Patient autonomy, advocacy and the critical care nurse
Shreedevi Balachandran

Ethics have always been an integral part of nursing on a daily basis. Exposure to frequent moral and ethical conflicts may affect the nurse, leading to burnout or resignation.

Nursing in general has defined its own code of ethics which spells out the principles of right and wrong conduct as well as providing standards for professional behaviour, so as to protect the interests of the public.

Countries like the USA and the UK have published codes of ethics for their nurse practitioners based on the document of the International Council of Nurses’ Code For Nurses, 1993. In the US, the Critical Care Nurses Association (CCNA) has further specified this Code for the use of critical care nurses. However, in India, to my knowledge, there has yet been no effort to separately document a code of ethics. Some textbooks describe four ethical principles; others describe six. The four usually mentioned are the principles of beneficence, non-maleficence, fidelity and justice. To these have been added the principles of veracity and autonomy.

Here, I would like to highlight the concepts of patient autonomy and nurse advocacy. These are current topics of debate in nursing circles the world over.

The United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) was established by an act of Parliament in 1983 and has effectively replaced nine other statutory or training bodies which had existed. In 1992, the legislation was amended in both the House of Commons and the House of Lords.

The UKCC which published the Code of Professional Conduct in 1992, added an additional chapter in 1996 called Patient Advocacy and Autonomy. The UKCC Guidelines for Professional Practice, 1996, read as follows:

As a registered nurse, midwife or health visitor, you are personally accountable for your practice and in the exercise of your professional accountability, must…

Clause I…act always in such a manner as to promote and safeguard the interest and well being of patients and clients;(advocacy)

Clause V…work in an open and cooperative manner with patients, clients and their families, foster their independence and recognise and respect their involvement in the planning and delivery of care.(autonomy)

The question that arises immediately is, in a medicine-dominated health care system as in ours, can nurses stand up for patient autonomy and advocacy? Do we understand the implications of these terms?

Nursing and patient autonomy

In health care, autonomy can be viewed as the freedom to make decisions about one’s own body without the coercion or interference of others. Autonomy is freedom of choice or self-determination, a basic human right. It can be experienced in all human life events.

According to the UKCC, autonomy implies that that one should respect patients’ and clients’ choices concerning their own lives. Here it becomes imperative for nurses and other health care professionals to respect the values, thoughts and actions of patients and not let their own values or morals influence treatment decisions.

An example of health care professionals allowing such biases to creep into their treatment decisions is seen when HIV positive patients are isolated for no reason and offered minimal treatment on the basis of their HIV status.

Another case in point is the conflict between the values of the patient and those of health care professionals while dealing with life-sustaining matters in critical care. In critical care areas, for patient autonomy to be maintained, patient decisions regarding treatment such as resuscitation must be supported.

The critical care nurse is often ‘caught in the middle’ in ethical situations. Promoting autonomous decision-making is one of those situations. As the nurse works closely with patients and their families to promote autonomous decision making, another crucial element becomes clear: patients and their families must have all information about a given situation to make the decision that is best for them. (For example, in the case of a kidney transplant, they must know the chances of rejection, the effects of immunosuppressive drugs, the cost of these drugs, the meaning of brain death, details of organ donations and so on.) Not only should they be given all this information, they must also have a clear understanding of what was presented.

This is where the nurse is an important patient advocate, providing more information, clarifying points, reinforcing information and providing support during the process of information giving.

Nurse advocacy

Advocacy, according to the Oxford dictionary is ‘one who pleads or speaks for another’. It has been claimed that advocacy is a means of transferring power back to the patient.

The nurse who has truly cultivated the skill of empathy and who is in frequent personal interaction with the patient may be able to interpret the patient’s needs to others and act as a go-between when other health care professionals appear, to the patient, to be unapproachable. This may also require the nurse to explain to the patient the possible alternative lines of treatment and ensure that the patient is fully aware of the implications before consent for treatment is given. This does not absolve other health care professionals from their responsibility, but it does place the nurse in a special position of responsibility by virtue of her close and continuing relationship with the patient.

Advocacy for nurses includes advising, acting as a liaison, sharing information, making recommendations, and assisting patients to make informed choices Advocacy also involves providing support if the patient refuses care or withdraws consent.

Advocacy of nurses is documented to have its own risks, in the following four areas:

• Conflicts between nurses and others involved in the care of the patient (when there are varying interpretations of what is the best interest).
• Risks can be more personal and directed at nurses’ professional positions (damage to reputation).
• Risks can be to the personal integrity (constant dilemma between professional duty and personal convictions).
• Risks of personal suffering that nurses experience through the care of patients (if nurses are unable to relieve the patient’s suffering, they believe that the advocacy was inadequate).

Conclusion

Autonomy is a part of the values of life. There is no such thing as complete autonomy, only maximal autonomy. This involves a person being autonomous in all circumstances. It is important for nurses and other health care professionals to remember that patients have a right to their own bodies and lives. Hence, patient autonomy becomes central to health care.

Seedhouse states, “Respecting autonomy is bedeviled with controversy. The only strong reason to not respect autonomy is when it will harm one or more people. Beyond this, the issue must be resolved by personal judgement and appropriate moral reasoning.”

The view has been expressed that the nurse advocate allows the patient to make the decision, the nurse then abides by it and defends the patient’s right to make it. However, nurses may have to live with moral uncertainties, which accompany their attempts to act in the best interests of patients when they carry out their duty to care.

Suggested reading:

Thelan et al: Critical Care Nursing, 2nd edition, Mosby Pub, St Louis, 1996.

Tingle John and Cribb Alan: Nursing Law and Ethics, Blackwell Science, Oxford, 1995.

United Kingdom Central Council for nursing, midwifery and health visiting: Scope of Professional Practice, 1996.

Sheldon Sally and Thomson Michael eds: Feminist Perspectives on Health Care Law, Cavendish Publishing Limited, Sydney, 1998.

Burnard P, Chapman C: Professional and Ethical Issues in Nursing: The Code of Professional Conduct, Scutari Press, London, 1994.

Perry A, Jolley M: Nursing: A Knowledge base for Practice, Edward Arnold, London, 1992.

Chinn P, Kramer M. Theory and Nursing, Mosby Year Book, 1991.

Seedhouse D: Ethics, The Heart of Health Care, John Wiley and Sons, New York, 1988.

Meila Kath M: Everyday Nursing Ethics, Macmillan Press Ltd., London.

Henry C, Pasley G: Health and Nursing Studies, Quey Publishing, Lancaster, 1990. 

The papers by Dr George John, Dr Sebastian and Ms Balachandran were presented at a workshop at the Seventh National Critical Care Congress CCCON 2001 held in Bangalore from January 2 to 7, 2001.