NUR09322: Analysis of Law, Ethics and Reasoning in Nursing Practice

This report analyzes a nursing case study involving a 60-year-old patient with stage four breast cancer in a palliative care unit who requests a Do Not Resuscitate (DNR) order. The report examines the ethical and legal considerations surrounding the patient's request, including the application of ethical principles such as autonomy, beneficence, non-maleficence, and justice. It explores the role of advance medical directives (AMD) and the legal requirements for DNR orders in Singapore. The report discusses the ethical theories of utilitarianism and deontological theories in the context of the case, considering the conflicting interests of the patient, family, and healthcare providers. The case highlights the importance of respecting patient autonomy, ensuring proper legal documentation, and navigating the complexities of end-of-life care. The report also discusses the Code for Nurses and Midwives in Singapore and how it applies to the situation, emphasizing the nurse's responsibility to act in the patient's best interest while adhering to legal and ethical guidelines. The nurse's actions are analyzed in light of ethical frameworks, and the report concludes by emphasizing the importance of ethical decision-making in nursing practice.

Running head: NUR09322 1
Exploring the Theory and Application of Law and Ethical Reasoning in Nursing Practice.
(Author’s name)
(Institutional Affiliation)

NUR09322 2
Introduction.
Health ethics are based on questions about what is right and wrong and what constitutes
professional conducts while taking justification based on situations, value conflicts or ethical
dilemmas, systematic analysis and the resolution processes of those conflicts(American Nurses
Association, 2016). Health ethics takes a broader perspective including issues faced by health
care providers, health policy-makers, patients and their families and health researchers in various
health-related contexts. Primarily, health ethics are built on complex and empirical realities on
certain and specific health issues. (WHO, 2016) Ethics and laws are highly related since they
both define how individuals ought to act. They are sometimes complementary than a person may
be legally required to do what is ethically required. However, some laws can conflict with ethical
standards. This is because ethics are majorly concerned with wide aspects of behaviors and
relationships than most forms of legal relationships. For instance, abusing elders may be seen
unethical but not against the law(Johnstone, 2016). Health care professionals are obligated to
follow codes of ethics which largely align with legal regulations. Therefore, health care
providers need to follow ethical standards in every clinical decision-making.
Ethical standards are important in order to make sure nurses and other health workers do
what is best for the interest of the patients(Gough, 2014). Such bio-medical ethics seek to defend
and protect patients rights and dignity through the use of specific norms, principles, and values
that regulates ethical conducts(International Council of Nurses, 2012b). Ethics makes all nurses
to be legally and professionally answerable to their actions. In this regard, ethics provides
guidelines and a framework in which health care professional work. Other than that, ethics
protect nurses and patients as they contain all requirements needed during clinical practice. The
code for nurses and midwives provide guidelines for nurses while they are working with people,

NUR09322 3
during their practice, in their profession and while working with co-workers(Pitama et al., 2017).
Therefore, ethics and laws equip and govern nurses with knowledge and skills while tackling
ethical and legal issues.
Patient choose to do not resuscitate at the end of life care
Mrs. M, a 60 years old female patient, was admitted in the palliative care unit six months ago
with stage four breast cancer. She is married and has two children, a daughter, and a son. Mrs.
M has a history of diabetes and hypertension which she has been receiving treatment at the
palliative care unit. She is also under pain management for cancer. Mrs. M is a Christian who
strongly believe that it is the will of God when a person dies and therefore nobody should
interfere with Gods Work. Her children often come to visit her with her glad children. She is
often happy and like preaching to other patients requesting them to repent at their final days.
Some of her most consistent symptoms include joint pain and urine incontinence. Sometimes she
refuses to eat saying she had nausea, or she is contented. The doctors and nurses on duty have
been trying to help her day by day to alleviate the symptoms.
When admitted to the palliative care, her medical doctor explained to her that she had
about eighteen months to live and the reason for admission was for monitoring and pain
management only. She said she has made peace with God and when the time of death comes she
will be ready. However, over the past two weeks, her condition has been deteriorating more than
expected. She is currently bedridden, and she barely talks as usual. She frequently complains of
pain in a different part of the body from time to time. Three days ago she called the nurse on
duty and requested her if she has to die the nurse should not resuscitate her. The nurse on duty
tried to explain to she still had more time to live, but she still insisted that she did not require
resuscitation. She said that was the will of God and no one should interfere with it. She then

NUR09322 4
asked the nurse on duty not to tell her children and husband since they would refuse to comply
with her request. The nurse on duty was in dilemma and therefore she consulted the doctor and
explained the whole situation. The doctor said the patient has to sign a consent form together
with the family members as the protocols provided.
Discussion.
Do not resuscitate and advance medical directive as applied in ethics
In palliative care, especially cancer patients a do not resuscitate(DNR) decision is
commonly made(Santonocito, Ristagno, Gullo, & Weil, 2013). DNR decision is often made
when patients decline resuscitation if it is considered that the patient may not survive the
cardiopulmonary resuscitation taking into account the quality of life or in a poor prognosis.
Quality of life is commonly defined as the personal subjective perception of how and where they
live, expectations, associated goals and objectives, standards and concerns(Chen et al., 2014). A
DNR order involves refraining from basic CPR and advance CPR that include drugs and
defibrillation(Bailey et al., 2012). If there is no official DNR order, a CPR must be started
immediately as guided by the clinical guidelines in Singapore.
In Singapore, an Advance Medical Directive(AMD) is a legal document usually signed
by the patient as a directive of what nurses and doctors should use whenever there is an
extraordinary life-sustaining intervention to prolong one's life(Lachman, 2010). Nurses and
doctors are obligated to inform patients all form of treatment and in that case-patients can decide
what form of treatment they should receive at the end of life(Sanderson, Zurakowski, & Wolfe,
2013). For instance, any patient over the age of 21 and mentally fit can decide on his or her own
whether to receive CPR or not. In our scenario, the patient had not signed the AMD and thus
there was no legal justification indicating the patient admitted DNR decision. In that case, a

NUR09322 5
nurse was obligated by law to resuscitate the patient. In addition, while signing an AMD, it is
legally required that the decision must be witnessed by two individuals. However, AMD does not
necessarily require the presence of a lawyer(Silvennoinen et al., 2014).
Ethical principles as related to DNR decisions.
According to the American Nurses Association, a DNR decision is guided by various
ethical principles(Johnstone, 2015). These include the principles of beneficence, non-
maleficence, autonomy, and justice. The principle of autonomy recognizes that the patient has
the independence to determine whether to receive treatment or not as far as the rights and
liberties of others are respected. In this regard, a mentally fit patient should be treated with
autonomy(WHO, 2016). That means the patient has a right to voluntarily choose the kind of
procedures he or she receives including life support and advance care. In our case scenario, Mrs.
M had the right to reduce CPR and receive the kind of care she wanted. The nurse on duty had
simply to acknowledge and respect her decision as in nursing care patient’s priority comes first.
However, this right can be affected if there were no legal evidence to prove that the patient has
declined certain treatments(International Council of Nurses, 2012a). It is the responsibility of a
nurse and other health care workers working for the benefit of the patient to seek consent to have
a legal document that indicates what type of care the patients have chosen.
The ethical principle of non-maleficence forbids nurses and doctors from inflicting harm
to the patient(Holt, 2017). Disease and pain are kind of harm to the patients and therefore, a
nurse is obligated to perform a CPR to Mrs. M. However, at times the treatment can become an
insult or meaningless to the patient and thus turning to harm to the patient. Most of the patient
perceives CPR in different ways and some like Mrs. M will opt not to be done on them(Kulju,

NUR09322 6
Stolt, Suhonen, & Leino-Kilpi, 2016). The spiritual, traditional and any other aspect of the
patient is important and therefore it should be respected(Imran, Haider, Jawaid, & Mazhar,
2014). In this regard, it was more harm doing a CPR to Mrs. M. According to ANA, patients
always know what is better for them and therefore their decisions should be respected.
The ethical theory of beneficence obligates that a nurse should always work to promote
the welfare of the patient(Santonocito et al., 2013). This means a nurse should work in the
prevention of harm and the interest of the patient. This principle is most applicable where
sustaining life for the patient is no longer for his or her own best interest. Sustaining life by
doing CPR was no longer her best interest(Johnstone, 2016). She wanted to die with dignity as
God had planned. Doing a CPR was extraordinary care for her which only prolonged the dying
process and suffering. Sometimes, especially at the end of life care, death can be the patient
priority and thus acting on what the patient needs are the patients best interest(Shrestha S & Jose
P, 2014). In addition, preserving the poor quality of life can be for denying the patient her well-
being and dignity.
The theory of Utilitarianism as applied in the case.
The theory of utilitarianism seeks to answer the question ‘what ought a nurse can do?' in
order to act in a way that could bring the best consequences possible(Everett, Pizarro, &
Crockett, 2016). When checking the consequences, the theory deems to include both good and
bad produced by a certain act. Where the differences in consequences are not that large, many
healthcare providers do not make the choice an ethical or moral issue(Terminology, Constituents,
& Designation, 2016). This theory suggests that acts should only be classified as either morally
right or wrong and the consequences should have a significance in a person life. In determining
the results' something is held to be good itself regardless of other values. For instance, the theory

NUR09322 7
of utilitarianism analyses happiness as a balance of pleasure over pain and suggest that such
feelings are the intrinsic value and dis-value(Conway & Gawronski, 2013). In this regard, nurses
have to make a possible comparison of intrinsic values produced by two alternatives or dilemma
to estimate which would produce a better consequence.
From the scenario of Mrs. M, the nurse on duty was in dilemma. Mrs. M had requested
not to be resuscitated which is against the nursing standards. Furthermore, Mrs. M wanted a
nurse to keep it a secret from family members. If Mrs. M could have died, the family member
would have probably sued the nurse on duty due to negligence. On the other hand, the patient
would have not contended if the nurse informed the family members. This would be a breach of
privacy, which is against the principle of confidentiality. According to the code of conduct for
nurses, a patient with a sound mind has the right to receive treatment the way he or she wants. In
that regard, not informing the family members would be morally right. However, the nurse took
the correct cause of action by informing the doctor who suggested the patient should fill an AMD
for legal purposes. In that way, she protected herself and the patient ethically and legally. Mrs. M
in the case does not seem to see the consequences for her actions when she dies and thus the
theory of utilitarianism is applied. To her living with poor quality of life is worse than death.
Therefore, the case presents two major conflicting issues, live and die. Her children and husband
have a right to know her condition(Szekely & Miu, 2015). But by determining what is morally
right could have been difficult for her. Telling her family she did not want to live any longer
could have been a problem and thus she devalued what was morally right in terms of family
matters.
Deontological Theories as applied in case Scenario.

NUR09322 8
Deontological theories are different from utilitarianism theories in essence that, they do
not judge morals in terms of their consequences but the state of affairs they bring about. This
theory suggests that some circumstances cannot be judged on the results they bring no matter
how good they are(Gillon, 1985). This means some choices are morally forbidden no matter how
good their effects are. Similarly, people should not do wrongful things no matter how much such
things bring minimal effects. Such norms and values should be obeyed by each person and are
not to be maximized or exaggerated(Szekely & Miu, 2015). Therefore, the deontological theory
suggests that doing what is right have greater morality that doing what is good. If the act is in
relevant with the right, it has to be undertaken no matter how good or bad effects it produces.
Therefore, certain actions might be right but not necessarily bringing maximum goodness as
relevant to morals and values. In this regard, such actions are permitted in essence that someone
is permitted to do so even if the alternatives might have better morals and values(Terminology et
al., 2016). In that case, therefore, nurses should do the permitted actions because they are
obligated to do so and more importantly they should not do what is not obligated.
From the case, the nurse on duty was obligated to do what was right but not what was
necessarily good. This includes performing such acts that are for the benefit of the patient but not
family members or any other healthcare worker. Therefore, the nurse should have complied with
the patient decision of avoiding doing the CPR. However, a DNR decision has to follow legal
and ethical protocols such as making sure the patient has signed the AMD. The patient, on the
other hand, was doing what was right following the principle of autonomy. It was her decision
and thus no one could have interfered with it.
Reflection Using Gibbs reflection cycle.

NUR09322 9
The case scenario was about Mrs. M who was admitted at palliative care for monitoring and
pain management. The patient condition stated deteriorating making her bed-ridden. During that
period the patient requested the nurse on duty to not resuscitate her if her condition should
worsen more leading to death. Furthermore, she asked her not to inform her family members.
The nurse on duty did not know what to do and therefore consulted the doctor who advised on
signing the AMD.
After hearing the event, I was surprised since I have never encountered such a scenario where
patients refuse CPR and prefer death than life. I have heard of such cases and read in the class
unit about ethical dilemmas but not in a real-life situation. However, from the case, the nurse
handled the scenario ethically since the patient has the right to receive treatment or not. By
deciding to consult the doctor, the nurse on duty was able to solve the case where she was
advised on AMD.
This event presented a medical dilemma in a real clinical scenario. After consulting with the
doctor, the nurse was at ease of knowing the right thing to do. Both the patient and the nurse
have contended. The nurse and the doctor used ethics and moral standards while solving the
issue. There was no breach of privacy and all they did was following ethical principles as guided
by the code of professional conducts.
From the case scenario, I learned that at times patient at the end stage of life can decide not to be
resuscitated. In that case, it is always right to respect the patient right of autonomy and adhere to
what she or he wants. This is where ethical principles apply such as autonomy, beneficence,
respect, confidentiality, and maleficence. Besides, I came to realized that such cases are legally
boded and it is good to consult and work as a team during such scenarios.

NUR09322
10
In the future, when I come with such cases, I will always try to do what is right but not what is
necessarily good. The patient has the right to receive resuscitation or not even if the intervention
is meant to save a life. In addition, I will try to use all ethical principles and theories I learned
into class to make sure my action is both legally and ethically obligated.
Conclusion.
In conclusion, law and ethical principles are key elements that govern what a nurse
should or not in a given clinical conflict. Health ethics takes a broader perspective including
issues faced by health care providers, health policy-makers, patients and their families and health
researchers in various health-related contexts. The code for nurses and midwives provide
guidelines for nurses while they are working with people, during their practice, in their
profession and while working with co-workers. Therefore, ethics and laws equip and govern
nurses with knowledge and skills while tackling ethical and legal issues.

NUR09322
11
References.
American Nurses Association. (2016). American Nurses Association Position Statement on
Nurses’ Roles and Responsibilities in Providing Care and Support at the End of Life. ANA
Position Statement, 1–10. Retrieved from
http://www.nursingworld.org/MainMenuCategories/EthicsStandards/Ethics-Position-
Statements/etpain14426.pdf
Bailey, F. A., Allen, R. S., Williams, B. R., Goode, P. S., Granstaff, S., Redden, D. T., & Burgio,
K. L. (2012). Do-not-resuscitate orders in the last days of life. Journal of Palliative
Medicine. https://doi.org/10.1089/jpm.2011.0321
Chen, Y. Y., Gordon, N. H., Connors, A. F., Garland, A., Lai, H. S., & Youngner, S. J. (2014).
Factors associated with two different protocols of do-not-resuscitate orders in a medical
ICU. Critical Care Medicine. https://doi.org/10.1097/CCM.0000000000000411
Conway, P., & Gawronski, B. (2013). Deontological and utilitarian inclinations in moral decision
making: A process dissociation approach. Journal of Personality and Social Psychology.
https://doi.org/10.1037/a0031021
Everett, J. A. C., Pizarro, D. A., & Crockett, M. J. (2016). Inference of Trustworthiness From
Intuitive Moral Judgments. Journal of Experimental Psychology: General.
https://doi.org/10.1037/xge0000165
Gillon, R. (1985). Utilitarianism. British Medical Journal (Clinical Research Ed.).
https://doi.org/10.1136/bmj.290.6479.1411
Gough, I. R. (2014). The significance of good medical practice: A code of conduct for doctors in
Australia. Medical Journal of Australia. https://doi.org/10.5694/mja13.11334
Holt, J. (2017). Ethical Issues at the end of Life. Key Concepts and Issues in Nursing Ethics.
https://doi.org/10.1007/978-3-319-49250-6_10
Imran, N., Haider, I. I., Jawaid, M., & Mazhar, N. (2014). Health ethics education: Knowledge,
attitudes, and practice of healthcare ethics among interns and residents in Pakistan. Journal
of Postgraduate Medical Institute.
International Council of Nurses. (2012a). The ICN Code of Ethics for Nurses. The Michigan
Nurse. https://doi.org/10.1111/j.0028-1425.2007.ethics.x

NUR09322
12
International Council of Nurses. (2012b). The ICN Code of Ethics for Nurses. In International
Council of Nurses. https://doi.org/10.1097/00000446-200110000-00029
Johnstone, M. J. (2015). Decolonizing nursing ethics. International Nursing Review, 62(2), 141–
142. https://doi.org/10.1111/inr.12197
Johnstone, M. J. (2016). Key milestones in the operationalization of professional nursing ethics
in Australia: A brief historical overview. Australian Journal of Advanced Nursing, 33(4),
35–45.
Kulju, K., Stolt, M., Suhonen, R., & Leino-Kilpi, H. (2016). Ethical competence: A concept
analysis. Nursing Ethics. https://doi.org/10.1177/0969733014567025
Lachman, V. (2010). Do-not-resuscitate orders: nurse’s role requires moral courage. Medsurg
Nursing : Official Journal of the Academy of Medical-Surgical Nurses.
Pitama, S. G., Bennett, S. T., Waitoki, W., Haitana, T. N., Valentine, H., Pahina, J., …
McLachlan, A. (2017). A proposed Hauora Māori clinical guide for psychologists: Using
the Hui Process and Meihana Model in clinical assessment and formulation. New Zealand
Journal of Psychology.
Sanderson, A., Zurakowski, D., & Wolfe, J. (2013). Clinician perspectives regarding the do-not-
resuscitate order. JAMA Pediatrics. https://doi.org/10.1001/jamapediatrics.2013.2204
Santonocito, C., Ristagno, G., Gullo, A., & Weil, M. H. (2013). Do-not-resuscitate order: A view
throughout the world. Journal of Critical Care. https://doi.org/10.1016/j.jcrc.2012.07.005
Shrestha S, & Jose P. (2014). cz#w2x$$""$#$_KNOWLEDGE & PRACTICE OF NURSING
ETHICS AND LAWS. Journal of Universal College of Medical Sciences, 02(03), 30–33.
Silvennoinen, K., Meretoja, A., Strbian, D., Putaala, J., Kaste, M., & Tatlisumak, T. (2014). Do-
not-resuscitate (DNR) orders in patients with intracerebral hemorrhage. International
Journal of Stroke. https://doi.org/10.1111/ijs.12161
Szekely, R. D., & Miu, A. C. (2015). Incidental emotions in moral dilemmas: The influence of
emotion regulation. Cognition and Emotion. https://doi.org/10.1080/02699931.2014.895300
Terminology, S., Constituents, U., & Designation, R. (2016). Deontological Ethics. In Stanford
Encyclopedia of Philosophy.
WHO. (2016). Ethical standards and procedures for research with human beings. World Health
Organization.