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Family issues, safety top ethical concerns
Ability to provide quality care may be hindered
One of the most attractive aspects of hospice and other types of home health nursing is the constantly changing job; no two days are exactly alike. That same diversity also raises issues that hospital-based nurses don't face.
"The biggest difference between hospital care and home health care nursing is that I am inflicting my rules upon you in your home," points out Lucia Wocial, RN, CCNS, PhD, nurse ethicist at Clarian's Charles Warren Fairbanks Center for Medical Ethics in Indianapolis.
One example of a touchy situation is a home health nurse caring for a patient on the liver transplant list. "What do I do if it is clear that alcohol has been consumed in the house because there is an empty bottle on the table?" she asks. "A nurse won't want to tell on her patient, because a patient who is still drinking is no longer eligible for a liver transplant."
After deliberation and talking through the issue with someone, the nurse might decide to report only what she saw: The empty bottle. "In reality, the nurse did not see the patient drink, so it could have been consumed by someone else," she says. The importance of discussing issues in an ethics context is to help people avoid making decisions based on inaccurate information, incorrect perceptions, or untrue assumptions, she adds.
Most ethical issues for hospice and home health revolve around safety for the patient, the patient's family, and the employee, says Sigrid Fry-Revere, PhD, JD, medical ethicist and president of the Center for Ethical Solutions in Lovettsville, VA. A common concern when children are in the house with the patient is the children's access to medications, she says. There are times that families keep the medications out to make it easy for the patient or the caregiver, without thinking about the danger to children, she explains. "The nurse is a guest in the patient's home; so how far can she go when talking to family members about the danger of the medication?" she points out.
Unsanitary conditions for medications or for patients also raise questions for the home health nurse, who must decide if it is safe to leave a patient in a home with no water, no electricity, or no one to keep the home clean, says Fry-Revere. "Nurses have to ask themselves at what point does it become impossible to maintain the standard of care," she adds.
Safety of employees also can be a difficult issue for nurses. "Nurses want to take care of their patients, and they are reluctant to complain, but there are some circumstances that are dangerous for the employees," says Fry-Revere. "Aggressive dogs in the house, weakened or unstable flooring, or an intimidating family member can create difficult situations."
There are times, even when the family or patient initially might not agree, that care within a skilled nursing facility is the safest and best decision for the patient, says Fry-Revere. In those cases, talking about concerns with a third party can help the staff member figure out how to present the situation to a manager and to the family, she adds.
"One emerging issue that our home health ethics committee has discussed in recent months is emergency preparedness and surge capacity issues should care be diverted from hospitals to the home setting in response to a disaster or pandemic," says Leslie Kuhnel, MPA, clinical ethics officer for Alegent Health in Omaha, NE. "This discussion includes the ethical considerations related to the staff's duty to care in situations of increased personal risk," she adds.