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Subtle Ethical Issues

05 Dec 2017Essay Samples

Subtle Ethical Issues and Challenges in Nursing Working with Death and Dying

Nursing is a profession that involves the constant development of personal relationships, many of them intensified by crisis situations. I feel deeply that as a nurse it is a part of my preparation as a nurse to examine the many potential situations that could arise in my professional relationships and prepare myself with forethought.

Often the subject of ethics becomes intertwined with the current atmosphere of fear around litigation. It is important for every professional to be aware of the laws that set the definite perimeters of their appropriate behavior. However, with focus externalized onto the legalities of the professional relationship, the larger truth of the profoundly intimate nature of the nurse and client relationship may not be examined with the diligence necessary

I feel that true preparation to be a nurse requires not only sincere inquiry but also the time to develop insight. This paper will focus on subtler areas of ethics in nurse patient relationship and will also focus on special circumstances that arise when working with death and dying. I will be calling upon my own experiences in nursing and also those I have learned about through conversations and reading.

Ethics in the Nursing Relationship

The most basic ethical value of any relationship, I feel is that which is expressed by the golden rule. "Do onto others as you would have them do unto you." First of all, the golden rule is only valid if the patient and I share the same needs and boundaries. Perhaps it would be my desire to have someone demonstrate caring by asking me about my family and situation. Or perhaps it would be my desire to be massaged as a way of relaxing. It could well be that either of these actions could be considered intrusive by some patients. Therefore I must not simply use this rule to project my own needs onto a patient and then fill them but must take the understanding to a deeper level. On this level I would first want a caretaker to be sensitive to what my boundaries as well as my needs might be. In all cases the golden rule must be brought into appropriate context. A set of skills must be developed for determining how each individual can have their needs for nurturance, understanding and support given in a way that is appropriate and meaningful to them.

Rachel Naomi Remen (1988) in an article "On Defining Spirit" states, "ethics is a set of values, a code for translating the moral into daily life." In order to be able to express my moral values into my work, I must define them clearly. I feel that honesty and congruence are very important moral values. Yet, I may often have to express caring, honestly and congruently, while serving patients that are making decisions that are far different than what I would choose. In my experience with Hospice, I have developed my own "moral" ideas about the way in which death should be approached. It is a strong moral belief of mine that the approach of death provides an opportunity for growth personally and completion in family and friendship relationships that is very valuable. Yet, I may need to work with a patient that simply wants to be as numb as possible mentally as well as physically until death relieves them.

It thus seems that while the personal value clarification that comes with examining my own experiences may actually make my belief systems stronger, this must always be balanced by the willingness to allow the patient their own choices in the dealing with the life and death issues that I will be a part of in my position as a nurse. In relationship we are constantly expressing our intentions through our actions. Our intentions to "do no harm" and to be of help require that we are not so blinded by our intentions for good that we do not see the actual effects of each of our subtle choices. In examining this desire to "do onto others as I would have them to on to me," I find that it is most important that I learn to be aware of each response and communication from my patients to be guided in relationship. I can learn from each experience, but I must also be aware that individuals that come under my care have their own needs, value, experiences and boundaries. With awareness of this individuality I can express the ethical principal of the golden rule in a manner that respects these differences.

Intensity of Experience - Opportunity with Responsibility

There are many situations in which a nurse is drawn into an intense experience with a patient. The very nature of nursing often involves the care of another individual at a time of crisis. In Chinese the hexagram for crisis also means opportunity. In working around the dying I have found myself profoundly changed as well as observing change in others. The recognition of a terminal illness opens a person to a reevaluation of their life and their priorities. The family and friends may also engage in a profound process of change to varying degrees. They often look to the caregiver as an "expert" or at least one more experienced. They may open up and talk to a nurse that is providing nurturance and physical care in ways that they would not do even with close friends.

Just as survivors of such things as airplane crashes or floods, or other natural disasters come to be bonded with a special bond, a nurse if constantly forming profound bonds with those who are involved in a health crisis together and yet must maintain a professional perspective.

In a situation which is altered and amplified by the possibility of death, each and every expression of caring and also of understanding can be incredibly meaningful both to the patient and to the family. Yet it is important to allow the patient and the family to find their own truths and their own growth in the situation. As a nurse I must be willing to engage on a very deep level while understanding that I must be sensitive and ready to withdraw at any moment that the family needs to communicate and share without an outside presence.

Some very unusual challenges face a nurse who enters into work such as providing care for dying patients. Hospice has done much to allow health care professionals to understand that there is a point when death is no longer the enemy, needing to be fought and overcome. At that point it becomes a part of the professional nurse's task to move into a role that is not so much one of restoring health as of helping the patient maintain comfort while making many adjustments towards the final moment of death.

It has been my experience with patients that are nearing death that they may enter into "non-ordinary states of consciousness." This state has been defined in Kylea Taylor's 1995)book, The Ethics of Caring, as "a normal and expanded consciousness that promotes healing, reconnection with self, others and nature, and psychospiritual development and insight." It is my personal belief that these states are not due to medication, dehydration or other physical causes but may be a natural human phenomenon preparatory to death. In seeking to  make a conscious ethical decision regarding my behavior around these states, or other sensitive communications that often occur during the patient's progression towards death, I need to consider my communications to the patient and to the family with care. My interpretation and actions may well provide a foundation for those of the patient and family. I feel that I must be willing to provide my own knowledge and experience without projecting any of my own interpretations; spiritually, religiously, or metaphysically. These types of ethical situations may be subtler than those that are generally spoken of but they are very real and must be dealt with responsibly.

Transference and Counter-transference in Nursing

Another subtle area of ethical behavior in nursing occurs due to the possibility of transference and counter-transference. Transference is defined as occurring when "the client reacts unconsciously to the caregiver's feelings, thoughts, expectations, patterns of behavior and beliefs and may project his/her own feelings, thoughts expectations, and beliefs onto the caregiver. Counter-transference conversely occurs when "the caregiver reacts unconsciously to the client's feelings, thoughts, expectations and beliefs and may project his own feelings, thoughts, expectations, patterns of behavior, and beliefs onto the client. These terms come from the psychoanalytic field but are realities for those in the nursing profession as well.

I as well as many others have entered the nursing profession not only for financial gain and an interesting dynamic career but also because of my desire to be of service and thus "needed". Elisabeth Kubler-Ross in her teaching differentiates between "care-giving' and "care-taking" to point out that those in the helping professions must not let their need to be needed be inappropriate. I must always be conscious of my motives in general and my response to each individual patient relationship to assure that it is the patient's needs that are being attended to.

A client who is facing a health crisis or impending death may be feeling intense needs to be heard, recognized, nurtured or loved. They may therefore perceive my desire to be of service to them and to treat them with kindness and compassion as an opening to project their own personal needs onto our relationship. Again as a nurse it is important to find ways to create clarity of boundaries that facilitates the potential for offering profound as well as superficial care without fostering transference based ideation.

It has been my experience that each nurse must find a way of dealing with transference and counter-transference that is congruent with their own personality. Maturity in this area is a very important aspect of nursing. I must allow myself to be positively motivated by my willingness to give and to be needed without ever becoming dependent on being needed in any negative fashion. The patient must be willing to be cared for and receptive to all levels of care and compassion without taking the relationship to an inappropriately personal level.

As a professional in the nursing field it is up to me to find the combination of words, body language, and skillful care-giving that will facilitate the highest ethical relationship between my patients and myself. I must set the tone and maintain it.

In dealing with death and dying it becomes apparent that as a nurse and as a person I may be the catalyst or simply the recipient that allows for a person to come to an insight or express a level of truth that is a truly meaningful breakthrough. I may come to be important to a person that I care for in this very intimate way. If I simply feel that it is inappropriate to be intimate and withdraw from communication or eye contact I may prevent a person from having a truly transformative experience. Many who work with death and dying feel that it is these Tran formative experiences that make "it all worthwhile." Therefore the nurse-patient balance must found and maintained through a great deal of sensitivity, awareness and willingness to grow.

Only a few of the subtle ethical considerations that I have pondered are expressed here. Each and every patient that I work with continues to teach me that I must be aware and vigilant in all of my interactions. And yet I must also be genuine, relaxed, and focused on using my nursing skills to provide the care that they need. I enjoy this challenge and look forward to becoming more consciously ethical in all of the varieties of caring relationships that nursing so richly provides. Our profitable writing service offer quality academic writing help 

Works Cited

  • Remen, R.N. (Autumn, 1988), On defining spirit. Noetic Sciences Review. 63.
  • Taylor, K. (1995) The ethics of caring. Hanford Mead Publishing.

Other Resources

  • Kubler-Ross, E. (1997). On death and dying. Collier Books.
  • Kubler-Ross E. (1997). Death:The final stage of growth. Simon and Schuster.
  • Bishop, A.H. (1996)Nursing Ethics: Therapeutic Caring Presence Wadsworth Pub. Co.
  • Furrow, Greaney, Johnson, Jost, & Schwartz. (1999) 1999 Supplement to bioethics : Healthcare law & ethics. The West Group.
  • Quinn, C.A. (1987) The Professional commitment: Issues and Ethics in Nursing.

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