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Chaper 25

© Jonesand
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Learning,
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Ethical
Legal
Issues
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Ryan Bratcher
James J. Farrell
Kathleen A. Stevens
Kevin
W. Vanderground
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Bartlett
Learning, LLC

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Learning Objectives

At the end of this chapter, the reader will be able to
• Use the American Nurses Association Code of Ethics and Interpretive Statements as a guide for

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LLC
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practice.
• Discuss how nurses apply ethical concepts
decision
making
in rehabilitation.
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OR
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• Describe why guardianship is important and when it should be considered in rehabilitation.
• Recognize different types of advance directives and relevance in rehabilitation. Explain key protections
within the Americans with Disabilities Act.

Key Concept and Terms

Advance directive
American Nurses Association
Code of Ethics
Americans with Disabilities Act
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(ADA)
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OR DISTRIBUTION
Autonomy
Beneficence
Bioethics

Capacity
Living will
Do not resuscitate (DNR)
Medical power of attorney
Guardian ad litem
Nonmaleficence
Guardian
Patient Self-Determination Act
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Guardianship
Psychiatric advance directive
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Individuals with Disabilities Act Reasonable accommodations
Informed consent
Veracity
Justice

Ethical issues have been known to cause distress among
Defining Ethics
nurses, resulting in decreased job satisfaction and inIn the course of daily life we make decisions as to the best
creased turnover intention (Hart, 2005). This is especially
or morally right action to take. How we make decisions
problematic when the©ethical
concern
has some
legal
Jones
& Bartlett
Learning,
LLC
© Jones & Bartlett Learning, LLC
is based on our values and beliefs as well as laws or rules
consequences. In some cases new laws have been created
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of society. Ethics is the branch of philosophy that deals
to provide guidance in response to ethical dilemmas.
with the values relating to human conduct and with
The two offer different ways of thinking about common
respect to the rightness or wrongness of certain actions
problems related to rights of individuals with a disability
and to the goodness and badness of motives and ends of
within our society. For this reason we address both ethi© Jones
& Bartlett
Learning,
LLC
Jones
&ofBartlett
Learning,
LLC
such actions. ©
These
values
human conduct
are based
cal and
legal issues
in this chapter.
The intent
is for the
on
shared
beliefs
within
a
society
or
culture.
Ethics
most
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reader to appreciate the basis for ethical decision making
commonly refers to the reasons for decisions about how
and utilize resources that can provide guidance in decione should act based on the shared values and beliefs of
sion making. For more details on ethics and models of
the group. Ethics refers not to a specific set of principles
ethical decision making for nurses, please see texts on
or rules but rather presents a way of guided thinking.
these
specific Learning,
topics.
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Bartlett
LLC
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& Bartlett Learning, LLC

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Professional Code of Conduct

387

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society there are values outlined in the U.S.
has provided
full disclosure,
verified understanding,

constitution that provide the foundation for our sociand allowed the individual to make a choice, supporting
ety. The guiding principles of ethical decision making
the competent person’s autonomy. Conflicts arise when
are autonomy, beneficence, justice, nonmaleficence and
before administering a medication the nurse assesses the
veracity (Masters-Farrell,
2007).
Autonomy
is
the
duty
patient does not have full or©adequate
to make
© Jones & Bartlett Learning, LLC
Jonesknowledge
& Bartlett
Learning, LLC
to allow the individual
rightSALE
to makeOR
his or
her own
a decision or is incompetent
to doFOR
so. SALE OR DISTRIBUTION
NOT
NOTthe
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decision. Conflicts arise when individuals or persons
The last ethical principle is justice. Justice is the
served make a decision that conflicts with that of the
duty to treat all fairly or act in a manner such that risks
healthcare team, such as refusing treatment or pursuand benefits are distributed equally. When healthcare
ing a discharge plan the team believes is unsafe. The
services depend on payer, decisions about type, frequency,
© Jones &
Bartlett
© Jones
& Bartlett
Learning,
individual’s
decision
mayLearning,
not be what LLC
the healthcare
and duration
of treatment
occur. Some
cliniciansLLC
quesNOT
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team prefers or recommends; however, the principle of
tion whether justice is being served. Some have argued
autonomy says that professionals must respect the decithat having paid more dollars to an insurance carrier that
sion made by the person served. Decision making can be
negotiates a more comprehensive benefits package than
problematic when the individual is unable due to illness,
the public payer is fair, whereas others see this as preferred
functional
level,
cognition,
language,
or
age
to
participate
treatment.
When Learning,
confronted with
an ethical dilemma,
© Jones & Bartlett Learning, LLC
© Jones
& Bartlett
LLC
in
the
decision-making
process,
so
a
surrogate
is
used
to
rarely
does
one
principle
alone
provide
adequate guidance
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execute decision making. This has been an important
for decision making. The best decisions occur when all
principle in several prominent court decisions and is
the principles are considered and applied to the thought
discussed later in this chapter.
process.

The value of human life and our responsibility as nurses to do
Models for Ethical Decision
Making
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good, promote health,
and FOR
serve asSALE
a patient OR
advocate
should
be the foundation for our practice.
Several models for ethical and moral decision making

have been developed by nurses. These include the threestep ACT model by Graham-Eason (1996) and the Savage
The second principle is beneficence, which is the
Model for©
Facilitating
Ethical
Decision
Making (Savage,
duty
to
do
good.
It
frequently
is
paired
with
nonma© Jones & Bartlett Learning, LLC
Jones &
Bartlett
Learning,
LLC&
Michalak,
1999).
These
models
have
several
commonalileficence,
which
is
the
duty
to
do
no
harm.
So
when
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ties. First, it is important to gather the facts and engage all
presented with a choice of treatment options, the nurse
stakeholders, including family, healthcare providers, and
is expected to elect to choose the option will do good and
the healthcare organization early on. Second, identify the
cause no harm. A conflict arises when a treatment with a
ethical principles that are the source of conflict, and,
high likelihood for success comes with exceptional risk.
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Learning,
LLC
©
Jones
& Bartlett
Learning,
finally,
discuss options
with keyLLC
stakeholders. Often, it
Should a nurse recommend a patient take a medication
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OR significant
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OR DISTRIBUTION
is helpful
to engage
the assistance of the organization’s
that poses
health hazards to affect a cure and
ethics committee to serve as a neutral facilitator in these
yet could be potentially lethal for the person? In this case
discussions. The cases mentioned here have all led to legal
the conflict for the nurse occurs in deciding between the
precedents or legislation designed to help guide future
potential for doing good and doing no harm.
decision making, especially©inJones
cases when
an individual
The principle©ofJones
veracity&refers
to theLearning,
duty to be LLC
Bartlett
& Bartlett
Learning, LLC
is not able to express their own healthcare wishes.
truthful and provide the person served with adequate
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information necessary to make an informed decision.
This principle is the foundation for informed consent
Professional Code of Conduct
in patient care and research studies. In the case of the
To provide guidance, many societies or professions have
medication that is beneficial but carries significant risk,
© Jones
& Bartlett
Learning,
© Jones
Learning,
formal written
codes&ofBartlett
conduct that
outline theLLC
values
the
importance
of truth telling
is key. TheLLC
clinician would
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OR
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of
the
group
and
expectations
of
those
that
belong
to
be expected to disclose the risks and benefits to the person
the group. The American Nurses Association Code of
in a manner that is understandable and in a language the
Ethics (2001) is the code of conduct that guides nursing
person can understand. Upon disclosing full information,
practice within the United States. In essence, the Code
if the person freely elects to take the medication, then no
of Ethics (American Nurses Association, 2001) defines
moral or ethical issue results. In this case the clinician

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388 Chaper 25 / Ethical and Legal Issues

© Jones & Bartlett Learning, LLC
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FOR SALE
OR code
DISTRIBUTION
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ethicalOR
obligations
and duties of individuals who have NOT
knowledgeable
of their
of ethics as well as those of

entered into and practice within the profession of nursother disciplines (Table 25.1).
ing. The Code is based on the shared belief that “nursing
Another potential source of conflict in the rehaencompasses the prevention of illness, the alleviation of
bilitation setting is consumer expectations and beliefs
suffering, and the protection,
promotion,
and restoration
set forth in regulatory requirements.
© Jones
& Bartlett
Learning,asLLC
© Jones In
& particular,
Bartlett Learning, LLC
of health in the care ofNOT
individuals,
groups
and
the Commission on Accreditation
of FOR
Rehabilitation
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FOR families,
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communities” (American Nurses Association, 2001, p.
cilities, a regulatory body for rehabilitation, expects the
5). All nurses are expected to be familiar with the Code
team to include and respect the decisions of the person
and act in accordance with the beliefs and values set
served throughout the rehabilitation process. When paforth in the Code.
tients and/or family members refuse healthcare provider
©the
Jones
& Bartlett
Learning,
LLC
© Jones
& Bartlett
Learning,
LLC
In
rehabilitation
setting,
nurses work
with colrecommendations
or treatments,
this can
pose a moral
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OR
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leagues from a variety of different disciplines as a member
dilemma for staff. A moral dilemma occurs when two
of the rehabilitation team. Each discipline has a unique
or more clear moral principles apply but they support
set of beliefs and values that underscore the philosophy
mutually inconsistent sources of action (Redman & Fry,
of the discipline. Each profession also has a code of ethics
1998). Case Study 25.1 describes how nurses at one facilthat
serves
to
guide
professionals
within
the
discipline.
ity addressed
a conflict
with a parent
over unsafe oral
© Jones & Bartlett Learning, LLC
© Jones
& Bartlett
Learning,
LLC
Although
many
disciplines
share
some
common
values
feeding
of
a
child.
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and beliefs related to the value of human life, respect for
Ethical conflicts can arise when two or more indithe humanness, and desires of the person seeking services
viduals on the rehabilitation team have different expecof the professional, there are also differences in relation to
tations of what is right or morally appropriate action.
delivery of services that can be a source of conflict (SavSavage et al. (2009) suggests guidelines for resolving team
©
Jones
&
Bartlett
Learning,
LLC
© care
Jones
& Bartlett
age, Parson, Zollman, & Kirschner 2009). For example, a
disagreements
regarding patient
during
nonemer- Learning, LLC
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OR DISTRIBUTION
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FOR
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nurse may believe it is important for a physical therapist
gent situations (Box 25.1).
to treat a patient. If the therapist determines there are no
Although many of these conflicts can be resolved
active goals that can be achieved with therapy services,
through respectful communication and guidance prothen according to the profession’s code of ethics it would
vided by the discipline’s code of conduct, some require
be unethical
for
the
therapist
to
treat
the
patient
and
more in-depth
discern appropriate
action
© Jones & Bartlett Learning, LLC
©discussion
Jones &toBartlett
Learning,
LLC
charge
for
services
delivered.
Team
members
should
be
to
be
taken.
It
may
be
helpful
to
seek
consultation
from
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Bartlett
Learning, LLC
© Jones & Bartlett Learning, LLC
25.1 Rehabilitation Disciplines’ Web Links to Code of Ethics
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Profession

Web Link

Physiatrist

http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/
principles-medical-ethics.shtml

Rehabilitation nurse
Physical therapy

http://nursingworld.org/ethics/code/protected_nwcoe629.htm

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http://www.apta.org/AM/Template.cfm?Section=Policies_and_Bylaws1&TEMPLATE=/CM/
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ContentDisplay.cfm&CONTENTID=73012

Occupational therapy

http://www.aota.org/Consumers/Ethics/39880.aspx

Speech-language
pathology

http://www.asha.org/docs/html/ET2010-00309.html

Pharmacy

http://www.uspharmd.com/pharmacist/pharmacist_oath_and_code_of_ethics

Therapeutic recreation

http://www.atra-online.com/displaycommon.cfm?an=1&subarticlenbr=41

Social work

http://www.naswdc.org/pubs/code/code.asp

& Bartletthttp://www.apa.org/ethics/code/index.aspx
Learning, LLC
© Jones & Bartlett Learning, LLC
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OR
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Respiratory therapy
http://www.aarc.org/resources/position_statements/ethics.html

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Dilemmas in Rehabilitation: Where Ethics and Legal Issues Come Together

389

The following case study is excerpted from Savage
provide nourishment via gastrostomy feedings during
(2005).
hospitalization; however, if the mother is present staff
An 11-year old
girl who &
is several
yearsLearning,
post–trau- LLC
would be able to secure a pureed
meal&soBartlett
the mother
© Jones
Bartlett
© Jones
Learning, LLC
matic brain injured is admitted to the rehabilitation
can feed the child. Seek consultation from experts in
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unit after hip surgery. She is nonambulatory, nonverbal,
pediatric feeding who can provide strategies to provide
and cortically blind. She has a gastrostomy tube in
adequate nourishment as the child’s needs change as
place; however, at home her mother feeds her pureed
the child matures. Finally, suggest other interventions
foods with a spoon or eye-dropper. It usually takes the
such as gentle rocking, skin massages, warm showers,
©mother
Jones
Bartlett
Learning,
LLC8 ounces of
© Jones
& Bartlett
Learning,
an &
hour
to feed her
daughter about
or play that
offer pleasure
to the child
but are LLC
safer
food. FOR
The mother
believes
her daughter has few pleaNOT
SALE
OR DISTRIBUTION
FOR
than oralNOT
feeding.
The SALE
ultimateOR
goalDISTRIBUTION
according to the
sures in life and that oral feeding, while risky, provides
consultant is to provide nourishment while maintainsome degree of pleasure for her daughter. The mother
ing the mother–child bond, respecting the integrity of
has asked that her daughter be fed by mouth during
the nursing staff, and forging an alliance between the
her hospitalization. Staff members on the unit were
mother
and the rehabilitation
© Jones & Bartlett Learning, LLC
© Jones
& Bartlett
Learning,team.
LLC
uncomfortable with oral feeding and feared potential
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harm would occur with feeding.
Questions
The ethics consultant recommended several actions
to the staff. First, approach the mother acknowledging
1. What would the next step be in this process if the
the love and concern she has for her daughter and her
mother refuses to heed the advice of the consul& Bartlett
© Jones & Bartlett Learning, LLC
willingness to go©
to Jones
great lengths
to provideLearning,
oral feeding LLC tant?
in the home. Second,
sharedOR
concern
of staff
NOT
NOTexpress
FORthe
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2. If this case came before
the FOR
ethics SALE
board ofOR
theDISTRIBUTION
about the safety of oral feedings and concern that they
facility, how would you respond to this dilemma as
may not be adequately prepared to feed the child safely
a rehabilitation nurse? As an ethics board member?
and in a manner consistent with what the mother has
As the nurse manager on the unit?
done at home. Third, seek a compromise or common
3. What risks are inherent in this situation to the hos© Jones & Bartlett Learning, LLC
© Jones & Bartlett Learning, LLC
ground. Perhaps offer that for the child’s safety staff
pital? To the unit? To the patient? To the mother?

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Box 25.1 Suggested
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Learning,Guidelines
LLC for Resolving Team
Disagreements
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Dilemmas in Rehabilitation: Where

Advances in technology and knowledge since the turn of
1. Clarify the plan of care with other members of the
healthcare team.
the 20th century allow modern medicine to accomplish
2. Identify the specific issue that is the source of conflict.
feats of supporting birth, sustaining life, and promoting
3. State the source of the disagreement and rationale.
longevity for individuals with chronic illness or dis© Jones
Learning, LLC
© Jones & Bartlett Learning, LLC
4. Propose an alternative
action&
orBartlett
plan.
ability. Concurrently, the Internet has increased public
5. Determine whether
there
is
agreement,
consensus,
or
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awareness of healthcare options while creating a forum
acceptance of the new plan that is acceptable for all.
for dialogue on ideological issues. Bioethics is the branch
6. Implement the plan of care.
Adapted from Savage et al. (2009).

a hospital ethics committee or ethics consultant in these
cases. The latter can serve as objective reviewers and offer
alternatives to help the team reach a mutually acceptable
decision.

of ethics concerned with issues surrounding health care
and the biological sciences. Bioethical issues may occur
© Jones
& Bartlett
Learning,
LLC
from before
birth, in the
case of in vitro
fertilization
and
abortion,NOT
to end-of-life
decisionOR
making
and euthanasia.
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The 20th century began with bioethicists asking how far
modern medicine could go in prolonging life, and now
the debate has shifted to how far should modern medicine go and how should end-of-life decisions be made.

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390 Chaper 25 / Ethical and Legal Issues

© Jones & Bartlett Learning, LLC
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SALE
DISTRIBUTION
NOT FORSome
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OR
DISTRIBUTION
of the
most
notable cases in bioethics are related NOT FOR
The case
wentOR
to the
Supreme Court of New Jersey
to end-of-life decision making and the subsequent legal
decisions that have significant relevance for rehabilitation nursing.

where it was acknowledged that Karen was in a “persistent vegetative state.” Her condition was clearly determined to be incurable, and the court was confronted
determining if a person in
position
possessed Learning, LLC
© Jones & Bartlett Learning,with
LLC
© her
Jones
& Bartlett
the right of choice regarding the
disruption
or continuNOT
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OR DISTRIBUTION
NOT
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Decision Making for
the
ance
of
life-prolonging
medical
procedures.
The
court
Incompetent and Dying
concluded that the family could, after consultation with
Perhaps the most commonly debated ethical and legal
the hospital ethics committee, withdraw life-sustaining
dilemma has been when an individual is incapacitated
equipment. The court only required that a responsible
© Jones
& Bartlett
Jones &that
Bartlett
Learning,
LLC
and unable
to make
healthcareLearning,
decisions onLLC
his or her
physician first©determine
there was
no possibility
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OR
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behalf. How far can a surrogate decision maker go in
of Karen ever coming out of her present condition to a
terms of removing life support devices? In the current era,
cognitive, functional state (Karen Ann Quinlan Memowhen modern medicine appears to be at the point of being
rial Foundation, 2010).
capable of supporting vital organs almost indefinitely,
In the aftermath of this case, several interesting
serious
ethical
issues
have
arisen.
Should
individuals
be
things
MostLearning,
importantly,LLC
living wills evolved
© Jones & Bartlett Learning, LLC
© Jonesoccurred.
& Bartlett
able
to
terminate
their
own
existence
where
no
hope
of
from
this
case
as
a
means
of
communicating
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NOT FOR SALE OR DISTRIBUTION to family
quality or cure exists? Or should the family, acting on
members and medical staff the wishes of the competent
behalf of the individual, be permitted to withdraw lifepatients in the event they are unable to make their wishes
prolonging medical procedures, even when withdrawing
known.
life-prolonging procedures will almost certainly cause
© individual
Jones &and/or
Bartlett
Learning,
LLC and Schiavo and the©Patient
Jones & Bartlett Learning, LLC
Cruzan
death? How far can the
family
go in
Self-Determination
Act
of
1990
NOT
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OR
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deciding to terminate life? At what point does terminating
life become homicide and prohibited by the law? FurtherThe cases of Nancy Cruzan and Theresa Schiavo are
more, what can be done to prevent some mistakes of the
unmistakably linked with the Quinlan case in the public
past from being repeated? Three cases, Quinlan, Cruzan,
debate over honoring an individual’s wishes. Although
and Schiavo,
stand
at
the
crossroads
of
ethical
and
legal
removing someone
from &
a ventilator
current society
© Jones & Bartlett Learning, LLC
© Jones
BartlettinLearning,
LLC
issuesNOT
in medical
practice.
These
cases,
which
started
appears
to
a
socially
acceptable
and
even
a
benevolent act,
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as ethical issues, evolved into legal cases that ultimately
the removal of a feeding tube, as in these cases, raised
set the precedent for the national use of living wills and
concern for many individuals, including some healthcare
future advance directive laws. These cases are examined
workers. Some even argued that it was cruel and inhuman
as examples in the following sections.
punishment, because no one would voluntarily choose
© Jones & Bartlett Learning, LLC
© Jones
Bartlett Learning, LLC
to “die of&starvation.”
Quinlan
and
Advance
Directives
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NOT FOR
NancySALE
CruzanOR
wasDISTRIBUTION
born in Missouri and on the
The Quinlan case is the landmark case in the patient’s
night of January 11, 1983 she lost control of her car and
right of self-determination. On the night of April 15,
crashed into a ditch with the injury resulting in anoxia
1975, Quinlan ceased breathing for two 15-minute into the brain (FindLaw, 2010). After determining that her
tervals and was transported
to the &
hospital,
where
it was
condition
asked&the
hospital Learning, LLC
© Jones
Bartlett
Learning,
LLC was irreversible, the family
© Jones
Bartlett
determined her pupils were unreactive and she failed to
to cease nutrition and hydration. The hospital refused to
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respond to deep pain (Karen Ann Quinlan Memorial
grant the family’s wishes without a court order requiring
Foundation, 2010). She was placed on a ventilator at the
them do so. The family then appealed to a trial court who
hospital and received a tracheotomy. In the ensuing days
agreed that Nancy’s wishes, as declared in a conversation
after her respiratory arrest, her parents watched the conwith a housemate, should be upheld. The decision was
©ofJones
& Bartlett
©Supreme
JonesCourt
& Bartlett
Learning,
LLC
dition
their daughter
furtherLearning,
deteriorate. LLC
After much
appealed to the
of Missouri,
who reversed
NOT and
FOR
SALE OR
DISTRIBUTION
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OR DISTRIBUTION
discussion
counseling,
the family
determined that it
the decision, stating
they found
insufficient
grounds for
was in her best interest to remove the ventilator. Whereas
removing the feeding tube.
the hospital initially consented to authorize removing the
The case made its way to the Supreme Court, who
ventilator and life support, the hospital would later dissupported the right of Nancy to have a feeding tube
agree with the decision and took the case to court (Karen
removed once sufficient evidence was found stating this
© Jones &
Bartlett Learning, LLC
© Jones
& Bartlett Learning, LLC
Ann Quinlan Memorial Foundation, 2010).
was Nancy’s wish. In the aftermath of the Supreme Court

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Advance Directives

391

© Jones & Bartlett Learning, LLC
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decision,
family found additional witnesses who testiGuardianship
of Estelle
M. Browning in which it was

fied on Nancy’s behalf regarding her desires about lifedetermined that every person has the “fundamental right
sustaining medical treatment and ultimately the feeding
to the sole control of his or her person” (In Re: The Guardtube was removed. As a follow-up to this case, the Patient
ianship of Theresa Marie Schiavo from the Circuit Court
Self-Determination
Act
was
enacted
in
1990
requiring
for Pinellas County, Florida
Probate Division
File Learning,
No.
© Jones & Bartlett Learning, LLC
© Jones
& Bartlett
LLC
all medical facilities
thatFOR
acceptSALE
Medicare
Medicaid
90-2988GD-003). Furthermore,
stated
the Browning
NOT he
FOR
SALE
OR DISTRIBUTION
NOT
ORorDISTRIBUTION
funding to provide counseling for patients on advance
case established this right to reject medical treatment
directives.
was not “diminished by virtue of physical or mental
Most recently, the case of Theresa Marie Schiavo
incapacity or incompetence” (In Re: The Guardianship of
(Cerminara & Goodman, 2010) may have started as an
Theresa Marie Schiavo from the Circuit Court for Pinellas
© Jones
& Bartlett
Learning,
© Jones
& Bartlett
Learning,
LLC
ethical
concern
about the right
to removeLLC
a feeding tube,
County, Florida
Probate
Division File
No. 90-2988GDNOT
FOR
SALE
OR
DISTRIBUTION
NOT
FOR
SALE
OR
DISTRIBUTION
but it would become a legal quagmire and a highly politi003). To invoke the patient’s rights of self-determination,
cal battle. In this case disagreement among family memthe surrogate or guardian must meet three criteria: (1)
bers would lead to a protracted court battle. Terri Schiavo
the surrogate must be satisfied that evidence in regards
suffered a cardiac arrest in February 1990. Although her
to the patient’s wishes is uncoerced and reliable, (2) the
husband
sought
medical
intervention
and
rehabilitation
surrogate
must have
reasonable assurance
© Jones & Bartlett Learning, LLC
© Jones
& Bartlett
Learning,
LLC that the patient
therapy
with
the
hope
of
Terri
regaining
some
level
of
does
not
have
probability
of
recovering
NOT FOR SALE OR DISTRIBUTION
NOT FOR SALE OR DISTRIBUTIONcompetence, and
consciousness, he would eventually lose hope and request
(3) the surrogate must ensure that any written or oral
to have the feeding tube removed.
statements are considered and honored.
The legal battles over Terri began in 1998 when her
The laws regarding end-of-life decisions are not unhusband asked the court for permission to have her feedclear. It is without question that decisions like this one
Jones
Bartlett
© Jones
LLC
ing tube removed.©Her
parents&opposed
theLearning,
motion. In LLC
and others related to intensity
and use&
of Bartlett
healthcareLearning,
inNOT
FOR
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OR
DISTRIBUTION
NOT
FOR
SALE
OR
DISTRIBUTION
February 2000 Judge Greer ruled for the first time that
terventions are made in hospitals across the nation. When
sufficient evidence existed to demonstrate that Terri
family members disagree, authority for decision making
would want the feeding tube removed.
is by state law assigned to the closest next of kin unless
Ultimately, due to the parents’ public statements and
the individual has created an advance directive assigning
widespread
discussion
in
the
public
media
and
on
the
a surrogate
act on his
her behalf.
The importance
© Jones & Bartlett Learning, LLC
© to
Jones
& or
Bartlett
Learning,
LLCof
Internet,
politicians
stepped
into
the
fray
over
Terri’s
right
communication
between
healthcare
providers
and
family
NOT FOR SALE OR DISTRIBUTION
NOT FOR SALE OR DISTRIBUTION
to die. Now for the first time the legal debate extended
members is often key to resolving ethical dilemmas.
beyond the courts into the political and legislative arena.
In October 2003 the Florida House and Senate passed the
Advance Directives
bill into law, informally known as “Terri’s Law,” which
© Jones & Bartlett
© Jones
& Bartlett
Learning,
LLCtheir wishes known
prohibitedLearning,
the removalLLC
of Schiavo’s feeding tube. Judge
It is important
for individuals
to make
NOT FOR SALE
DISTRIBUTION
OR
DISTRIBUTION
Baird OR
and the
Florida Supreme Court declared this NOT
law FOR
beforeSALE
an event
occurs.
The Quinlan case encouraged
unconstitutional in September 2004. In December 2004
individuals and families to have discussions about endthe Governor of Florida asked the U.S. Supreme Court to
of-life care and encouraged the use of advance directives,
overturn the Florida Supreme Court’s decision, repealsuch as a living will. After the Cruzan case, the Patient
ing Terri’s Law. The Supreme Court rejected this motion
Self-Determination Act of 1990
institutionalized
thisLearning,
de© Jones & Bartlett Learning, LLC
© Jones
& Bartlett
LLC
(Cerminara & Goodman, 2010).
cision making by mandating that all patients upon entry
NOT FOR SALE OR DISTRIBUTION
NOT FOR SALE OR DISTRIBUTION
In 2005 the federal government got involved when
into a healthcare facility be queried about the existence of
a congressional committee subpoenaed Terri’s family.
an advance directive and if none exists it was the duty
The congressional committee asked for a stay on the
of the healthcare facility to offer education and assistance
removal of the feeding tube. The stay was denied, and
should an individual wish to create an advance directive.
© Jones
& Bartlett
Learning,
LLC
Jones
& ofBartlett
Learning,
Terri’s
feeding
tube was removed
for the
last time on
There are©several
types
advance directives,
andLLC
nurses
March
18, 2005
(Cerminara
& Goodman, 2010). She
NOT FOR
SALE
OR DISTRIBUTION
ORtypes
DISTRIBUTION
should beNOT
awareFOR
of theSALE
different
and limitations
passed away 2 weeks later on March 31.
associated with each type of advance directive.
The pivotal person in this case was the Circuit Judge,
Advance directives are legal documents that convey
George W. Greer. He presided over this case and made
an individual’s decisions regarding end-of-life care and
his decision to allow the feeding tube to be removed
treatment. These documents are used to direct family
© Jones & Bartlett
Learning, LLC
© Jones
& Bartlett Learning, LLC
on 11 February 2000. In his ruling he cited the case of
members, friends, and healthcare providers’ decisions

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392 Chaper 25 / Ethical and Legal Issues

© Jones & Bartlett Learning, LLC
© Jones & Bartlett Learning, LLC
FOR SALE OR DISTRIBUTION
NOT FORregarding
SALE OR
DISTRIBUTION
health
care and treatment in the event the NOTBox
25.2 Sample of Items Addressed by a Living Will

patient is unable to make or convey these decisions on
• Resuscitation. Resuscitation is the attempt to restart
his or her own due to some incapacity, such as a coma.
the heart when it has stopped beating. Common forms
In theory, by preparing an advance directive the patient
of resuscitation are by cardiopulmonary resuscitation
can maintain some control
over his&orBartlett
her medical
treat© Jones
Learning,
LLC
© Jones
& an
Bartlett Learning, LLC
(CPR) or a defibrillator device that
administers
ment while at the same
timeFOR
relieving
family,
electric shock in an effort to stimulate
the heart.
NOT FOR
SALE OR DISTRIBUTION
NOT
SALE
ORfriends,
DISTRIBUTION
and doctors of making difficult decisions on behalf of
• Artificial nutrition and hydration. The patient can
express whether or not he or she desires nutritional and
the patient when the patient is unable to express his or
hydration assistance via a tube or intravenously. In his or
her intentions. Often, an advance directive will set forth
her living will, the patient can express the duration of
the patient’s wishes depending on the extent of his or her
time he or she
would desire
life to be sustained
by theseLLC
© Jones
& Bartlett
Learning,
LLC
© Jones
& Bartlett
Learning,
ailment
or incapacity.
For example,
an advance
directive
methods.
FOR
ORifDISTRIBUTION
NOT FOR SALE OR DISTRIBUTION
couldNOT
describe
whatSALE
treatment,
any, the patient desires
• Mechanical ventilation. Mechanical ventilation refers
in the event he or she is unlikely to recover or is permato devices that substitute or assist spontaneous
breathing. Again, the patient can express the duration
nently unconscious. The advance directive can also direct
of time he or she would desire life to be sustained by
healthcare providers to provide treatment regardless of
mechanical ventilation.
theBartlett
severity ofLearning,
the patient’s LLC
ailment or condition.
© Jones &
© Jones & Bartlett Learning, LLC

NOT FORLiving
SALE
OR DISTRIBUTION
Will

• Dialysis. Dialysis refers to artificial replacement for

NOT FOR
SALE
OR
DISTRIBUTION
diminished
or lost
kidney
function. In receiving this
treatment, machinery will assist the body by removing

Generally speaking, there are three types of advance
waste from the patient’s blood. In a living will, the
directives: a living will, a power of attorney for healthpatient can determine the duration of time he or she is
desirous of this treatment.
care decision making, and a do not resuscitate (DNR)
©
Jones
&
Bartlett
Learning,
LLC
© Jones & Bartlett Learning, LLC
order. A living will, otherwise known as a healthcare
NOT FOR SALE OR DISTRIBUTION
NOT
FOR
SALE
OR
DISTRIBUTION
declaration or healthcare directive, is a written document that sets forth the types of medical treatments or
Medical or Durable Power of
life‑sustaining measures the patient wants or does not
Attorney for Healthcare
want in the event the person has a terminal illness and

is unable
to communicate.
This
document goes
advance &
directive
is a medical
powerLLC
of
© Jones
& Bartlett
Learning,
LLCinto ef- A second type©ofJones
Bartlett
Learning,
fect once
the
patient
has
been
deemed
terminal
by
a
duly
attorney,
also
known
as
a
durable
power
of
attorney
with
NOT FOR SALE OR DISTRIBUTION
NOT FOR SALE OR DISTRIBUTION
authorized physician and is unable to articulate his or
healthcare powers. The medical power of attorney has
her own desires regarding treatment. When preparing a
broader powers than a living will. A medical power of
living will, a patient can choose the treatments he or she
attorney allows the patient to choose an individual to
would like to receive if unable to articulate these on his
make medical decisions on his or her behalf when the
© Jones &
Learning,
LLC Typically, a living will © Jones
Bartlett
LLCThis allows the
or Bartlett
her own due
to an incapacity.
patient is&unable
to doLearning,
it him or herself.
NOT FORsets
SALE
OR DISTRIBUTION
FOR
OR DISTRIBUTION
forth whether
or not the patient would like to receive NOT
patient
to SALE
give decision-making
powers to a trusted intreatments as described in Box 25.2.
dividual in the event the patient’s living will does not
A living will can convey the patient’s decision regardaddress a particular situation. This appointed individual
ing organ donation as well.
acts as the patient’s healthcare agent (or proxy) and may
It should be noted©
that
a
living
will
does
not
necesdecisions
the pa- Learning, LLC
Jones & Bartlett Learning,make
LLCa broad range of healthcare
© Jones
& on
Bartlett
sarily convey the patient’s decision to obtain or refrain
tient’s behalf. This person is entrusted to make decisions
NOT FOR SALE OR DISTRIBUTION
NOT FOR SALE OR DISTRIBUTION
from certain treatments. In some cases the patient, by
on behalf of the patient that are consistent with the pahis or her living will, may expressly state that he or she
tient’s living will or discussed wishes related to healthcare
is intentionally making no decision regarding what treatdecisions.
ment to receive. In doing so, the patient is purposely
For obvious reasons an individual should select a
© Jones
& Bartlett
Learning,
LLC
© Jones
Bartlett
Learning,
leaving
such decisions
to family
members and
doctors.
healthcare agent
they trust&and
who is not
opposed to LLC
the
NOT of
FOR
SALE decisions
OR DISTRIBUTION
NOT
FOR
SALE
OR
DISTRIBUTION
Regardless
the patient’s
set forth in a living
individual’s healthcare or end-of-life wishes and desires.
will, it is advisable for healthcare providers to discuss the
In fact, choosing a healthcare agent is perhaps one of the
treatments available. In doing so, the patient can make
most important decisions in advance directive planning.
informed decisions regarding prospective treatments and
This person should have the individual’s best interests
possible outcomes of those treatments.
at heart, and most importantly should understand the

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Psychiatric Advance Directive

393

© Jones & Bartlett Learning, LLC
© Jones & Bartlett Learning, LLC
DISTRIBUTION
NOT FOR SALE
OR DISTRIBUTION
individual’s
wishes. The individual should discuss NOT
the FOR
and isSALE
carriedOR
by them
from one healthcare setting to

issue with the potential healthcare agent to ensure they
the next (Illinois Department of Public Health, 2005).
are willing to serve in this capacity. When choosing a
This order spells out what the individual wants in terms
healthcare proxy or surrogate, the individual should
of resuscitation while they are being transported from
choose a person who
is
mature
and
capable
of
making
one facility to another or ©
in Jones
the case &
of Bartlett
some patients
© Jones & Bartlett Learning, LLC
Learning, LLC
difficult decisions.NOT
The FOR
personSALE
selectedOR
need
not be a
in rehabilitation when theyNOT
are being
as anOR
outpaFORseen
SALE
DISTRIBUTION
DISTRIBUTION
family member, and at times the patient’s best interests
tient at another hospital or physician office. The nurse
may best be served by choosing an agent who is not famshould be aware of their hospital policy and state rules
ily. In any event the patient should not choose an agent
and regulations on DNR orders. In addition, residents
out of a sense of obligation or feelings of guilt. It is also a
in long-term care facilities are now urged to place their
© Jones
Bartlett
Learning,
©and
Jones
& Bartlett
good
idea, for&practical
reasons,
that theLLC
agent live near
living wills
DNR orders
on theirLearning,
refrigeratorsLLC
so that
NOT
FOR
SALE
OR
DISTRIBUTION
NOT
FOR
SALE
OR
DISTRIBUTION
the patient. This allows the agent to more readily conin the event of an emergency, rescue personnel
have ready
sult with the patient’s healthcare providers and to make
access to these legal documents that can aid in upholding
better-informed decisions regarding care. Selecting an
the person’s wishes.
alternate power of attorney is also recommended in the
event the Learning,
primary power
of attorney is unable or unwill© Jones & Bartlett
LLC
© Jones
& Bartlett
Learning,
LLC
Psychiatric
Advance
Directive
ing
to
serve
if
the
time
to
do so arises.
NOT FOR SALE OR DISTRIBUTION
NOT FOR SALE OR DISTRIBUTION
It is important to understand the distinction between
A relatively new way to deal with mental health decisions
a power of attorney and a medical power of attorney. With
in advance is through a psychiatric advance directive,
the former, the authority conveyed typically allows the
sometimes called a declaration for mental health treatagent to conduct business or financial transactions on
ment. As the name implies, this legal document can be
©
Jones
&
Bartlett
Learning,
LLC
© Jones
& Bartlett
Learning, LLC
behalf of the person who has granted the authority to act
used to declare in advance one’s
desires regarding
the psyNOT
FOR
SALE
OR
DISTRIBUTION
NOT
FOR
SALE
OR
DISTRIBUTION
in this way. A medical power of attorney conveys specific
chiatric or mental health treatment they wish to receive.
authority to an agent for the express purpose of making
A psychiatric advance directive may be used to document
medical decisions on behalf of the grantor. Given this
a competent person’s specific instructions or preferences
distinction, it is important that the healthcare provider
regarding future mental health treatment. This is done in
be
aware
of
the
extent
to
which
the
agent
has
authority
preparation
for the possibility
thatLearning,
the person may
lose
© Jones & Bartlett Learning, LLC
© Jones
& Bartlett
LLC
to
make
decisions
on
behalf
of
a
patient.
A
doctor
should
capacity
to
give
or
withhold
informed
consent
to
treatNOT FOR SALE OR DISTRIBUTION
NOT FOR SALE OR DISTRIBUTION
not look to a patient’s agent for medical treatment deciment during acute episodes of psychiatric illness.
sions if the only authority conveyed to the agent by the
Advance directives can be prepared in a variety of
patient is to sign checks on his or her behalf.
ways. Many times, healthcare professionals have a form
a patient can fill out to make known his or her desires.
DNR Order
© Jones & Bartlett
Learning, LLC
© Jones
& Bartlett
LLC
A patient
can alsoLearning,
write his or her
own desires. Another
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OR
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OR is
DISTRIBUTION
A third
common
advance directive is a DNR order. This
potential
resource
also a local health department or
is a request by the patient to not receive cardiopulmoother local or state agency that can provide a form. Finary resuscitation in the event his or her heart stops or
nally, and perhaps the best resource for preparation of an
he or she stops breathing while at the hospital. A DNR
advance directive, is an experienced, licensed attorney.
order can typically be placed in the patient’s chart by
Although this may be slightly
more expensive
for Learning,
the
© Jones & Bartlett Learning, LLC
© Jones
& Bartlett
LLC
the request of the patient. Hospital policy defines the
patient, the cost for this type of legal work is relatively
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organization’s responsibilities for who can request a DNR
small, and counseling offered by the attorney can go a
order and the organization’s responsibility for honoring
long way in avoiding future complications. The legal
the DNR order.
requirements for advance directives vary from state to
Typically, the DNR applies only when the individual
state, and the individual creating the documents should
Jones & care
Bartlett
Learning,
LLC
is©undergoing
and treatment
at the
hospital, but
keep this©
inJones
mind. & Bartlett Learning, LLC
nursing
home SALE
residentsOR
mayDISTRIBUTION
have a standing DNR on the
NOT FOR
NOT of
FOR
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Regardless
the source
for OR
the advance
directive, the
medical record after going through the proper channels
preparer should keep in mind that the document need not
to have this implemented. Within the past few years a
be long and complicated. A short, simple statement of the
select number of states have created a universal or unipatient’s desires regarding treatment should suffice. Once
form DNR order request that is initiated by the individual
an advance directive is prepared, it is advisable to have the

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394 Chaper 25 / Ethical and Legal Issues

© Jones & Bartlett Learning, LLC
© Jones & Bartlett Learning, LLC
FOR SALE OR DISTRIBUTION
NOT FORpatient
SALE
ORthe
DISTRIBUTION
review
document with his or her doctor. This NOTCase
Study 25.2

will assist the healthcare provider to understand exactly
You are working with a female patient who has suswhat the patient’s intentions are regarding treatment.
tained a C-5 complete ASIA A spinal cord injury. The
Any advance directive should be notarized and a copy
patient
of &
daily
living Learning, LLC
given to the patient’s doctor
and any
agent appointed
in
© Jones
& Bartlett
Learning,
LLC is dependent for all activities
© Jones
Bartlett
and
has
a
tracheostomy
in
place.
The
patient
tells
you
the medical power of attorney
document.
NOT FOR SALE OR DISTRIBUTION
NOT FOR
SALE OR DISTRIBUTION
she
wants
to
die
rather
than
live
with
this
disability.
The patient should also be aware that an advance
She has been eating poorly and refusing turns and
directive can be changed at any time as long as the patient
therapy. At team conference several team members are
is of sound mind. To be of sound mind means that the
recommending discharge to a skilled nursing facility
patient can think rationally and can communicate his or
©
Jones
&
Bartlett
Learning,
LLC
Jones
Learning,
LLC
because the ©
patient
has &
noBartlett
rehabilitation
goals. You
her wishes clearly (i.e., is deemed competent). It is also
and
other
team
members
are
concerned
about
her
wellNOT
FOR
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OR
DISTRIBUTION
NOT
FOR
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OR
DISTRIBUTION
recommended that the patient periodically review his or
being and not comfortable with the discharge plan.
her advance directives to ensure the documents still ac-

curately reflect his or her intentions. Any changes should
Questions
be made known to the patient’s doctor and any individu1. How can this dilemma be resolved?
alsBartlett
appointed Learning,
as a healthcare
agent. In the absence of an © Jones
© Jones &
LLC
& Bartlett Learning, LLC
What factors should be considered?
directive,
family members and physicians are NOT 2.
NOT FORadvanced
SALE OR
DISTRIBUTION
FOR SALE OR DISTRIBUTION
3. What role might the ethics board play in a situaleft with the unfortunate task of making difficult decition such as this?
sions without the benefit of knowing the patient’s wishes
4.
What legal and ethical factors/principles should
and desires. State law dictates the legal order of decision
be considered?
making within the state. The typical order is spouse, par-

Jones
& Bartlett
Learning, LLC
© Jones & Bartlett Learning, LLC
ent, child, and sibling. ©
Only
a few states
have a provision
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NOT
FOR
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OR
DISTRIBUTION
allowing domestic partners to serve as decision makers.
are working in. Generally, once an individual has been
At times the order of decision making can be a source of
determined to be incapacitated, the court can appoint
conflict, as in the case of a woman with a traumatic brain
a guardian to make some or all decisions for that indiinjury sustained as a result of domestic abuse. If criminal
vidual.
charges
are
not
filed
against
the
spouse,
the
spouse
will
© Jones & Bartlett Learning, LLC
© Jones & Bartlett Learning, LLC
in most
states
be
primary
decision
maker
(see
Case
Study
NOT FOR SALE OR DISTRIBUTION
FOR SALE OR DISTRIBUTION
Identifying aNOT
Guardian
25.2). Dealing with such situations is stressful enough,
A “guardian” is a person who has the legal authority and
but often the absence of an advance directive can lead to
duty to care for another’s person or property (Garner,
conflict among family members, friends, and healthcare
1999). A guardian or conservator may be appointed for
providers. Nurses as patient advocates should encourage
© Jones &
BartletttoLearning,
LLC an advance directive © Jones
& Bartlett
Learning,
LLC
all purposes,
for a specific
purpose, or
a specific period of
individuals
consider preparing
time.
The term
includes
a temporary guardian, a limited
NOT FORlong
SALE
NOT
FOR
SALE
OR DISTRIBUTION
beforeOR
it isDISTRIBUTION
actually needed.
guardian, and a successor guardian but excludes one who
is only a guardian ad litem (a guardian ad litem usually
Guardianship
only appears in court for the incapacitated individual).
The guiding principle in all guardianship is that of least
Safe decision making is
of every
day life, yet
some
©part
Jones
& Bartlett
Learning,
LLC
© Jones & Bartlett Learning, LLC
intrusive measures to ensure as much autonomy as pospatients in rehabilitation are unable to make decisions
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NOT FOR SALE OR DISTRIBUTION
sible. The guardian’s authority is defined by the court,
without jeopardizing their welfare. One of the most comand the guardian may not operate outside that authormon ethical and legal dilemmas in rehabilitation is how to
ity. However, guardianship duties are often not clearly
care for those who may not be able to make decisions in
defined. A good guardian takes into account the wishes
a cogent manner. As a result the law has developed a tool
Jones & Bartlett
Learning,
LLC
Jones
& Bartlett
Learning,
LLC
and desires of©the
incapacitated
person,
often called
a
called©“guardianship.”
The number
of guardianships
is
“ward,” whenNOT
making
decisions
about
residence,
medical
NOT and
FOR
SALE
OR baby
DISTRIBUTION
FOR
SALE
OR
DISTRIBUTION
increasing,
as the
so-called
boomer generation
treatments, and end-of life issues. The courts will remove
ages, the number of guardianships in the United States
only those rights that the proposed ward is incapable of
is projected to continue to grow.
handling.
Rehabilitation nurses should have an understandWhen the courts appoint a guardian, certain rights
ing of the general principles surrounding guardianship
© Jones & Bartlett Learning, LLC
© Jones
& Bartlett Learning, LLC
of the ward are removed. Table 25.2 lists the rights of the
and the specific rules applicable in the jurisdiction you
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NOT FOR SALE OR DISTRIBUTION

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Guardianship

395

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when family members perceive the individual is exercising poor judgment. When an elderly person has assets
Consent to medical
Make end-of-life decisions, such
that are desired by his or her heirs, many times the family
treatment
as the withdrawal of life support
members attempt to have ©
theJones
individual
declared toLearning,
be
© Jones
& Bartlett
Learning,
LLC
& Bartlett
LLC
or withholding
of medical
care
an incapacitated person so NOT
they can
establish
a guardianFOR
SALE
OR DISTRIBUTION
FOR aSALE
OR DISTRIBUTION
Determine place ofNOTPossess
driver’s license
ship and control the assets of the individual. As a result,
residence
family members will try to attribute what they perceive
Manage, buy, or sell
Own or possess a firearm or
to be a bad decision to incapacity.
property
weapon
Another common cause for guardianship requests is
into a contract
Marry
©Enter
Jones
& Bartlett
Learning, LLC
©Many
Jones
&the
Bartlett
Learning,
LLC
dementia.
times
one suffering
from dementia
Vote
NOT
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NOT
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OR
DISTRIBUTION
is unaware of the seeming absurdity of his or her decisions
and will thus fight the guardianship proceedings. In this
ward that are removed during guardianship. These rights
situation it is often difficult for the court and medical perare rights typically guaranteed by federal or state law to
sonnel to tell the difference between family and friends
citizens
so
any
removal
of
these
rights
can
significantly
of the
whoLearning,
are acting with
the well-being of the
© Jones & Bartlett Learning, LLC
© Jones
& patient
Bartlett
LLC
limit
an
individual’s
role
within
society
and
thus
the
patient
in
mind
and
those
acting
in
their
NOT FOR SALE OR DISTRIBUTION
NOT FOR SALE OR DISTRIBUTIONown self-interest.
process of guardianship is highly regulated.
Some research has indicated that persons with dementia
may fluctuate in their decision-making abilities (Menne
Capacity Determination
& Whitlatch, 2007), further complicating the issue. How
The first step in the guardianship process is to deterthen should courts and practitioners examine whether
© Jones
& Bartlett
Learning,
© Jones
Bartlett
Learning, LLC
mine “incapacitation.”
An incapacitated
person
is a per- LLC
an individual is incapacitated?
Many &
courts
use some
NOT
FOR
SALE
OR
DISTRIBUTION
NOT
FOR
SALE
OR
DISTRIBUTION
son who is impaired, for any of a variety of reasons, to
or all of the following criteria in assessing the capacity
the extent that personal decision making is impossible
of an individual:
(Garner, 1999). Each state has an official legal definition
• What is the current cognitive ability of the patient?
of an incapacitated person. The legal definition is not
• What is the medical condition that caused the curthe
same as a&medical
definition
of incapacitation.
The
© Jones
Bartlett
Learning,
LLC
© Jones & Bartlett Learning, LLC
rent condition?
legal definition often is based on a determination of an
NOT FOR SALE OR DISTRIBUTION
NOT FOR
SALE OR DISTRIBUTION
• Is it temporary
or reversible?
individual’s inability to manage his or her own property
• Can the person perform the activities of everyday
and/or provide self-care (Indiana Code § 29-3-1-7.5).
living (e.g., grooming, toileting, eating, dressing)?
Several states have very detailed explanations of what a
•
What is the risk of harm associated with the least
determination of incapacity involves. For example, Virrestrictive
means
available?LLC
ginia defines
an incapacitated
© Jones & Bartlett
Learning,
LLC person as follows (Virginia
© Jones &
Bartlett
Learning,
Code OR
§ 37.2-1000):
NOT FOR SALE
DISTRIBUTION
NOT FOR
OR DISTRIBUTION
Some SALE
courts attempt
to understand the values or preferences of the incapacitated person. Of course, if the
An adult who has been found by a court to be incapable
incapacity is mental or psychological, such as demenof receiving and evaluating information effectively or
tia, understanding the person’s preferences can become
responding to people, events, or environments to such
rather complicated.
& Bartlett
Learning,
© Jones & Bartlett Learning, LLC
an extent that ©
theJones
individual
lacks the capacity
to (i) LLC
Establishing
guardianship
a legal SALE
process that
meet the essential
requirements
for
his
health,
care,
NOTis FOR
ORinDISTRIBUTION
NOT FOR SALE OR DISTRIBUTION
volves the removal of an individual’s rights. There are
safety, or therapeutic needs without the assistance or
protection of a guardian or (ii) manage property or
several due process hurdles one seeking a guardianship
financial affairs or provide for his support or for the
of another must overcome:
support of his legal dependents without the assistance
© Jones
& Bartlett
Learning, LLC
Jones &must
Bartlett
Learning,
• The ©individual
be notified
of allLLC
court
or protection
of a conservator.
proceedings.
NOT FOR SALE OR DISTRIBUTION
NOT FOR SALE OR DISTRIBUTION
• The individual is entitled to representation by an
It is important for rehabilitation nurses to know the ofattorney.
ficial definition for their state to articulate the standard
• The individual can and may be compelled to attend
by which the capacity of patients will be judged.
hearings regarding his or her capacity/guardianship
Poor judgment does not constitute incapacity. For
© Jones & Bartlett Learning, LLC
© Jones & Bartlett Learning, LLC
unless excused due to physical impossibility.
relatives of elderly individuals, there is a temptation to
Guardianship

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396 Chaper 25 / Ethical and Legal Issues

© Jones & Bartlett Learning, LLC
© Jones & Bartlett Learning, LLC
FOR
DISTRIBUTION
NOT FOR •SALE
OR DISTRIBUTION
The individual
is entitled to compel, confront, and NOT
At the
verySALE
least oneOR
could
argue for an ethical obligation

cross-examine all witnesses and present his or her
to entrust as much of his or her own affairs as possible
own evidence.
to the individual.
• The individual may appeal the determination of the
One tool that has been increasing in popularity is the
lower court.
limited
only those Learning, LLC
© Jones & Bartlett Learning, LLC guardianship. A limited©guardian
Joneshas
& Bartlett
• The individual hasNOT
the right
to aSALE
jury trial.
powers specifically stated in theNOT
court FOR
order making
SALEhim
OR DISTRIBUTION
FOR
OR DISTRIBUTION
or her a guardian. In other words, the court can decide
The due process required for the removal of an individthe guardian can only do certain things on behalf of
ual’s rights may vary from state to state, and as such the
the incapacitated person. For example, an incapacitated
state’s statutes and case law will be the final authority.
individual may be perfectly capable of determining livAnyone
can act
as a guardian.
The courtLLC
will decide
© Jones
& Bartlett
Learning,
© Jones
Bartlett
ing arrangements
or his or&her
degree ofLearning,
participationLLC
in
who NOT
shouldFOR
be theSALE
guardian
an incapacitated indiORof DISTRIBUTION
NOT
FOR
SALE
OR
DISTRIBUTION
family or religious events, but a court may
decide he or
vidual. There may be different types of guardians specishe are not currently capable of understanding a new lease
fied, depending on the patient’s condition and needs. For
agreement on an apartment or making a major purchase.
example, a patient with complex needs and a large estate
The decision to pursue guardianship is not to be taken
may have a guardian of person (who handles daily affairs
lightly. Yet
when usedLearning,
properly guardianship
can be a
© Jones & Bartlett Learning, LLC
© Jones
& Bartlett
LLC
including health and home maintenance), a guardian of
valuable
resource,
allowing
the
individual
to
live
with
NOT FORhisSALE
FOR SALE OR DISTRIBUTION
or her OR
estateDISTRIBUTION
(who handles all financial aspects), and NOT
a high quality of life.
a guardian ad litem (for legal counsel).
As a general rule, courts prefer close relatives to be the
Individuals with Disability
guardian (of person) because they are often best prepared
and
to understand the individual’s
needs
and desires.
Many
© Jones
& Bartlett
Learning,
LLCRight to Life Issues © Jones & Bartlett Learning, LLC

community organizations,
some
state and
NOT
FOR
SALE
NOTand
FOR
SALE
ORnational
DISTRIBUTION
A second area where ethical and
legal
issues
mergeOR
is DISTRIBUTION
organizations, can connect individuals with volunteer
related to rights of individuals with disability within
advocates who will act on behalf of the incapacitated indisociety. For many years individuals with disability where
vidual. When the court appoints a guardian of the person,
denied either by law or societal handicap basic rights as
the responsibilities of the guardian are as follows:
citizens, such as right to a public education or the right

to vote. As recently
as 1979
it was OR
legalDISTRIBUTION
for some state
NOT FOR
OR
NOT FOR
SALE
• Determine
andSALE
monitor
theDISTRIBUTION
residence of the incagovernments
to
sterilize
disabled
individuals
against
pacitated individual
their will or prohibit people with certain disabilities from
• Consent to and monitor medical treatment
marrying (Regents of the University of California, 2004).
• Consent to and monitor services such as education
In the early 1970s the disability rights movement started
and counseling
© Jones &• Bartlett
Learning,
LLC
©
Jones
& Bartlett
Learning,
LLC The disability
at the University
of California
at Berkley.
Consent to and release of confidential information
rights
movement
that people with disabilities are
NOT FOR SALE
OR DISTRIBUTION
NOT
FOR
SALEasserts
OR DISTRIBUTION
(i.e., healthcare
records)
human
beings
with
rights
equal to any American citizen.
• Make end-of-life decisions
The
movement
sought
to
secure these rights through
• Act as representative payee
political
action.
As
a
result
of their efforts a number of
• Report to the court about the guardianship status
within our society.
at least annually © Jones & Bartlett Learning,legislative
LLC victories have occurred
© Jones
& Bartlett Learning, LLC
Table 25.3 outlines 20 years of legislation to secure rights
NOT FOR SALE OR DISTRIBUTION
NOT FOR SALE OR DISTRIBUTION
Often, a guardian will have to right to make financial
for individuals with disabilities.
decisions on behalf of the incapacitated person. PracOne of the first successes was the passage of the
titioners need to be careful as well when deciding for
Rehabilitation Act of 1973. This federal law for the first
themselves as to the capacity of an individual. Often,
time protects individuals with disabilities from discrimi© Jones
& Bartlett
Learning,
© their
Jones
& Bartlett
LLC
physicians
and other
medical personnel
can LLC
be called to
nation based on
disability.
The Act Learning,
defined qualified
testify
in court
as SALE
to what OR
they DISTRIBUTION
observed and the funcindividuals with
disabilities
as persons
with a physical
NOT
FOR
NOT
FOR SALE
OR DISTRIBUTION
tionality of an individual. Because so much is at stake for
or mental impairment that substantially limits one or
the supposedly incapacitated person and there is so much
more major life activities as well as persons who have a
risk of wrongdoing and potential loss, some laws create
history of or are regarded as having a physical or mena duty to maximize the independence of the individual.
tal disability. According to the Act, major life activities

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Individuals with Disability and Right to Life Issues

397

© Jones & Bartlett Learning, LLC
© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION
NOT FOR SALE
OR DISTRIBUTION
Table 25.3 Federal Disability Rights Laws and Court Decisions
Law

Date

Summary

Architectural
Barriers Act (ABA)

1968

Requires that buildings and facilities that are designed, constructed, or altered with Federal
funds, or leased by a Federal agency, comply with Federal standards for physical accessibility.
&
Bartlett Learning, LLC
© Jones & Bartlett Learning,
Facilities of the U.S. Postal Service are not covered by this Act.

Rehabilitation
Act

© Jones
LLC
NOT
FOR
SALE
OR
DISTRIBUTION
NOT
FOR
SALE
OR
DISTRIBUTION
1973
Prohibits discrimination on the basis of disability in programs conducted by Federal agencies,
in programs receiving Federal financial assistance, in Federal employment and in the employ
ment of Federal contractors.

1975
This Act requires public schools to make a free appropriate public education in the least
Individuals with
restrictive environment available to all eligible children. It also requires public school systems
Disabilities
© Jones & Bartlett Learning,
LLC
© Jones & Bartlett Learning, LLC
to develop appropriate individualized education programs (IEPs) for each child. The IEP must
Education Act
NOT
FOR
SALE
OR
DISTRIBUTION
NOT FOR
SALE
OR DISTRIBUTION
be developed by a team of knowledgeable persons
and must
be reviewed
at least annually.
(IDEA)
Voting
Accessibility for
the Elderly and
Handicapped Act

1984

This Act requires polling places across the U.S. to be physically accessible to people with
disabilities for federal elections. If no accessible location is available, an alternate means of
casting a ballot must be offered. States must make registration and voting aids available for
disabled and elderly voters.

© Jones & Bartlett Learning, LLC
© Jones & Bartlett Learning, LLC
Fair Housing Act
1988
Prohibits housing discrimination on the basis of race, color, religion, gender, disability, familial
NOT FOR SALE OR DISTRIBUTIONstatus, and national origin.
NOT
FOR SALE OR DISTRIBUTION
Amendments are applicable to government housing as well as
private housing that receives federal assistance. It also requires landlords to allow tenants
with disabilities to make reasonable access-related modifications to their private living space,
as well as common areas. Any new multifamily unit with four or more units be designed and
built to allow access for persons with disabilities.

Americans With
Disabilities Act
(ADA)
Air Carrier Access
Act

© Jones & Bartlett Learning, LLC
© Jones & Bartlett Learning, LLC
1990
The ADA prohibits discrimination on the basis of disability in employment, state and local
NOT FOR
OR DISTRIBUTION
NOT FORgovernment,
SALE OR
DISTRIBUTION
public accommodations, commercial facilities, transportation
andSALE
telecom
munications. It also applies to the U.S. Congress.
1990

Prohibits discrimination in air transportation by domestic and international carriers against
qualified individuals with physical or mental impairments. It applies only to air carriers that
provide regularly scheduled services for hire to the public.

© Jones & Bartlett Learning, LLC
© Jones & Bartlett Learning, LLC
National Voter
1993
This Act requires all offices of state-funded programs that are primarily engaged in providing
NOT
FOR
SALE
OR
DISTRIBUTION
NOT
FOR applicants
SALE OR
Registration Act
services to persons with disabilities to provide
all program
withDISTRIBUTION
voter registration
forms, to assist them in completing the forms, and transmitting the completed forms to the
appropriate state official.

“Motor Voter Act”
Telecommunications Act

1996

Requires manufacturers of telecommunications equipment and providers of telecommuni
cations services to ensure that such equipment and services are accessible and usable by
© Jones & Bartlett Learning, LLC persons with disabilities,©
Jones
& Bartlett
Learning,
LLC
if readily
achievable.
The amendments
ensure
that people with
NOT FOR SALE OR DISTRIBUTIONdisabilities have access toNOT
FOR
ORand
DISTRIBUTION
a broad
rangeSALE
of products
services such as telephones, cell
phones, pagers, call waiting, and operator services that previously were inaccessible to
persons with disabilities.
Civil Rights of
Institutionalized
Persons Act

1997

Olmstead
Decision

This Act authorizes the U.S. Attorney General to investigate conditions of confinement at
state and local institutions such as prisons, jails, pretrial detention centers, juvenile
© Jones &
Bartlett
Learning,
LLC nursing homes, and institutions
© Jones
& Bartlett
Learning, LLC
correctional
centers,
publicly operated
for persons
with
psychiatric
or
developmental
disabilities.
The
purpose
is
to
all
the
Attorney
General
to
NOT FOR SALE OR DISTRIBUTION
NOT FOR SALE OR DISTRIBUTION
uncover and correct any widespread deficiencies that would jeopardize the health and safety
of the residents.
1999

U.S. Supreme Court affirmed that unjustified institutionalization of people with disabilities is
discrimination and violation of the ADA. States are required to provide community-based
services forLLC
persons with disabilities otherwise
entitled to&institutional
when the
© Jones & Bartlett Learning,
© Jones
Bartlettservices
Learning,
LLC
state’s treatment professionals reasonably determined
thatSALE
community
is
NOT FOR SALE OR DISTRIBUTION
NOT FOR
ORplacement
DISTRIBUTION
appropriate; the person does not oppose such placement; and the placement can reasonably
be accommodated, taking into account resources available to the state and the needs of
others receiving state-supported disability resources.
Source: Adapted from U.S. Department of Justice (2005).

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398 Chaper 25 / Ethical and Legal Issues

© Jones & Bartlett Learning, LLC
© Jones & Bartlett Learning, LLC
FOR SALE
OR DISTRIBUTION
NOT FORinclude
SALEcaring
OR DISTRIBUTION
for one’s self, walking, seeing, hearing, NOT
healthcare
professionals
is the prohibition of discrimina-

speaking, breathing, working, performing manual tasks,
tion against those with disabilities within the realm of
and learning (U.S. Department of Justice, 2005). Under
public accommodations.
the Act employers may not deny qualified individuals the
Private hospitals or medical offices are covered by
opportunity to participate
in
or
benefit
from
federally
Title
III of the ADA as places of©public
accommodation.
© Jones & Bartlett Learning, LLC
Jones
& Bartlett Learning, LLC
funded programs, services,
otherSALE
benefits.OR
Qualified
Public hospitals and clinics andNOT
medical
offices
operated
FOR
SALE
OR DISTRIBUTION
NOTorFOR
DISTRIBUTION
individuals with a disability could not be denied acby state and local governments are covered as programs
cess to programs, services, benefits, or opportunities to
of public entities. Section 504 covers any of these that
participate as a result of physical barriers and, finally,
receive federal financial assistance, which can include
could not be denied employment on grounds of their
Medicare and Medicaid reimbursements. In other words,
© Jones
Bartlett
Learning,
LLC
Jonescare,
& Bartlett
LLC
disability.
The law&applied
to employers
or organizations
if you provide©medical
it is highlyLearning,
likely that you
NOT
FOR
SALE
OR
DISTRIBUTION
NOT
FOR
SALE
OR
DISTRIBUTION
receiving federal funding, so there were still a number
are required to abide by the ADA. The ADA requires
of private entities exempt from the Act. The Act for the
that medical care providers provide individuals with
first time provided a legal definition of individuals with
disabilities
disability and clearly prohibited discrimination on these
• Full and equal access to their health care services
grounds.
© Jones &
Bartlett Learning, LLC
© Jones
Bartlett
and &
facilities;
andLearning, LLC
A second
piece of legislation provided indi- NOT FOR SALE OR DISTRIBUTION
NOT FOR SALE
OR major
DISTRIBUTION
• Reasonable modifications to policies, practices, and
viduals with a disability access to public schooling. The
procedures when necessary to make healthcare serIndividuals with Disabilities Act, commonly referred
vices fully available to individuals with disabilities,
to as IDEA, provides eligible children with disabilities a
unless the modifications would fundamentally alter
free appropriate public education in the least restrictive
the nature of the services©(i.e.,
alter &
theBartlett
essential Learning, LLC
© Jones
& Bartlett
Learning, LLC
Jones
environment. Previously,
many children
with disabilities
nature
of
the
services).
NOT FOR SALE OR DISTRIBUTION
NOTdedicated
FOR SALE
OR DISTRIBUTION
were segregated in schools
to children
with
disabilities. Children with disabilities were now accorded
Equal treatment for individuals with disabilities can
public education opportunities equivalent to able bodied
mean an adjustment to the normal practices of healthcare
children.
providers. For instance, generally it is not acceptable to
Over
the
next
10
years
federal
legislation
eliminated
examine an individual
or her wheelchair
because
© Jones & Bartlett Learning, LLC
© Jonesin&hisBartlett
Learning,
LLC
barriers
in
voting
and
housing
with
federal
funding.
Althe
exam
would
not
be
as
thorough
as
an
exam
on an
NOT FOR SALE OR DISTRIBUTION
NOT FOR SALE OR DISTRIBUTION
though the federal government was moving to eliminate
exam table. Thus, accommodations may be necessary to
barriers, a number of barriers continued to exist in the
get the patient from the wheelchair to the exam table.
private sector. In 1990 President George H. Bush signed
Accessible room design, training in proper techniques,
the Americans with Disabilities Act (ADA), a landmark
and certain equipment (such as adjustable exam tables and
© Jones &
Bartlett
Learning,
LLC the civil rights bill for © Jones
& Bartlett
Learning,
piece
of legislation
often considered
medical testing
equipment)
are likelyLLC
necessary to ensure
NOT FORindividuals
SALE OR
DISTRIBUTION
FOR
OR
DISTRIBUTION
with
disabilities. The ADA is a federal civil NOT
equal
treatSALE
ment. For
nurses
in particular, training regardrights law that prohibits discrimination in employment,
ing the proper techniques for lifting and moving patients
public services, and public accommodations against a
is becoming increasingly valuable. Because most medical
person with a disability. According to the Act, a disservice personnel are not in control of the equipment or
ability, consistent with the Rehabilitation Act of 1973, is
they &
canBartlett
do is be Learning, LLC
© Jones & Bartlett Learning,facilities
LLC available to them, the©most
Jones
a physical or mental impairment that substantially alters
sure they are using proper techniques. Because employNOT FOR SALE OR DISTRIBUTION
NOT FOR SALE OR DISTRIBUTION
one or more major life activities.
ers have a legal obligation to provide equal treatment,
Unlike the Rehabilitation Act of 1973, the ADA apthis training often readily available.
plies to both governmental and private entities (U.S. Department of Justice, 2005). However, the discrimination
Olmstead Decision: Institutionalization
Jones
& Bartlett
Learning,
LLCpublic
© Jones & Bartlett Learning, LLC
is not©barred
everywhere,
only
in employment,
or Community-Based Services
services,
publicSALE
accommodations.
In employment,
NOTadFOR
OR DISTRIBUTION
NOT FOR SALE OR DISTRIBUTION
employers are required to make reasonable accommoIn the late 1990s two women in Georgia whose disabilities
dations for a disabled employee. The word “reasonable”
included mental retardation and mental illness filed suit
has sparked a lot of litigation. Also, the government is
stating that their institutionalization was discriminatory
not allowed to discriminate against the disabled in the
and in violation of the ADA (U.S. Department of Health
© Jones & Bartlett Learning, LLC
© Jones
& Bartlett Learning, LLC
provision of public services. Of particular importance for
and Human Services, 2000). At the time the women were

NOT FOR SALE OR DISTRIBUTION

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Summary

399

© Jones & Bartlett Learning, LLC
© Jones & Bartlett Learning, LLC
NOT FOR SALE OR DISTRIBUTION
NOT FOR SALE
OR
covered
byDISTRIBUTION
the state Medicaid program that restricted
Box 25.3 Web Exploration

payments for ongoing health services to payment for
Code of Ethics for Nursing and Interpretive Statements
services provided during an inpatient stay at healthcare
http://nursingworld.org/ethics/code/protected_
institution. According to the suit, local health professionnwcoe629.htm
als involved in the©care
of the&women
had Learning,
determined LLC
Jones
Bartlett
© Jones & Bartlett Learning, LLC
A Guide to Disability Rights Law
that appropriate mental
provided
NOT FOR SALE OR DISTRIBUTION
NOThealth
FORservices
SALEcould
ORbe
DISTRIBUTION
http://www.ada.gov/cguide.htm
in a community setting, yet at the time Medicare and
Stem Cell Research, National Institutes of Health
Medicaid funding was not available to provide the suphttp://stemcells.nih.gov/info/defaultpage
port needed for community care. As a result of the court
decision the Department of Health and Human Services
© Jonesto&working
Bartlett
Learning,
LLC
© Jones & Bartlett Learning, LLC
committed
with
state Medicaid
directors to
NOT
FOR
SALE
OR
DISTRIBUTION
NOT FOR
SALE
ORis only
DISTRIBUTION
testing reinforce
the belief
that life
valued for able
craft fiscally responsible solutions that support complibodied children and that children with disability should
ance with the ADA, including making funding available
not be allowed to live?
for individuals with disability to live in the community
The therapeutic use of stem cells is a potential ethiwith the right support (U.S. Department of Health and
cal
concern
for many.
ScientistsLLC
postulate that stem cell
Human
Services,
2000).
© Jones & Bartlett Learning, LLC
© Jones & Bartlett
Learning,
therapy
may
be
of
benefit
to
patients
NOT FOR SALE OR DISTRIBUTION
NOT FOR SALE OR DISTRIBUTION with a number
of chronic illnesses, such as diabetes and Alzheimer’s
Individuals With Disabilities:
disease, as well as individuals with disabilities such as
A Growing Voice
spinal cord injury (Chapman, Frankel, & Garfinkel, 1999;
National Institutes of Health, n.d.). Currently, there is
Individuals with disabilities were vocal not only about
©
Jones
&
Bartlett
Learning,
LLC
© stem
Jones
&and
Bartlett
Learning, LLC
a limited supply of available
cells,
it is anticilegal issues but also ethical matters related to the value
NOT
FOR
SALE
OR
DISTRIBUTION
NOT
FOR
SALE
OR
DISTRIBUTION
pated that new sources of live stem cells will be needed
and quality of life associated with disability. One specific
in the future. Under the Bush administration federal
concern was the case of Ashley X (Kirschner, Brashler,
funding for human embryonic stem cell research was
& Savage, 2007), a young disabled girl diagnosed with
limited by presidential order. In March 2009 President
static encephalopathy. As a result of the disability she was
Obama revoked
this &
order
and removed
the limitation
dependent
in
all
activities
of
daily
living,
nonverbal,
and
© Jones & Bartlett Learning, LLC
© Jones
Bartlett
Learning,
LLC
on
scientific
exploration
of
the
use
of
stem
cell therapy
received
all
nutrition
through
a
feeding
tube.
As
Ashley
NOT FOR SALE OR DISTRIBUTION
NOT FOR SALE OR DISTRIBUTION
to reduce disease and disability (National Institutes of
approached puberty her parents were concerned that her
Health, www.stemcells.nih.gov/policy/defaultpage.asp).
physical growth would make it difficult for them to care
For some individuals the use of stem cells presents a moral
for Ashley at home. After discussion with her physician,
and ethical challenge to their values.
a plan was devised to provide high-dose estrogen to at© Jones & Bartlett
Learning,
LLC
© aJones & Bartlett Learning, LLC
tenuate her
growth. Concurrently,
Ashley underwent
NOT FOR SALE
OR DISTRIBUTION
NOT FOR
SALE OR DISTRIBUTION
hysterectomy
and breast bud removal. The combination
Summary
of medication regimen and the surgery was referred to
Perhaps it was inevitable that with the advances in modas the “Ashley treatment” (Kirschner et al., 2007). This
ern medicine since the turn of the 20th century that
treatment raised significant concern among individuals
ethical issues would arise. Where the life expectancy
with disabilities who
viewed&the
parents’ Learning,
decision as LLC
© Jones
Bartlett
© Jones & Bartlett Learning, LLC
once was in the 40s, modern medicine has increased it
evidence of an ongoing stigma against individuals with
NOT FOR SALE OR DISTRIBUTION
NOT FOR SALE OR DISTRIBUTION
to 78 years old. With increased life expectancy came the
disabilities in society. Did the parents’ decision to have
increase of chronic disease and associative suffering.
the hysterectomy performed in the absence of disease
Also, modern medicine found a way to sustain people on
violate the rights of Ashley as a person? Do cases such
life support nearly indefinitely. Consequently, we began
as this further the image of life with disability as less
© Jones
& Bartlett Learning, LLC
© Jones
& Bartlett
Learning,
LLC
the 20th century
asking
how far modern
medicine
could
than
adequate?
go. We ended
20thSALE
centuryOR
asking
how far modern
NOT
FORconcerns
SALE have
OR been
DISTRIBUTION
NOTthe
FOR
DISTRIBUTION
Similar
voiced related to decimedicine should go.
sions on euthanasia and genetic testing. In the case of
The collision between personal rights and modern
genetic testing, if testing reveals gene for one of several
medicine continues today. The battle between rights
diseases that result in severe disability, is it ethical to then
and medicine will likely continue throughout the 21st
proceed with a therapeutic abortion? Is manipulation of
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difficult
decisions
in their practice or work settings. NOT
Personal
Reflection

Yet, certain foundational beliefs such as the belief in our
• Do you have an advance directive? If so, why? If
society that all life has value and meaning will hopenot, why not?
fully underscore ethical decision making in the future.
•
Think about three or four©individuals
whom Learning, LLC
Second, the rights of the
be infringed
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Learning, LLC
Jones &with
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you have had conversations about your end-of-life
upon except when suchNOT
exercise
of those
rights
endanger
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wishes. How would they represent your decisions
others. Third, medical treatment and procedures must be
when questioned by the court?
received voluntarily and the medical community must
•
Do you know someone with a disability? When
honor all stated wishes except where those wishes violate
you initially learned about the disability how did you
personal ethical responsibility to do no harm. The value
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© does
Jones
Bartlett
Learning,
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react? How
this &
person
describe
his or her life
of human life and our responsibility as nurses to do good,
since
the
onset
of
the
disability?
Has
this
changed
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promote health, and serve as a patient advocate should
your initial perception about the person’s life with
be the foundation for our practice.
a disability?
• Can you describe a scenario in a clinical setting when
Critical Thinking
you had a hard time deciding on the right action to
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Describe
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factors did you take into account when deciding?
your daily practice as a nurse.

2. Your patient today is a young woman who sustained
a traumatic brain injury as a result of an assault.
Recommended Books on Ethics and Nursing
She has significant cognitive impairments and is
American
of ethics&forBartlett
nurses with Learning, LLC
Jonesof&daily
Bartlett
Learning,
LLC Nurses Association. (2001).©Code
Jones
dependent for most©activities
living. She
has a
interpretive statements. Washington,
DC:
Author.
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gastrostomy tube in place for nutrition. Her husband
Bandman, E., & Bandman, B. (2002). Nursing ethics through the
is the suspected assailant; however, criminal charges
life span (4th ed.). New York: Prentice Hall.
were never filed against him. The discharge plan is
Bartter, K. (2001). Ethical issues in advanced nursing practice.
for the woman to return home with the husband as
Philadelphia: Elsevier.
the
primary
caregiver.
What
should
you
consider
Beauchamp,
T. L.,
Childress,&J. F.
(2001). Principles
of biomedical
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©&Jones
Bartlett
Learning,
LLC
when
preparing
this
patient
for
discharge?
ethics
(5th
ed.).
New
York:
Oxford
University
Press.
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3. You are working in the outpatient clinic. Today your
Bosek, M. S. D., & Savage, T. A. (2007). The ethical component of
nursing education: Integrating ethics into clinical experience.
patient’s family members report her memory is bePhiladelphia: Lippincott Williams & Wilkins.
coming more impaired and they are fearful of her
Danis,
M., Clancy, C., & Churchill, L. R. (2005). Ethical dimensions
living alone. The physician has recommended the
of
policy. NewLearning,
York: Oxford University
© Jones & Bartlett
Learning,
LLC
& Bartlett
LLC Press.
family pursue
obtaining
guardianship. The family © Joneshealth
Jecker, N. S., Jonsen, A. R., & Pearlman, R. A. (2007). Bioethics:
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asks you
pros and cons of guardianship. What NOT FOR SALE OR DISTRIBUTION
An introduction to the history, methods, and practice (2nd
advice do you have for the family?
ed.). Sudbury, MA: Jones & Bartlett.
4. What are the critical factors to be considered when
Macrina, F. (2005). Scientific integrity: An introductory text with
allowing a surrogate to make healthcare decisions
cases (3rd ed.). Washington, DC: American Society for Mion a patient’s behalf?
crobiology Press.
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© Jones & Bartlett Learning, LLC
5. You are a nurse manager. A qualified applicant just
Morrision, E. E. (2006). Ethics in health administration: A pracNOT FOR SALE OR DISTRIBUTION
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accepted a position on your unit. The human retical approach for decision makers. Sudbury, MA: Jones &
Bartlett.
sources representative notifies the nurse has a lower
extremity amputation and uses a prosthesis. What
should you consider when planning the nurse’s oriReferences
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© Jones & Bartlett Learning, LLC
entation?
American Nurses Association. (2001). Code of ethics for nurses with
NOTpatient
FORhas
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OR DISTRIBUTION
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6. Your
a medication
ordered that is derived
interpretive statements. Washington, DC: Author.
from human embryonic stem cells. You believe the
Cerminara, K. A., & Goodman, K. (2010). Schiavo case resources:
use of stem cells is morally wrong. What options are
Key events in the case of Theresa Maria Schiavo. Retrieved
available to you and how will do decide what option
May 20, 2010, from http://www6.miami.edu/ethics/schiavo/
to pursue?
schiavo_timeline.html

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References

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ORA.DISTRIBUTION
Chapman,
R., Frankel, M.S., & Garfinkel, M.S. (1999). Stem
Masters-Farrell,
P. A. DISTRIBUTION
(2007). Ethical, moral and legal consider-

cell research and applications, monitoring the frontiers of
ations. In K. Mauk (Ed.), The specialty practice of rehabilitabiomedical research. American Association for the Advancetion nursing: A core curriculum (5th ed., pp. 27–34). Glenview,
ment of Science and the Institute for Civil Society. Retrieved
IL: Association of Rehabilitation Nurses.
September 1, 2010, from http://stemcells.nih.gov/info/ethics
Menne, H. L., & Whitlatch, C. J. (2007). Decision-making in© Jones & Bartlett Learning, LLC
© Jones & Bartlett Learning, LLC
FindLaw. (2010). Cruzan v. Director, Missouri Department of Health.
volvement of individuals with dementia. The Gerontologist,
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FOR
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Retrieved August 1, 2010, from http://caselaw.lp.findlaw.com/
47(6), 810–819.
scripts/getcase.pl?court=us&vol=497&invol=261
National Institutes of Health. (n.d.) Stem cell information—federal
Garner, B. A. (1999). Black’s law dictionary (7th ed.). St. Paul,
policy. Retrieved September 10, 2010, from http://stemcells.
MN: West Group.
nih.gov/policy/defaultpage.asp
Graham-Eason, C. (1996). Ethical considerations for rehabilitaRedman, B. K., & Fry, S. T. (1998). Ethical conflicts reported
© Jones & Bartlett Learning, LLC
© Jones & Bartlett Learning, LLC
tion nursing. In S. Hoeman (Ed.), Rehabilitation nursing:
by certified rehabilitation registered nurses. Rehabilitation
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Process and application (2nd ed., pp. 34–46). St. Louis, MO:
Nursing,
23(4),FOR
179–184.
Mosby.
Regents of the University of California. (2004). The disability
Hart, S. E. (2005). Hospital ethical climates and registered nurses’
rights and independent living movement: Introduction. Returnover intentions. Journal of Nursing Scholarship, 37, 173–
trieved from http://bancroft.berkeley.edu/collections/drilm/
177.
introduction.html
© Jones & Bartlett Learning, LLC
© Jones &
Bartlett Learning, LLC
Illinois Department of Public Health. (2005). Illinois Department
Savage, T. A. (2005). Clinical consultations: How do we handle
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Public Health announces new uniform do-not-resuscitate
conflicts with parents over unsafe oral feedings? Rehabilitaorder form. Press release June 1, 2005. Retrieved April 15,
tion Nursing Journal, 30(1), 7–8.
2010, from http://www.idph.state.il.us/public/press05/6.1.05
Savage, T. A., & Michalak, D. R. (1999). Ethical, legal and moral
.htm
issues in pediatric nursing. In P. A. Savage, T. A., Parson, J.,
In Re: The Guardianship of Theresa Marie Schiavo from the CirL. (2009). Rehabilitation team
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& Bartlett Learning, LLC
cuit Court for Pinellas County, Florida Probate Division File
disagreement: Guidelines for resolution. Physical Medicine
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No. 90-2988GD-003.
and Rehabilitation, 1, 1091–1097.
Karen Ann Quinlan Memorial Foundation. (2010). Karen Ann QuinU.S. Department of Health and Human Services. (2000). The Olm
lan: She changed the way people looked at life and death. Restead decision fact sheet. Retrieved December 1, 2010, from
trieved July 1, 2010, from http://www.karenannquinlanhospice
http://www.acf.hhs.gov/programs/add/otherpublications/
.org/history.htm
olmstead.html
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Kirschner, K., Brashler, R., & Savage, T. A. (2007). Ashley X.
U.S. Department of Justice. (2005). A guide to disability rights
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American Journal of Physical Medicine and Rehabilitation,
laws. Retrieved December 10, 2010, from http://www/ada
86, 1023–1029.
.gov/cguide.htm

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