This paper presents a structured code of ethics developed for the nurse case management of a 30-year-old male client living with HIV who refuses medication. Drawing on established ethical frameworks in nursing and human services, the code addresses six core principles: respect and dignity, access to treatment information, patient involvement in care planning, the right to refuse treatment, confidentiality protections, and interdisciplinary collaboration. Each principle is accompanied by an interpretive commentary that situates it within relevant legal, clinical, and ethical contexts, including informed consent doctrine, substituted judgment, HIPAA compliance, and patient self-determination rights.
There have been many changes in the ethical codes of nursing and other medical and helping professions over the past few decades. While there is still a great deal of progress to be made, ongoing discussion and refinement of current practices have come under debate and are continuing to adapt.
As Adrian and O'Connell (2000) observe, "This debate is healthy as it challenges the nursing profession to focus on key issues… As more creative ways are developed to deliver consumer-focused quality health services, the traditional picture of the nurse, the doctor and the patient is being transformed" (p. 41).
The following is a code of ethics primarily concerned with the care of a 30-year-old male client with HIV who refuses to take his medications.
1. The nurse must at all times treat the patient with respect and dignity, following the code of conduct established by the hospital and applicable state and federal laws.
a. Nursing care will serve the best interests of the patient, highlighting patient confidentiality, respecting personal dignity, and giving full consideration to the client's humanity and self-esteem.
Interpretation: While this principle is generally part of every code of ethics, it carries particular importance in cases where living or dying with dignity is of paramount concern — as it often is when caring for someone with HIV that may progress to full-blown AIDS. It is important to establish a written understanding between the patient and nurse. The Ethical Standards of Human Service Professionals provides a useful model: "Human service professionals negotiate with clients the purpose, goals, and nature of the helping relationship prior to its onset as well as inform clients of the limitations of the proposed relationship" (Codes, 2004, p. 68). The word negotiate is key here. The relationship should always be one of give and take and, above all, mutual understanding.
As Gallagher (2004) notes, "Dignity can be considered as two values: other-regarding by respecting the dignity of others, and self-regarding by respecting one's own dignity or self-respect" (p. 5).
2. The nurse has the responsibility to provide full access to all information from health care providers about current FDA-approved or other proven HIV/AIDS treatments, as well as information concerning HIV-related social and support services.
Interpretation: It is important to recognize that there is a large scope of care associated with HIV patients, both within a hospital setting and in the broader community. Ensuring patients understand the full range of available options is a foundational nursing responsibility.
3. The nurse must allow the patient to have full access, understanding, and control regarding his or her care plan.
Interpretation: Complete involvement of the patient in his or her care is crucial. It is also necessary to check for understanding, as the medical issue may be complex and require a great deal of interpretation by the nurse, who should take advantage of other available services to assist in this process.
4. The nurse must respect the patient's right to refuse services of any kind as well as the right to refuse treatment. The patient may change his or her mind after such refusal without affecting services already in place.
a. Should the patient refuse treatment — such as medication — and that decision is life-threatening, the patient's wishes must be brought to the attention of hospital management and administration.
b. The nurse must ascertain the status of a health care proxy and other patient-directed mandates, such as Do Not Resuscitate (DNR) orders.
"Informed refusal, DNR, and substituted judgment"
"HIPAA and hospital confidentiality compliance"
"Teamwork and coordinated HIV patient care"
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