Ethics Exam #3 - Behavioral Control and Truth Telling/Medical Errors and Caring for Unhoused People

Physical effects of restraint use

1. Increased BP
2. Increased adrenal steroids
3. Chronic stress syndromes
4. Ulcers
5. Depression of immune system
6. Impairment of memory
7. Irreversible nerve cell damage

Psychological effects of restraint use

1. Anger
2. Loss of independence
3. Abandonment
4. Psychological distress
5. Fear (general) of fire and inability to escape
6. Withdraw and regress to a state of learned helplessness
7. Degradation
8. Loss of dignity
9. Loss of control

Other effects of restraint use

1. Serious accidents
2. Skin breakdown
3. Incontinence
4. Decreased mobility
5. Death by asphyxiation
6. Functional decline
7. Increased pulmonary infections
8. Circulatory impairment
9. Vicious cycle
10. Dehydration
11. Increased complication
12. Increased LOS
13. Increased NH placement
14. Mortality

Reasons for restraint use

1. Safety
2. Prevent self harm
3. Behavioral control
4. Fall prevention
5. Wandering prevention
6. Improved positioning
7. Protection of medical devices
8. Confusion
9. Combative
10. Resisting care

Ethics of Restraints

Duty to protect the patient from harm vs. duty to protect the patient's dignity and autonomy

Reasons against restraint use

1. Utilitarianism - do more good letting the patient go and preventing complications
2. Deontology - nurses have a duty to promote autonomy

Factors associated with failure to reduce restraint use

1. Failure to appreciate dangers and destructiveness of stress
2. Lack of comprehension of the paradigm shift that is necessary to achieve restraint free care
3. Thought to be required for clinical management
4. Lack of knowledge of alternatives
5. Disbelief that it is possible to reduce PRU
6. Peer pressure
7. Liability if patient injury occurs
8. Reconcile safety with autonomy

Adherence

1. Patient centered
2. Clinical patient collaboration
3. Non-judgmental
4. More about partnership
5. Activities are negotiated
6. Rules matched to lifestyle
7. Resistance provides information for adaptation

Compliance

1. Clinician oriented
2. One way relationship with a provider
3. Information dictated
4. Patient obedience
5. Persuade
6. Resistance not tolerated
7. Often implied judgment toward the patient

Adherence to Therapy

1. Agree on the problem
2. Negotiate reasonable goals and generate options
3. Decide on a mutual regimen
4. screen for readiness

Ethical implications of adherence

1. 50% rule - only 50% of patients leave an office visit understanding what they were told by the physician
2. When physicians asked patients to restate the physician's instructions, the patient responded incorrectly 47% of the time
3. 50% of the patients when asked to state how they were supposed to take a medication, did not understand how the physician had prescribed the medication

Ethical dilemma in applying strategies to prevent falls in elderly patients

Autonomy and beneficence vs nonmaleficence

Medical error

1. Failure of a planned action to be completed as intended
2. Use of a wrong plan to achieve an aim

Adverse event

1. Injury that results from medical care
2. Not a part of the natural disease process

Patient's/family member's expectations (truth telling/medical errors)

1. Confession - full disclosure to the patient
2. Repentance - apologize and what will be done to prevent recurrence
3. Forgiveness - physicians need to forgive themselves so that learning from the incident and healing can begin (Foundation laid for possible future patient forgiveness of the physician)

Blame free reporting for medical/nursing errors

Freedom to report without the fear of repercussions

Second victim phenomenon

1. the suffering of caregivers in the face of a serious medical error is called the second victim phenomenon
2. In most healthcare settings, caregivers have no one they can turn to for support or guidance in the midst of an unanticipated mistake
3. results in silence for the caregiverr

Factors that increase the risk for medical errors

1. Understaffed units
2. Under qualified nurses
3. Long shift hours
4. Inadequate time available for proper nursing care
5. Failure to follow requirements for continuing education
6. Personal life interfering with professional life
7. Too stressed to think clearly
8. Take on to large of an assignment
9. Show up to work impaired r/t alcohol or drug use

Who is affected by homelessness?

anyone

Strategies for caring for people who are unhoused

Advocate for them, set up programs to help them, meet up with them