Rural Bioethical Situations: Resources Rural Bioethical Situations: Resources for Informing Public Health Providers for Informing Public Health Providers

and Studentsand StudentsAngeline Bushy, PhD, RN, FAAN, PHCNS-BCAngeline Bushy, PhD, RN, FAAN, PHCNS-BC

University of Central Florida University of Central Florida College of NursingCollege of Nursing

Angeline.bushy@ucf.edu

OBJECTIVESOBJECTIVES

The participant will be able to: The participant will be able to: Articulate feature of the rural context and its impact on ethical Articulate feature of the rural context and its impact on ethical situations.situations.Identify the impact of ethics conflicts on rural health care Identify the impact of ethics conflicts on rural health care organizations. organizations. Discuss approaches for anticipating and decreasing ethics Discuss approaches for anticipating and decreasing ethics conflicts.conflicts.List at least two resources to address ethics conflicts in the rural List at least two resources to address ethics conflicts in the rural context.context.

What is Bioethics?What is Bioethics?

Branch of applied philosophy that deals with moral Branch of applied philosophy that deals with moral issues in the health professionsissues in the health professions

Attempts to answer the question; “What is right” with Attempts to answer the question; “What is right” with regard to human behaviors in matters of life and deathregard to human behaviors in matters of life and death

Implies that a judgment should be made about rightness/ Implies that a judgment should be made about rightness/ wrongness or goodness/badness of a given medical or wrongness or goodness/badness of a given medical or scientific practicescientific practice

What is Rural Health Care Bioethics?What is Rural Health Care Bioethics?

Focuses on how the unique rural context influences the:• presentation of ethical challenges • response to those challenges.

Reflects on ethical issues encountered in the unique environment of rural settings

Common(Bio)Ethical SituationsCommon(Bio)Ethical Situations

Informed consentInformed consent ProxyProxy Withholding & with drawl of life supportWithholding & with drawl of life support ConfidentialityConfidentiality Justice in the distribution of healthcare resourcesJustice in the distribution of healthcare resources Advances in medical technologies/therapiesAdvances in medical technologies/therapies Advanced directives (individual versus family versus Advanced directives (individual versus family versus

provider preferences/understanding)provider preferences/understanding) Costs versus benefits of services/careCosts versus benefits of services/care Intra/inter professional competence issues Intra/inter professional competence issues Other relative to PH and rural practice/context ?Other relative to PH and rural practice/context ?

Characteristics of RuralCharacteristics of RuralCompared to more populated areas rural has:Compared to more populated areas rural has:Small/low population density Small/low population density Few personnel in local health departmentFew personnel in local health departmentOverlapping personal & professional relationships Overlapping personal & professional relationships Isolation; great distances between resources; professionalsIsolation; great distances between resources; professionalsFew specialistsFew specialistsSmall hospitals (many 25 beds or less)Small hospitals (many 25 beds or less)Close-knit relationships; interdependence; self-reliance Close-knit relationships; interdependence; self-reliance Economic climate; higher rates of uninsured; lower per person/family Economic climate; higher rates of uninsured; lower per person/family income; OSHA defined hazardous occupationsincome; OSHA defined hazardous occupationsPoor(er) health status Poor(er) health status Limited ethics resources ( rural-focused literature, ethicists, education, Limited ethics resources ( rural-focused literature, ethicists, education, ethics/IRB committees)ethics/IRB committees)

Features Rural Context(s)Features Rural Context(s)

DiversityDiversity Overlapping relationshipsOverlapping relationships Disease stigmaDisease stigma Values and preferencesValues and preferences Diffuse role boundariesDiffuse role boundaries Privacy and confidentialityPrivacy and confidentiality Local versus outside preference for supportLocal versus outside preference for support

Moving Ethics Upstream . . . Moving Ethics Upstream . . .

Promoting ethical awareness among staff/communityPromoting ethical awareness among staff/community Facilitating ethical discussions (intra/inter professional)Facilitating ethical discussions (intra/inter professional) Examining actual and potential ethical casesExamining actual and potential ethical cases Identifying relevant ethical resources Establishing ethical practice guidelines Directing activities to enhance the quality of care and the

organization’s overall culture Monitoring effects of bioethical educational initiativesMonitoring effects of bioethical educational initiatives

(Bio)Ethics Resources(Bio)Ethics Resources

Web-based resources Web-based resources Growing number of publications on rural bioethicsGrowing number of publications on rural bioethics Little written relative to ethics in rural Public Health Little written relative to ethics in rural Public Health

practice settingspractice settings Needed case studies and best practice rural ethics Needed case studies and best practice rural ethics

awareness, education and decision modelsawareness, education and decision models

http://dms.dartmouth.edu/cfm/resources/rhc/

http://dms.dartmouth.edu/cfm/resources/manual/manual.pdfhttp://dms.dartmouth.edu/cfm/resources/manual/manual.pdf

Implications for Rural Public Health Implications for Rural Public Health ProfessionalsProfessionals

Integrate rural ethics content in PH professional educationIntegrate rural ethics content in PH professional education Implement Ethics & IRB Committees in rural communitiesImplement Ethics & IRB Committees in rural communities Facilitate ethics awareness among rural residentsFacilitate ethics awareness among rural residents Disseminate information on rural PH ethics initiativesDisseminate information on rural PH ethics initiatives Publish rural PH bioethical case scenarios to inform educatorsPublish rural PH bioethical case scenarios to inform educators

SummarySummary

Potential and actual ethics ethics issues frequently encountered Potential and actual ethics ethics issues frequently encountered in rural and urban PH settingsin rural and urban PH settings

Ethics issues are influenced by the rural contextEthics issues are influenced by the rural context Ethical issues have an impact on allocating resources & quality Ethical issues have an impact on allocating resources & quality

of careof care Go beyond reacting to Go beyond reacting to ethics conflicts; PH ethics conflicts; PH professionals/students professionals/students must move upstream must move upstream to decrease ethics to decrease ethics conflictsconflicts

ReferencesReferences

Bushy A. (2011). Bushy A. (2011). ANA-CE Program-ANA-CE Program- Rural nursing: Practice and issues.Rural nursing: Practice and issues. Accessed on Accessed on June 7, 2011 at: June 7, 2011 at: http://nursingworld.org/mods/mod700/rurlfull.htmhttp://www.nursingworld.org/http://nursingworld.org/mods/mod700/rurlfull.htmhttp://www.nursingworld.org/mods/mod700/rurlfull.htmmods/mod700/rurlfull.htm

Cook A & Hoas H. (2008). Ethics and rural healthcare: What really happens, what Cook A & Hoas H. (2008). Ethics and rural healthcare: What really happens, what might help? might help? American Journal of Bioethics, 8American Journal of Bioethics, 8(4), 52-56.(4), 52-56.

Cook A & Hoas H. (2008). Revisiting ethics and rural healthcare: What really Cook A & Hoas H. (2008). Revisiting ethics and rural healthcare: What really happens, what might help? happens, what might help? American Journal of BioethicsAmerican Journal of Bioethics.. In Focus. In Focus. Accessed on Accessed on June 3, 2011 at: http://www.informaworld.com/smpp/section?June 3, 2011 at: http://www.informaworld.com/smpp/section?content=a794419479&fulltext=713240928content=a794419479&fulltext=713240928

Bushy A . (2006). Nursing in rural and frontier areas: Issues, challenges and Bushy A . (2006). Nursing in rural and frontier areas: Issues, challenges and opportunities. opportunities. Harvard Health Policy Review, 9Harvard Health Policy Review, 9(1), 17-27(1), 17-27..

Grady C, Danis M, Farrar A, O'Donnell P, Soeken K, et al . (2008). Does ethics Grady C, Danis M, Farrar A, O'Donnell P, Soeken K, et al . (2008). Does ethics education influence the moral action of practicing nurses and social workers? education influence the moral action of practicing nurses and social workers? American Journal of Bioethics, 8American Journal of Bioethics, 8(4), 4-11.(4), 4-11.

Nelson B, Pomerantz A, Howard K & Bushy A. (2007). A proposed rural health care Nelson B, Pomerantz A, Howard K & Bushy A. (2007). A proposed rural health care ethics agenda. ethics agenda. Journal of Medical Ethics, 33, Journal of Medical Ethics, 33, 136-139.136-139.

Nelson, W (Ed). (2009). Nelson, W (Ed). (2009). Handbook for rural health care ethics: A practical guide for Handbook for rural health care ethics: A practical guide for professional. professional. Accessed on line June 7, 201 at: Accessed on line June 7, 201 at: http://dms.dartmouth.edu/cfm/resources/ethics/chapter-00.pdf

Nelson, W. & Schifferdecker K (2009). Rural health care ethics: A manual for trainers. Nelson, W. & Schifferdecker K (2009). Rural health care ethics: A manual for trainers. Accessed on line June 7, 2011 at: Accessed on line June 7, 2011 at: http://dms.dartmouth.edu/cfm/resources/manual/manual.pdf

Nelson W, Greene M & West A. (2010). Rural Health Care Ethics: No Longer the Nelson W, Greene M & West A. (2010). Rural Health Care Ethics: No Longer the Forgotten Quarter of Medical Ethics. Forgotten Quarter of Medical Ethics. Cambridge Quarterly for Healthcare Ethics, Cambridge Quarterly for Healthcare Ethics, 1919(4), 510-517.(4), 510-517.

Pavlish C, Brown-Saltzman K, Hersh M, et al. (2011). Early indicators and risk factors Pavlish C, Brown-Saltzman K, Hersh M, et al. (2011). Early indicators and risk factors for ethical issues in clinical practice. for ethical issues in clinical practice. Journal of Nursing Scholarship, 43Journal of Nursing Scholarship, 43(1), 13-21.(1), 13-21.

Larson K & Elliot R. (2010). The emotional impact of malpractice. Larson K & Elliot R. (2010). The emotional impact of malpractice. Nephrology Nephrology Nursing Journal, 37Nursing Journal, 37(2), 153-155.(2), 153-155.

Schlairet M. (2009). Bioethics mediation: The role and importance of nurse Schlairet M. (2009). Bioethics mediation: The role and importance of nurse advocacy. advocacy. Nursing Outlook. 77, Nursing Outlook. 77, 185-193185-193..

Questions???Questions???

Presenter DisclosuresPresenter Disclosures

Angeline Bushy

No relationships to disclose