Ethics (Review)

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You will find in this section, the information needed to prepare for the Home Health Aide In-Service exam. You can view, download and print for better preparation.

ETHICS

Health care workers face ethical issues in every setting. This is especially true in the home, where the independence of both the patient and the care providers, along with limited supervision, makes identifying and dealing with ethical issues a challenge.

For home health staff, ethical issues in the home may be due to patient care concerns, patient choice, family involvement and the staff member's personal involvement and compliance with agency policies and laws. To understand the risk involved and act responsibly, the staff member must have an understanding of ethics and be able to recognize and report potential ethical issues.

Ethics is the study of the difference between right and wrong. It is closely related to human behavior, values and morality. Over time, many people have accepted basic beliefs about right and wrong. Those common beliefs are known as ethical standards or principles.

The common standards, as well as a person's own standards, guide the way a person acts. Actions can show a person's understanding of right and wrong and the person's beliefs about ethics. Home health staff must also be aware of the ethical standards or requirements of their roles and their workplace. Those standards are used to guide ethical actions while providing care. Staff must also think about how well those standards match their own understanding of ethical actions.

KEY TERMS TO AID YOUR UNDERSTANDING

Bioethics:

health care ethics; the ways the standards of right and wrong are used in health care

Code:

a set of written rules

Compliance:

following the rules, doing what is expected

Morality:

acting in ways that agree with customs and traditions, often in relationship to personal or religious beliefs

Standards:

requirements for the way something should be done; in ethics, standards are also called principles

Values:

beliefs that are important to a person or group of people

Basic Ethical Standards

There are several ethical standards that revolve around the simple concept of doing good. Each can be described by the following guidelines:

Be kind to others.
Do no harm.
Treat people fairly.
Respect the rights of others to make their own choices.
Keep promises.
Tell the truth.
Respect privacy and personal property.

Most people agree to follow those guidelines and try to live by them each day. In many cases, "doing good" can be quite simple, such as donating food or helping a neighbor.

Doing good and doing no harm are two concepts that go hand in hand. Sometimes it becomes harder to tell the difference between doing good and avoiding harm.

It's usually good to tell the truth. Occasionally, though, telling the truth might hurt someone's feelings, especially if it concerns something such as the person's weight or new hairstyle. When health care issues are involved, it can become even more difficult to tell the difference.

Ethical Requirements in Health Care

Health care professionals encounter situations daily that require ethical behavior and decision-making.

These may involve patient care, families or a health care staff member's personal behavior. Additionally, sometimes there are ethical and legal requirements affecting the same situation, making it difficult to tell the difference between the two. For example:

Patient care. When caring for patients, it is normal for health care workers to want to do the right thing and avoid harming those patients. Following policies and procedures helps ensure that care is provided properly. However, patient care questions may occur, such as how to care for a patient who refuses to eat. Health care workers often find themselves wondering whether to support the patient's right to make choices when it seems that the patient is making a poor choice.
Advance directives. Patients may sign these documents to indicate their choices about care at the end of their life. These statements are signed in advance because patients may not be able to make choices when they reach the final stages of illness. Health care workers are required by laws and ethical standards to follow advance directives.
Patient mental status. There are a number of ethical questions health care workers must answer when a patient's mental status changes and the patient begins having problems making decisions and choices. To meet basic ethical standards, the team of care providers must often work together. Sometimes obtaining legal advice is necessary.
Families. Working with families also requires understanding ethical, and sometimes legal, standard. The Health Insurance Portability and Accountability Act (HIPAA) is a law that protects patient information. Doing the right thing means allowing the patient to decide how much information is shared with family members.
Personal behavior. In addition to ethical concerns about patient care, care providers must be aware of their own behavior as employees. This includes telling the truth when documenting care and reporting the number of hours worked. It also includes behavior toward patients and their families, as well as protecting property that belongs to the patient or the employer.
Billing and finance. A health care organization's billing practices receive a great deal of attention. Organizations must follow ethical standards when billing patients and insurance companies, including the Medicare and Medicaid programs. This means accurate reporting of time and services, along with accurate charges. Every employee who is involved with billing or reporting the amount of care given to a patient must act ethically. When unethical practices occur, individual employees and entire organizations can be charged with legal offenses.
Compliance with laws. In addition to the regulations for accurate billing, hospitals and home health agencies must meet many other federal and state regulations and requirements for providing care. Hospitals and home health agencies usually have a "compliance plan," which explains how employees will meet these requirements.

Ethical Dilemmas in Health Care

Ethical conflicts or disagreements occur when people have different beliefs about what is right and wrong. This happens in both personal lives and in the professional world. When different beliefs and backgrounds are combined with the many choices and technologies of today, it's easy to understand how there can be disagreement.

Sometimes the disagreement occurs because a health care choice can have both positive and negative results. People may follow ethical standards but still find that there is no correct answer. This is known as an ethical dilemma.

Think about ethical dilemmas in health care by comparing actions that seem to agree with standards but also have both good and harmful effects or may conflict with the patient's rights. Figure 16.1 describes potential ethical dilemmas.

FIGURE 16.1 | EXAMPLES OF ETHICAL DILEMMAS

In each of these situations, following the ethical standard can seem to conflict with "doing the right thing." Good communication is most important. A review of the different possibilities and viewpoints of those involved is necessary. Health care organizations such as hospitals and home health agencies usually have an ethics committee that will help staff discuss these types of difficult situations and make the best decision possible.

Educating those involved in ethical dilemmas about different options is helpful, although these situations also involve human emotions. It's important to be concerned about both the type of information communicated and the way communication occurs.

Professional and Organizational Ethics

Most health care professions have a written code of ethics such as the American Nurses Association (ANA) Code of Ethics for Nurses. A code contains guidelines that members of a profession have created over time.

The guidelines, or standards, help staff members understand the expectations for their daily work, as well as how to make decisions when facing ethical dilemmas.

Job descriptions often include statements that are similar to ethical standards. Organizations such as home health agencies may choose to use basic ethical standards and professional codes when creating job descriptions. An example of a job description that includes a requirement for ethical behavior is:

The home health aide will function according to the agency's code of conduct. The aide will demonstrate this by maintaining confidentiality, acting with ethics and integrity, protecting the property of the organization, reporting noncompliance and adhering to applicable federal and state laws and regulations and accreditation and licensure requirements.

Home health staff will be evaluated according to whether they meet the requirements of the job description.

However, even the job description cannot include guidelines for all the situations that might occur while working in home health.

Personal Ethics and Responsibilities

Health care workers must recognize there are times when their own actions or the actions of coworkers, patients and families may be questioned. As you've seen, there are times when even doing something good may cause other people harm or may conflict with someone's rights. Cultural differences, personal background, religion and other beliefs also may affect actions and the way actions are judged by others.

Working in home health allows staff members to be much more independent compared to working in hospitals and nursing homes. Working away from supervisors and other employees, along with the increased time spent working with families in their own homes, can sometimes make it challenging to act in an ethical manner. Agencies have policies that require ethical actions. Situations that may be addressed by policies, which may result in discipline or termination of employment if an employee does not meet standards, include the following:

It is unethical to become involved socially with patients or family members, such as dating a patient's son while also being responsible for the patient's care. This situation may make it difficult to make good decisions about the patient's needs.

Staff members are required to protect patient property, which includes not stealing or even borrowing from patients. Staff members should also avoid any involvement with a patient's finances.

Timesheets, visit notes and mileage records must be accurate. Unethical practices would include documenting a visit even though the patient cancelled or adding extra mileage to each visit in order to obtain additional reimbursement.

It's normal for patients and families to want to reward good care, but most agencies have specific guidelines for accepted tips, etc. (For example, a box of cookies may be accepted, but a check for $50 could not be accepted.)

It is unethical to provide extra care that is not part of the care plan. Patients sometimes request extra services, such as walking the dog or grocery shopping. Following the care plans means that each patient receives the necessary and fair amount of care. Meeting extensive extra requests can create conflicts.

Even though patients may have personalities that make it difficult to care for them, it's always right to "do good" for each patient as well as "do no harm," which means never physically or emotionally abusing a patient. In addition, there are ethical and legal requirements to report suspected abuse of patients.

Ethical behavior requires respect for each patient. As long as care can be provided in a safe manner and the patient is safe within the home, home health staff members must respect the patient's lifestyle and never try to force one's own beliefs and needs on the patient.

ETHICAL DECISION MAKING

When faced with a potential ethical problem, there are steps you can take to help make the best decision possible. Before acting, ask yourself the following questions:

Is it right?

Is it fair?

Will someone get hurt?

If my actions were reported in the newspaper, would I be embarrassed?

Would I tell someone else, especially a child, to do the same thing?

Does this "smell" right? (Your common sense may tell you that there's something wrong.)

Source: Bowditch & Buono, 1997, as cited in Sellers, 2008, in P. Kelly (ed.), Nursing leadership and management (2nd ed., p. 523). Clifton Park, N.Y.: Delmar Learning: Thomson.

Home Health Staff Role in Ethics

Ethical standards are part of everything you do as a home health staff member. Understanding the basic ethical standards helps you care for patients appropriately while also meeting the agency's employee standards.

Maintain knowledge of employee requirements

Even though you understand basic ethical standards, it's important to know how your agency includes those in its policies. Read your job description and ask questions about any requirements you don't understand.

Stay up to date with changes in agency policies, especially those that affect ethical and legal requirements. Read each new message or policy change that is posted. Attend meetings and complete annual education requirements. This might include annual training about HIPAA, the agency's compliance plan, or identifying and reporting abuse.

Avoid any appearance of unethical behavior by keeping careful records of the care that you've provided, the time it took and the mileage you drove. Complete agency forms immediately after providing care or completing a trip to a patient's home. Studies have shown that accuracy decreases as time passes between performing an activity and documenting the activity.

When you understand agency polices and standards, you will be better prepared to make good decisions about the care you provide, as well as respond properly to unexpected situations that you may face in a patient's home.

Uphold professional behavior

Recognize that your own personal problems may affect your reactions to work requirements. It may be tempting to talk about your own personal problems with patients and their families, but doing so places a burden on those who are already struggling with illness and their own problems. Ethical standards for doing good, treating patients fairly and showing respect require that you focus your attention on them while in their homes.

Provide personal care

The primary role of home health staff members is personal care. Since personal care is an intimate activity and even may be embarrassing to the patient, it's important to follow the plan of care and agency procedures carefully. Be sure that you understand the requirements of the plan of care, and ask questions if any part of the assignment does not seem to fit the needs of the patient. By acting in this way, you'll make sure that all your actions are good for the patient.

Offer support

Many patients have a need for emotional support. They may be lonely, dealing with a difficult diagnosis or in pain. As a result, they may be weepy, overdependent on you or demanding. Keeping in mind that you want to do good, you will also need to balance requirements to allow the patient to make choices and to be fair to all patients.

You can show your support by listening carefully when patients talk with you and by showing kindness through gentle touch and paying attention to details while providing care. If a patient likes to be covered with two blankets after a bath, or to be left with the television on when you leave, he or she will feel supported when you remember to do those things.

Remember to remain professional; while you may feel as though you're a family member, you are not. Performing your duties in an ethical manner is easier when you maintain your separate role as a caregiver.

Observe and report

Since you may be involved in ethical dilemmas at any time or may see situations that appear to be questionable, it's important to observe for changes in a patient's physical status, changes in a caregiver's behavior or changes in plans that patients may tell you about. Report these changes to your nurse or case manager. In particular, if a patient tells you about a new advance directive or a change in how he or she wishes to be cared for, report this to your nurse or case manager immediately.

Participate in team meetings

Team meetings at the agency are a time to discuss new information and different points of view. If ethical dilemmas already exist, attending the meeting can bring new ideas to light and team members can provide support to one another. Sharing information about patient care problems that you're having can also help you understand how to handle a situation and avoid future ethical issues.

Reinforce education

Supporting a patient's right to make his or her own choices depends on ensuring the patient has the right information. If a patient has questions or does not seem to understand information, follow up with the nurse or therapist, letting them know about possible problems you've observed.

Source: Essential In-Services for Home Health