicated. The most common health conditions of older patients in nursing homes are dementia, heart disease, high blood pressure, arthritis, and stroke. Other common problems include infections, urinary incontinence, falls, fainting, depression, malnutrition, and pressure ulcers.

Often, nursing home residents have more than one medical condition. Multiple conditions often mean multiple medications. Unfortunately, multiple medications increase the chances of having a bad reaction to a medication as well as other medical complications. Family members often are not prepared for these things to happen. Instead, complications tend to make people resist any treatment, which may actually end up decreasing the quality of life and independence of the resident.

The overall clinical care and the way specific problems are managed must be individualized for each patient. The approach can vary enormously from one person to another, ranging from measures that increase the patient's comfort to numerous diagnostic tests and treatment. Diagnostic issues are another complicating factor. Many older patients have symptoms that are subtle or not typical, making diagnosis difficult. In addition, many patients have mental impairment, and the strict regulatory (government) requirements in these situations further complicate medical decisions.

In addition to clinical care, health care providers must be sensitive to the complex legal and ethical issues that can arise. For example, think about a frail nursing home resident who requires tube feeding. Some of the many considerations include the following:

evaluation of the risks and benefits of tube feeding

evaluation of the underlying illness

the value system of the patient and the family

the resources available in the nursing home

staff acceptance of tube feeding

the need of the patient's family for specific educational, psychological, and social support

Regardless of these difficulties—or perhaps because of—the relationships that develop between patients, families, physicians, other health care providers, and staff in the nursing home are among the most rewarding. Good practice skill and technical practice knowledge are very important to obviate an ethical issue (Conrad & Joseph, 1991; Joseph, 1985), and it is tempting to explore the details of this case and the surrounding practice issues further. The purpose of this analysis, however, is to raise the issue to an ethical level rather than prioritizing around practice interventions. The technical aspects of practice are oriented to the effective accomplishment of the tasks of assessment, intervention, termination, and evaluation or the measurable outcome of an intervention, whereas the ethical aspects of practice are oriented to helping in accord with moral standards of professional conduct (Conrad & Joseph, 1991, p. 6). Joseph (1985) points out that ethical skills add to decision-making ability and client service. The central dilemma of this case is responsibility to ...