Euthanasia and Healthcare Ethics: An Ethical Dilemma

A recent case of euthanasia in Europe prompted me to post this. Here’s the link to the case:

http://www.dailymail.co.uk/news/article-11291995/Woman-23-survived-2016-Brussels-airport-ISIS-bomb-euthanised-Belgium.html

(NOTE: Some laws may have changed since I wrote this in 2017.)

Euthanasia and Healthcare Ethics: An Ethical Dilemma

by Dawn Pisturino

Abstract

Healthcare ethics deal with life and death situations which involve every member of the healthcare team.  But the patient is at the heart of healthcare ethics, and the rights, safety, and well-being of the patient must come first in all healthcare decisions.  It is not up to healthcare personnel to decide who will live and who will die.

Euthanasia and Healthcare Ethics: An Ethical Dilemma

       Every discipline has a code of ethics to follow when it comes to making ethical decisions, and healthcare is no exception.  Ethics in healthcare is so important, in fact, that most organizations have a process through which tough ethical decisions, such as end-of-life decisions, can be made.

The Hippocratic Oath and Modern Healthcare Ethics

       The origin of healthcare ethics dates back to the Hippocratic School of 200 B.C. (Geppert & Roberts, 2008).  Hippocrates devised the Oath of the Hippocratic School, which includes confidentiality, nonmaleficence, and beneficence (Geppert & Roberts, 2008).  Since then, technology has forced changes in healthcare ethics, adding principles of autonomy, respect for persons, compassion, privacy, and honesty (Geppert & Roberts, 2008).  Most of these principles can be applied to end-of-life issues.

The End-of-Life Debate 

       The end-of-life debate has been fueled by the preponderance of chronic disease in modern society, quality of life issues, and the soaring cost of healthcare.  In most countries around the world, euthanasia and patient-assisted suicide are illegal.  Hippocrates himself said, “I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect” (Doukas, 1995).

Dr. Jack Kevorkian

       In 1999, Dr. Jack Kevorkian was found guilty of second-degree murder by a Michigan jury in the death of Thomas Youk (Charatan, 1999).  Dr. Kevorkian had administered a lethal dose of medication to Youk, who was suffering from ALS (amyotrophic lateral sclerosis).  He could not prove that Youk had asked him to end his life.

       The Hemlock Society, a proponent of physician-assisted suicide, condemned the verdict (Charatan, 1999).  But many organizations devoted to disability rights applauded Dr. Kevorkian’s conviction, claiming that euthanasia is a threat to people with disabilities (Charatan, 1999).  The American Medical Association issued a statement by Dr. Nancy W. Dickey, who was president at the time: “Patients in America can be relieved that the guilty verdict against Dr. Jack Kevorkian helps protect them from those who would take their lives prematurely” (Charatan, 1999).

       John Roberts, North American editor of the British Medical Journal, labeled Dr. Jack Kevorkian “a medical hero.”  He considered Kevorkian an honest man who was acting according to his personal moral principles (Roberts & Kjellstrand, 1996).  Still, most physicians want to be perceived by the public as healers – not death dealers (Doukas, 1995).

Dutch Euthanasia Act

       In 2002, the Netherlands passed the Dutch Euthanasia Act, sparking a world-wide debate on end-of-life issues (Van der Heide, 2007).

       Euthanasia, as defined in the Netherlands, is “death resulting from medication that is administered by a physician with the explicit request of the patient” (Van der Heide, 2007).  In physician-assisted suicide, the physician prescribes the medication and the patient administers it himself, leading to death.  In both cases, the physician is legally protected by the Dutch Euthanasia Act for ending life “at the request of a patient who was suffering unbearably without hope of relief” (Van der Heide, 2007).

       Before making a decision, physicians are required to discuss euthanasia and physician-assisted suicide with the terminally-ill patient and his relatives.  If there is any question about the ethical nature of the decision, physicians may discuss the matter with colleagues.  In 2005, in the Netherlands, 73.9% of all patient-requested deaths were the result of neuromuscular relaxants or barbituates; 16.2% were the result of opioids (Van der Heide, 2007).

Ethical Dilemma Case Example

       Physicians are not the only healthcare workers faced with ethical dilemmas.  Nurses also find themselves in situations where they must apply ethical principles.

       The Charge Nurse at a local hospital wanted to open up a patient bed in order to admit a patient from the emergency room.  She asked this author – the patient’s nurse – to give a dose of intravenous morphine to a patient who was dying of end-stage kidney disease.  Legally, the patient was a “Do Not Resuscitate.”  The family was at the bedside.

       “Ethical dilemmas often provoke powerful emotions and strong personal opinions; however, emotions and opinions alone are not a satisfactory way of resolving ethical dilemmas” (Lo, 2013).   Faced with an ethical dilemma of tantamount importance, this nurse had only a short time in which to make the right decision.

       The first thing to consider was the law and the legal ramifications of any decision made in this situation (Pojman & Fieser, 2017).  How would the decision affect the Charge Nurse and the patient’s nurse?  Would we be held legally liable if the patient died after receiving an extra dose of morphine?  Would we lose our nursing licenses?  Would the family sue?  Would we lose our jobs?  Euthanasia in Arizona is against the law.

       Secondly, would the patient want to be given an extra dose of morphine?  A “Do Not Resuscitate” status merely indicates that the patient does not want to be revived if the heart stops beating or respirations cease.  It is not a request for euthanasia.  Would it violate the patient’s personal or religious beliefs to administer an extra dose of morphine?  Would it violate her core ethics?  Would it take away her right of self-determination and autonomy (Pojman & Fieser, 2017)?

       Thirdly, to go into the patient’s room and administer an injection of morphine without just cause would violate the culture and ethics of the hospital, the doctor, and most of the nursing staff (Pojman & Fieser, 2017).  It would look suspicious to the family.  They would question what this nurse was doing.  It would place this nurse in an uncomfortable situation.

       The ethical dilemma posed here is this: should the patient’s nurse do what the Charge Nurse requested or refuse?  In order to make a rational and ethical decision, the patient’s nurse must first analyze the situation.  According to Pojman and Fieser, “most ethical analysis falls into one or more of the following domains: (1) action, (2) consequences, (3) character traits, and (4) motives.”

Action

       Giving the patient an extra dose of morphine would be the right action if the patient was in pain and wanted the medication.  It would be the right action if the patient seemed uncomfortable and the patient’s family requested it.  It would not be an obligatory act if it was too soon to give the medication or if the patient did not need it at that time.  It would be considered an optional act, based on the nurse’s professional judgment and opinion.  On the other hand, it would be a wrong action to give the morphine if the patient did not need it or the patient’s family did not want it given.  If euthanasia were legal and the physician was at the bedside and requested the patient’s nurse to draw up the medication, it would be considered a supererogatory act if the physician administered it to the patient.  He would be ending the patient’s suffering.  The nurse would be involved in a legal and compassionate act.

Consequences

       If the patient was in pain and needed the medication, giving the morphine would be the right action because it eased the patient’s pain.  If the patient died as a result, there would be no legal or professional consequences because there is no way to predict if that particular injection will cause the patient to stop breathing.  The morphine was given according to medical guidelines ordered by the physician.  If the patient was not in pain and the extra injection of morphine caused the patient to stop breathing, it could raise ethical and legal issues for the nurse who administered the medication.  Those issues would most likely be raised by the family, if they were concerned.

Character Traits

       The Charge Nurse was more concerned about opening up a patient bed than respecting the rights of the patient who was dying.  It seems callous, malevolent, and unfeeling.  The patient’s nurse must examine her own feelings and attitudes and decide if the Charge Nurse was right or wrong in her request.

Motive

       The motive of the Charge Nurse was clearly to give in to pressure from the emergency room to admit a patient.  She showed no concern whatsoever for the patient who was dying.  She had no respect for the patient’s rights and autonomy – or for the patient’s family.

       The nurse’s motive should be to protect the rights and safety of her patient.  She is the patient’s advocate.  If she gives in to pressure from the Charge Nurse, she will fail in her duty to her patient.  Even if she believes that euthanasia is a moral act, neither she nor the physician has informed consent from the patient or the family.

What Happened

       The patient’s nurse evaluated the motives of the Charge Nurse, felt disgusted, and went into the patient’s room to check on her condition.  She was resting quietly with her eyes closed, and the nurse saw no evidence of pain or discomfort.  When the nurse asked the patient’s family if they wanted the patient to receive a morphine injection for pain, they agreed with the nurse that the patient was resting quietly and did not need it.  Relieved, the patient’s nurse reported all of this to the Charge Nurse.  As a parting shot she added, “And I’m not Dr. Kevorkian!”

Conclusion

       Patients and their families have the final say in what happens to terminally-ill patients.  It is not up to healthcare personnel to make decisions about end-of-life care for a patient.  This will be particularly true if euthanasia and patient-assisted suicide ever become legal on a widespread scale.  The medical community, in line with its own ethical principles, must respect the right of self-determination and autonomy of terminally-ill patients.

References

Charatan, Fred. (1999). Dr. Kevorkian found guilty of second degree murder. British medical

       journal, 318(7189), 962. Retrieved from

       http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1174693/

Doukas, D.J., Waterhouse, D., Gorenflo, D.W., Seid, J. (1995). Attitudes and behaviors on

       physician-assisted death: A study of Michigan oncologists. Journal of Clinical Oncology,

       13(5), 1055-1061

Geppert, M.A., & Roberts, L.W. (Ed.) (2008). Book of ethics. Center City, MN: Hazelden

       Foundation

Lo, Bernard. (2013). Resolving ethical dilemmas: A guide for clinicians. Philadelphia, PA:

       Lippincott, Williams and Wilkins

Pojman, L.P., & Fieser, J. (2017). Ethics: Discovering right and wrong. Boston, MA:

       Cengage Learning

Roberts, J., & Kjellstrand, C. (1996). Jack Kevorkian: a medical hero. BMJ: British

       Medical Journal, 312(7044), 1434

Van der Heide, A., Onwuteaka-Philipsen, B.D., Rurup, M.L., Buitina, H.M., van Delden, J.M.,

       Hanssen-de Wolf, J.E., . . . van der Wal, G. (2007). End-of-life practices in the Netherlands

       under the euthanasia act. New England Journal of Medicine, 356 (19), 1957-1965.

~

UPDATE:

Where is assisted dying legal in Europe? 

Assisted dying refers to both voluntary active euthanasia and physician-assisted death, when a patient’s life is ended at their request. 

Only three countries in Europe approve of assisted dying as a whole: Belgium, the Netherlands, and Luxembourg.

 The first two even recognise requests from minors under strict circumstances, while Luxembourg excludes them from the legislation.

 Germany, Switzerland, Germany, Finland, and Austria allow physician-assisted death under specific circumstances. 

Countries such as Spain, Sweden, England, Italy, Hungary, and Norway allow passive euthanasia under strict circumstances. Passive euthanasia is when a patient suffering from an incurable disease dies because doctors stops doing something necessary to keep them alive. 

Sources: Euronews

~

Dawn Pisturino

Philosophy 151

May 2, 2017; November 2, 2022

Copyright 2022 Dawn Pisturino. All Rights Reserved.

Rape Prevention in Arizona

(Photo by Brooke Cagle on Unsplash)

Rape Prevention in Arizona

by Dawn Pisturino

Abstract

Social services in Arizona are concentrated mainly in the Phoenix area.  Outlying areas may or may not have sufficient services.  In Mohave County, for example, domestic and sexual violence services are geared largely toward families and domestic violence.  Few services exist specific to rape prevention.  In fact, the nearest actual rape center is located in Flagstaff (Coconino County), which is two hours away.  Arizona does have a comprehensive Sexual Violence Prevention & Education Program aimed at prevention of sexual and domestic violence, but most state-funded organizations are located in southern Arizona.  National organizations like RAINN provide general guidelines and state-by-state information.

Rape Prevention in Arizona

       The Sexual Violence Prevention & Education Program in Arizona originated at the state level, conforms to CDC guidelines, and depends on funding from the CDC and other sources.

       In 2004, the Governor’s Office for Children, Youth, and Families formulated a state plan that would “increase capacity . . . to provide services, promote prevention, conduct trainings, and create public awareness activities statewide” in the area of sexual assault.  The primary goal was to “increase victim access to comprehensive crisis services” (Governor’s Office for Children, Youth, and Families, 2004).

       A statewide eight year plan was implemented through the Arizona Department of Health Services in 2010 that would “stop first time perpetration” through standardized educational curriculum in the schools, colleges, and universities; faith-based organizations; widespread media campaigns; and businesses that serve alcohol.  The mission was to achieve “the vision of a culture that supports healthy, respectful relationships through primary prevention efforts and zero tolerance of sexual violence in Arizona communities” (Arizona Department of Health Services, 2010).

       Sexual assault is a public health threat that requires preventative education and counseling before an assault occurs; interventions immediately after an incident; and long-term follow-up care, if necessary, with therapy and empowerment tools (University of Arizona, 2012).  Programs are now teaching bystander intervention skills to people who want to serve as role models and intervene when they witness a potential or actual sexual assault occurring.  The University of Arizona routinely screens students for past and recent sexual assaults and abuse so they can receive the therapy they need.  Male students learn how to evaluate their own attitudes and beliefs about male dominance and entitlement in order to gain new respect for their partners and develop more effective communication skills (University of Arizona, 2012).

       The Sexual Violence Prevention & Education Program implemented in 2012 on the campus of the University of Arizona in Tucson is also available to other campuses, organizations, and businesses through their community outreach program.  According to their research, alcohol is implicated in 50-70% of all sexual assaults.  Drug and alcohol screenings are now done on campus to screen students for substance use problems.  Students receive information about consent and the ability/inability to consent for sexual activity while intoxicated.  Freshmen are required to take an online course in sexual assault (University of Arizona, 2012).

       Research conducted at the University of Arizona supports new laws and public policies.  Researchers have found that community-based programs are most effective.  Their public awareness programs have been so effective, Governor Douglas Ducey proclaimed April 2016 Sexual Assault Awareness Month (Governor’s Office, 2016).

       According to the National Center for Injury Prevention and Control (2016), 1 in 5 women and 1 in 15 men experience rape or attempted rape.  By the age of eighteen, 40% of women have suffered some sort of sexual abuse or assault.  The long-term physical and psychological trauma can be devastating.  Family Advocacy Centers have been established in some areas of Arizona to provide post-sexual assault services, including forensic evidence collection, expert witness testimony, and legal representation.  Arizona state law allows victims to receive a forensic examination by a trained examiner within 120 hours (5 days), whether or not they plan to report the incident to police (Governor’s Office for Children, Youth, and Families, 2004).  Forensic biological evidence will be kept indefinitely in unsolved felony sexual offense cases (Arizona Revised Statute 13-4221).  There are no statutes of limitations in felony sexual offense cases (Arizona Revised Statute 13-107).  The definition of rape has been expanded in order to increase the number of convictions.  Sexual assault is a class 2 felony, but if a date rape drug was used, the sentence will be increased by three years (Arizona Revised Statutes 13-1406).  The minimum sentence for a first conviction under ARS 13-1406 is 5.25 years, but a life sentence may be imposed if intentional serious physical harm was inflicted.

       Cultural competence remains an important issue when dealing with victims of sexual assault since the United States has such a diverse population “with differing ideas about domestic violence and sexual assault” (Warrier, 2005).  Trained interpreters and bilingual educational materials must be available.  Professionals must be able to understand victims’ experiences of violence within the context of their own culture.  This is particularly crucial among the Native American population.

       Kathryn Patricelli, MA (2005), educates women on what to do after an assault or rape.  First off, they should not bathe or cleanse themselves.  Secondly, they should call the police and report what happened. Third, women should go to the emergency room and ask to be examined.  A forensic examination should be performed.  If a date rape drug was used, they should have a urine toxicology screen done.  Fourth, they should go stay in a safe place or have someone stay with them.  Fifth, victims should get help from a counselor to ease the shock, pain, and guilt.  If symptoms do not ease in a reasonable amount of time, the victim should get ongoing therapy for post-traumatic stress disorder.

Method

Process

       Research was conducted online through EBSCO and Google Scholar using the keywords “rape prevention,” “rape prevention in Mohave County,” and “rape prevention in Arizona.”  Other research was done in person and by telephone.

Results

       The best online results were found in Arizona government websites and publications.  Kingman Aid to Abused People/Sarah’s House did not answer their door or telephone.  Their primary focus is on family abuse and domestic violence.  Calling the Mohave Victim Witness Program phone number connected me to a pager.  There was no local rape prevention literature available at the Mohave County Library in Kingman; their resource list was out-of-date; and the librarian could only find two young adult books in the system related to teen dating safety and sexual harassment.

Discussion

       Local programs funded by the state of Arizona must provide “education on sexual harassment, definitions of rape, teen dating violence, assertive communication, and strategies to increase reporting and awareness of sexual violence” (Arizona Department of Health Services, 2016).  Some organizations also explain consent and Arizona law.

       Most programs and organizations in Mohave County provide post-incident crisis intervention, shelter, and hotlines for victims of domestic violence and sexual assault.  Mohave Community College has policies dealing with campus safety and sexual harassment and assault.  Mohave Mental Health and Southwest Behavioral provide long-term therapy services for depression, anxiety, and PTSD.  Local hospitals have trained forensic examiners, social workers, and counselors available for immediate care after a sexual assault.  The Mohave County Health Department performs confidential testing for STDs/HIV.

       Charles P. Nemeth (2012) defines rape as sexual intercourse with another person through the use of force, without consent, and with intent.  His guidelines for dealing with an attack include trying to dissuade the attacker from completing the act; pretending to have an STD or AIDS; acting insane; yelling; struggling and fighting back; using self-defense skills; using pepper spray or mace; avoiding resistance in order to survive (Nemeth, 2012).

       The Governor’s Office for Children, Youth, and Families (2004) describes rape “as a crime of power and control . . . motivated by aggression and hatred, not sex.”  The state of Arizona has implemented a statewide plan to address the problem through standardized educational programs, increased availability of services to victims, and expanded tools for prosecutors and police to increase the number of convictions for sexual assault.  But most comprehensive services are concentrated in the Phoenix/Tucson metropolitan areas.  More needs to be done for less populated counties like Mohave County.

References

Arizona Department of Health Services. (2016). Sexual violence prevention and education

       program. Retrieved from http://www.azrapeprevention.org.

Arizona Department of Health Services, The Bureau of Women’s and Children’s Health. (2010).

       Arizona sexual violence primary prevention and education eight year program plan.

       Phoenix, AZ: State of Arizona.

Arizona Legislature. (2016). Arizona revised statutes. Retrieved from http://www.azleg.gov.

Centers for Disease Control, National Center for Injury Prevention and Control, Division of

       Violence Prevention. (2016). Stop SV: A technical package to prevent sexual violence.

       Atlanta, GA: Centers for Disease Control.

Governor’s Office. (2016). State of arizona proclamation. Phoenix, AZ: State of Arizona.

Governor’s Office for Children, Youth, and Families, Division for Women. (2004). The state

       plan on domestic & sexual violence: A guide for safety & injustice in arizona. Phoenix,

       AZ: State of Arizona.

Nemeth, C.P. (2012). Criminal law. Boca Raton, FL: Taylor & Francis.

Patricelli, K., MA. (2005, December 15). Abuse – If you have been assaulted or raped. Retrieved

       from http://www.mentalhelp.net.

RAINN. (2016). State-by-state definitions. Retrieved from http://rainn.org.

University of Arizona, Mel and Enid Zuckerman College of Public Health. (2012). Sexual

       violence prevention & education program orientation manual & annual summary. Tucson,

       AZ: University of Arizona.

Warrier, S. (2005). Culture handbook. San Francisco, CA: Family Violence Prevention Fund.   

~

Dawn Pisturino

Substantive Law 225

October 22, 2016; July 27, 2022

Copyright 2016-2022 Dawn Pisturino. All Rights Reserved.                                                      

Your Own Best Friend

Once we have made the commitment to achieve a higher level of wellness, there are a few things we need to consider.

First off, making that kind of commitment could be interpreted as selfishness by the people around us.  Our spouses may not want us to go out jogging while they lay on the couch watching TV.  After all, this is an activity that has been shared for many years, and now that situation has suddenly changed.  They may feel abandoned.  They may feel threatened or afraid.  Hopefully, they will get the message and get up and join us.

Our kids may not be ready to give up mom or dad to activities that take us away from them.  They may become more demanding or attention-seeking.  On the other hand, there are many activities in which they can participate.  They, too, can achieve a higher level of wellness.

People who do not understand may try to discourage us.  Since they do not see anything wrong with themselves, they may tell us we are wasting our time.

Secondly, wellness can be costly.  Fitness center memberships and work-out gyms can cost a lot of money, especially if they go unused.  If choosing to buy organic foods, be prepared for a higher grocery bill.  Vitamins and other supplements can also lighten your wallet.

So what is the answer?

Take a moment to consider, “Who is my best friend?”

If you did not name yourself, then you need to reconsider your commitment to wellness.  In order to win on the path to wellness, you must first be your own best friend.  You must first be your own best nurse, doctor*, partner, fitness coach, mother, spiritual adviser, and cheerleader.  You must believe in yourself, your efforts, and your ability to succeed.

Make the choice.  Make the commitment.  Have faith in yourself.  Stay focused on what you are trying to achieve and stick with it.  This is not a commitment to last a day, a month, or a year.  This is a commitment to last a lifetime.

Dawn Pisturino, RN
November 2, 2006; June 29, 2022

Copyright 2006-2022 Dawn Pisturino. All Rights Reserved.

*Check with your doctor before engaging in exercise that may be harmful to your health. Even yoga and simple exercises can cause injury. Make sure that herbs and supplements do not interfere with your prescribed medications. Watch out for medical scams that promise miraculous cures. Watch out for practitioners who offer questionable therapies. DO NOT GO AGAINST YOUR DOCTOR’S MEDICAL ADVICE. DO NOT STOP TAKING PSYCHIATRIC MEDICATIONS UNLESS ORDERED AND SUPERVISED BY YOUR PSYCHIATRIST. DO NOT USE STREET DRUGS. Being “your own best doctor” means taking responsibility for your health, NOT self-diagnosing, NOT self-prescribing, and NOT self-medicating. If necessary, go to the emergency room and get the help you need.

The Path to Wellness

Wellness, from a holistic point of view, means wholeness.  We achieve wholeness when all the parts of our lives come into balance.  But how do we do this?

First, we make a choice.  Making the choice may or may not be easy.  We may genuinely enjoy smoking.  We may really like going out for Sunday dinner at the local steak house.  We may really believe that one more cup of coffee won’t hurt us.  But what is the end result that we want to achieve?

Do we want to breathe easy in our old age or be hooked up to an oxygen tank?  Do we want to maintain healthy arteries through our diet or to undergo surgical procedures to clean them out?  How many medications do we want to take — and who’s going to pay for them?  Do we really like the feeling of jitteriness that coffee brings? And oh, the heartburn!

Once we make the choice, it is all a matter of sticking with it.  Making a commitment to ourselves and our well-being goes a long way to achieving wellness.  After all, nobody else can do it for us.  The family doctor can prescribe drugs and suggest lifestyle changes, but he cannot do the exercise for us.  Neither is he going to give up his steak and ice cream for us.  He will, however, be more than happy to take care of us when we end up in the hospital.  Is that the outcome we want to achieve?

Frankly, it’s hard.  It’s hard to give up the things we love and which give us a sense of comfort when we are under stress or bored.  It’s hard to give up those little pleasures which make life worth living.  After all, isn’t that what life is all about? 

And who really wants to go out and jog five miles a day?  Who has the time?  And does it really matter whether we live to be 76 or 78?

Wellness means wholeness.  Wholeness means integration and quality of life.  It is not so much the number of years that we are trying to reach but the quality of life that we are trying to achieve.  A person may live to be 100, but if they are dragging around an oxygen tank, live in a nursing home, and have no family or friends, is that wellness?  Is that wholeness?  Is that the quality of life that we are striving to achieve?

Think about it.  Examine your life now and your possible life in the future.  What do you see?  Do you like what you see?  If not, then make a commitment to yourself to achieve a greater level of wellness in your life.
Dawn Pisturino, RN
November 2, 2006; June 28, 2022
Published in The Kingman Daily Miner, February 27, 2007

Copyright 2006-2022 Dawn Pisturino. All Rights Reserved.

The Meaning of Wellness

The term “wellness” means many things to many people but, generally speaking, it refers to a feeling of wholeness.  While many people may regard wellness as an absence of disease, it goes far beyond physical health.

When we view ourselves from the holistic point of view, we see that we are much more than a collection of flesh and bones meandering aimlessly through life.  We have physical needs that must be met such as food, warmth, shelter, sex, etc.  Most people do well meeting these basic needs.  But once these basic needs are met, we find that we need more.  Instead of just physical gratification, we long for love and affection.  Our bodies crave healthy, wholesome foods, not just whatever junk we find in the cupboard.  We want to create an environment of peace and comfort that we can go home to at night after a long day at work.  We seek relationships and environments that are nourishing and contribute to our fulfillment in life.

Wellness begins with our physical health.  We can choose to be healthier by making better food choices, exercising more, watching our weight, and getting more rest.  We can do what we can to prevent illness, rather than trusting to luck and treating the illness after the fact, when it is more difficult and more expensive — or may be too late.

For example, we can stop smoking if we are concerned about future lung disease.  We can cut back on red meat and consume more fruits and vegetables if we are concerned about heart disease.  We can lose weight, exercise more, and cut back on starches and processed foods if we are afraid of developing Type II diabetes.  This control is in OUR hands.

Taking this a step further, then, we can also find wellness in other areas of our lives.  We can end an abusive relationship and associate with people who treat us with love and compassion.  We can quit a dead-end job, go back to school, and follow a new career.  We can cut up the credit cards and avoid incurring more debt.  We can express our creativity through hobbies, loving relationships, service to others, and spiritual practices.

Wellness, from a holistic point of view, is wholeness.  We achieve wholeness when all the parts of our lives come into balance.  It is a feeling of being fully integrated and connected with the world.  It is living a quality of life which brings us inner peace and a sense of well-being.

Examine your life.  Are there areas which you could improve?  Look at your options.  Are there new or better ways that you could live?  Make a choice and go with it.  You can always choose new paths later on.

Dawn Pisturino, RN
November 2, 2006; June 27, 2022
Published in The Kingman Daily Miner, February 13, 2007
       and The Standard, week of February 12, 2007

Copyright 2006-2022 Dawn Pisturino. All Rights Reserved.

Health Information Technology Security

Abstract       

Due to threats of cybercrime and malware infestations, healthcare organizations all across the world are now forced to upgrade and monitor their cybersecurity systems on a constant basis for the sake of protected patient health information, financial stability, and uninterrupted operations.  Money that would normally be spent on patient care is being diverted to IT professionals, who are hired to keep cybersecurity systems intact.

Health Information Technology Security       

Protecting patient health information, as mandated by law, has become a priority for healthcare facilities all around the world.  From doctors’ offices to medical devices to ransomware, the healthcare industry is under attack by cyber threats that compromise the health, safety, and privacy of patients everywhere.       

Nurses are at the forefront in efforts to secure patient and employee information, promote responsible use of computer technology, and report possible threats and violations in a timely manner.

Cybersecurity is Crucial       

Almost every day, a news story comes out that a corporation, nonprofit organization, or government agency has been hacked.  The healthcare industry is no different, and the attacks are becoming more frequent and more serious.  This is such an important issue at the hospital where I work, it seemed pertinent to write a paper on it.  Our IT department frequently makes us aware of e-mail threats, blocks blog sites, mandates automatic logoffs and timed reboots, requires frequent password changes, and regularly reminds us to turn off our computers, log off when finished, and to not share passwords.  Cybersecurity is crucial to protecting patient health information and network systems.

All Healthcare Organizations are at Risk       

Smaller healthcare clinics and doctors’ offices must follow the same mandates as larger organizations when it comes to protecting patient health information.  Healthcare personnel divulging protected information to unauthorized people and hackers using stolen information in identity theft scams are huge concerns that must be addressed (Taitsman, Grimm, & Agrawal, 2013).  Not only must these smaller organizations take appropriate measures to secure patient health information, but personnel must strictly follow policies and protocols.  Simple safeguards, such as screening phone calls, logging off computers, shredding documents, background checks for employees, automatic logouts, and activity audits, protect and safeguard patients and organizations alike (Taitsman, Grimm, & Agrawal, 2013).  Insurance companies, too, must safeguard patients against fraudulent claims.  Consumers must be educated in ways to protect their own healthcare information (Taitsman, Grimm, & Agrawal, 2013).       

Nurses all across the healthcare spectrum are increasingly required to use computer technology, and they must honor patient privacy, confidentiality, and consent while doing so.  Use of the Internet opens the doorway to viruses, worms, adware, spyware, and other forms of malware (Damrongsak & Brown, 2008).  Something as simple as using a shared address book can infect an entire system.  Logging off the computer when the nurse has finished and frequently backing up data can prevent unauthorized intrusions and corrupted data (Damrongsak & Brown, 2008).  Most medical facilities use an intranet, or closed system, in addition to the Internet, that restricts data to a smaller group of people.  Firewalls, encryption, and the use of virtual private networks provide additional security (Damrongsak & Brown, 2008).       

Large government agencies, such as the Veterans Administration, have increased efforts to stave off cyber-attacks, which compromise patient health information and medical devices.  IT specialists have removed medical devices from the VA hospital’s main network systems and connected them to virtual-local area networks (VLANs) (Rhea, 2010).  Without access to the Internet, these devices can be used without fear of attack.  In the past, the main focus has been on identity theft.  But with the rise of international terrorism, there is a growing fear that medical devices may be hacked and used to intentionally harm patients (Rhea, 2010).  Healthcare IT systems have already been crippled by hackers looking to profit from cybercrime.  In 2009, healthcare facilities around the world found medical devices infected with the Conficker virus (Rhea, 2010).  Downtime caused by malware is expensive and inconvenient.  Hospitals are forced to spend money on security that normally would have gone to patient care (Rhea, 2010).  FDA regulations are also a hindrance to quick development of security patches (Rhea, 2010).       

According to author W.S. Chee (2007), a member of the Department of Diagnostic Imaging at K.K. Women’s and Children’s Hospital in Singapore, medical devices connected to a hospital’s network system can lead to critical threats and infestations of malware in these devices.  Hospitals need to act proactively to prevent intrusions and respond immediately if a system becomes infected (Chee, 2007).  Equipment vendors play a huge role because they supply the security measures which protect medical devices (Chee, 2007).  But they can be slow in providing updates and patches.  The FDA, furthermore, determines when and how changes can be made to biomedical equipment systems.  This places the burden on hospitals to protect themselves (Chee, 2007).       

Thomas Klein (2014), managing editor of Electronic Medical Device Technology, asserts that intentional sabotage of medical devices is only a matter of time.  According to researchers, vulnerabilities have been found in infusion pumps, x-ray machines, cardiac defibrillators, and other devices (Klein, 2014).  Since these devices are frequently connected to the Internet, they are vulnerable to malware.  If the network systems are not fully protected, the devices are subject to malicious attack.  The use of USB ports opens a doorway to security breaches and malware (Klein, 2014).  The risk is so great the FDA became involved and now requires that manufacturers consider cybersecurity risks when developing new products (Klein, 2014).       

The expansion of healthcare information technology improves profitability while exposing healthcare facilities to greater risks (Elliot, 2005).  Facilities must create and enforce policies that secure patient health information across all forms of networks and technology.  One solution for managing remote devices is the use of on-demand security services that cease to work once the remote device is no longer in use (Elliot, 2005).  The problem, then, is security on the other end, where patient health information can be leaked or accessed by the user.  This is called post-delivery security (Elliot, 2005).  Solutions include user malware protection, restrictions on use of data, and audits on computer use.  Developing and enforcing security policies that protect patient health information, especially information transmitted to remote devices, is tantamount to avoiding security breaches and corrupted data (Elliot, 2005).       

The latest, and most serious, threat comes in the form of professional IT criminals who use ransomware to extort money from hospitals (Conn, 2016).  One such threat, Locky, acts through ordinary-looking e-mail (Conn, 2016).  When opened, a virus activates software that encrypts the hospital’s IT system.  Then, a window pops up with a ransom demand.  Samas, another threat, uploads encryption ransomware through a hospital’s Web server (Conn, 2016).  A more sophisticated ransomware, CryptoLocker, demands bitcoin as payment because it is nearly impossible to trace (Conn, 2016).  Once paid, the criminals unlock the data in an infected system.  But, should hospitals pay in the first place?  Cybersecurity has become a booming business, with medical facilities now being forced to employ their services.  There is a major concern that medical devices will be the next systems to be hit by cybercriminals (Conn, 2016).

Topic Availability

This topic, as it relates to Nursing Informatics, is too important to ignore.  I used seven resources from scholarly and peer-reviewed publications for this paper.  I pulled my resources primarily from CINAHL and ProQuest.  I found enough materials to give me a broad overview of the topic, but I was disappointed that more current articles could not be found.  Technology changes so rapidly that even a few months can make a difference in security innovations.  I used both the basic and advanced search features and the key words “medical device malware security.”

Information Availability 

This information is available in scholarly and peer-reviewed journals and other publications.  Although the information was geared toward professionals, some publications include short articles that educate the general public about cybersecurity and protecting patient health information.  Nurses benefit from all of these resources because many do not understand the extent of the threat.

Personal Views 

The information I read shocked me (cyberterrorism), confirmed what I see our IT specialists changing at my hospital, and disturbed me (ransomware cybercrime.)  The general public does not seem to be aware of these threats.  As a nurse who uses computer technology every day, I was not aware of the seriousness of this problem.  It never occurred to me that a glucometer or infusion pump could be infected with a virus or that an unscrupulous person would deliberately sabotage somebody’s pacemaker.  When I mention this to other nurses, they are equally dismayed by the possibilities.  They always ask, “Why would somebody maliciously hack into a medical device?”  For people who devote their lives to saving people, the idea is unthinkable.       

The changing landscape in healthcare makes it crucial that ALL medical personnel understand the seriousness of the threats.  As technology becomes more sophisticated, so do the means by which cybercriminals hack into and infect network systems.  Information is compromised, and patient health and well-being are put at risk.

Conclusion

In conclusion, whether it’s a small private practice or a large healthcare system, the increased use of technology poses significant threats to protected patient health information, medical devices, and cybersecurity systems.  Users all across the healthcare spectrum have a duty to behave responsibly when accessing patient records, divulging information, searching the Internet, managing e-mail and faxes, and interacting with colleagues.  Nurses should provide feedback and input about vulnerabilities in security policies and protocols for the protection of themselves and their patients.  They must educate themselves about current threats so they can adapt their practice to avoid unintentional security breaches.  Nurses can also educate their patients in the use of computer technology, accessing patient portals, and protecting patient health information.        

Technology will continue to be a driving force in healthcare.  Along with the downside comes the possibility of lower costs to facilities and patients, improved outcomes, more accurate measurements, increased research, and greater opportunities for nurses to expand their involvement and role in improving healthcare and healthcare informatics.  Requiring nursing students to study nursing informatics increases their awareness of the problems and benefits of  technology.  Hopefully, our physicians and administrators are being trained in this area, as well.  Health information technology specialists are enjoying a surge in employment opportunities as healthcare systems realize the importance of their specialty.  Technology is expensive, but the threats of cybercrime and cyber-attacks are more damaging.  

References

Chee, W.S. A. (2007). IT security in biomedical imaging informatics: The hidden vulnerability. Journal of Mechanics in Medicine and Biology, 7(1), 101-106.

Conn, J. (2016, April). Ransomware scare: Will hospitals pay for protection. Modern Healthcare, 46(15), 8-8.

Damrongsak, M., & Brown, K.C. (2008). Data security in occupational health. AAOHN

 Journal, 56(10), 417-421. Retrieved from 

http://search.proquest.com.resources.njstatelib.org/docview/219399232?accountid=63787.

Elliot, M. (2005, September). Securing the healthcare border. Health Management Technology,

 26(9), 32-35.

Klein, T. (2014, September). How to protect medical devices against malware. Operating Theatre Journal, 14-14.

Rhea, S. (2010, December). Cyberbattle: Providers work to protect devices, patients. Modern

 Healthcare, 40(50), 33-34.

Taitsman, J. K., Grimm, C. M., Agrawal, S. (2013, March). Protecting Patient privacy and data security. The New England Journal of Medicine, 368, 977-979. doi: 10.1056/NEJMp1215258. Retrieved from http://www.NEJM.org.

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PowerPoint presentation shared at Flagstaff Medical Center in 2016. See it here on Dropbox:

https://www.dropbox.com/s/4o62z11sbzmg5tz/NUR-340%20Power%20Point%20Presentation%20Pisturino%20%281%29.pptx?dl=0

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Dawn Pisturino
Thomas Edison State University

August 31, 2016; June 10, 2022
Copyright 2016-2022 Dawn Pisturino. All Rights Reserved.

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