14.3 Ethics, Advocacy & Scope of Practice
Key Takeaways
- Core bioethics principles—autonomy, beneficence, nonmaleficence, and justice—guide GERO-BC ethical reasoning when values collide
- Advocacy means amplifying the older adult’s voice, rights, and access—especially when ageism, disability, or system barriers mute that voice
- Scope of practice is defined by state nurse practice acts, facility policy, and individual competency; certification does not expand legal authority alone
- Moral distress arises when nurses know the ethically appropriate action but face institutional constraints—use ethics resources and chain of command
- Professional boundaries, confidentiality, and truthful communication remain mandatory even in long-term relationships with older adults and families
Ethics, Advocacy & Scope of Practice
Quick Answer: GERO-BC III-A-6 pairs legal knowledge with ethics. Use the four principles—autonomy, beneficence, nonmaleficence, justice—to analyze dilemmas; advocate for the older adult’s informed preferences and equitable access; and stay within RN scope set by the state nurse practice act, employer policy, and your demonstrated competency. Certification (GERO-BC) signals specialty knowledge—it does not independently authorize medical acts reserved for APRNs or physicians.
Gerontological settings create recurring ethical tension: protecting safety without becoming paternalistic; supporting families without erasing the patient; stretching scarce resources without abandoning the most complex elders.
The Four Principles in Older-Adult Care
| Principle | Definition | Geriatric example |
|---|---|---|
| Autonomy | Respect self-determination of capacitated persons | Honor refusal of dialysis after informed discussion |
| Beneficence | Act to benefit / promote welfare | Mobilize early to prevent deconditioning |
| Nonmaleficence | Avoid harm | Stop a Beers-list sedative causing falls |
| Justice | Fairness in distribution of care and resources | Oppose denying rehab solely because of age |
Common collisions
- Autonomy vs. beneficence: Capacitated patient wants to return home alone despite fall risk → respect autonomy while negotiating safety supports (not covert restraint).
- Nonmaleficence vs. beneficence: Aggressive chemo may prolong life but devastate function → clarify the patient’s definition of benefit.
- Justice: Boarding “difficult” behavioral patients without specialty care while others get rapid consults → advocate for equitable access.
Exam pattern: when capacity is intact, autonomy usually prevails after information is given; when capacity is lacking, beneficence/nonmaleficence operate through lawful surrogates and least-restrictive protections.
Advocacy in Gerontological Nursing
Advocacy is deliberate action to support the older adult’s rights, preferences, and wellbeing within systems that often default to convenience, ageism, or family authority.
Advocacy actions that score on exams
- Ensure the patient (not only the family) is included in teaching and consent when capacitated
- Challenge ageist comments (“She’s 90—why bother with PT?”) with functional prognosis data
- Secure interpreters, hearing amplifiers, and accessible materials
- Escalate unsafe staffing, missed meds, or care omissions through chain of command
- Connect to ombudsman (LTC), legal aid, benefits counselors, or ethics committee when rights are threatened
- Support reporting of abuse/neglect per mandatory reporting laws
Advocacy is not promising outcomes you cannot control, taking over decisions the patient can make, or aligning automatically with whichever family member is most distressed.
Scope of Practice and Accountability
| Layer | What it controls |
|---|---|
| State nurse practice act & BON rules | Legal RN authority (assessment, nursing diagnosis, teaching, medication administration within orders/protocols) |
| Facility policy / privileging | Local limits (who may insert IVs, pronounce death, take verbal orders) |
| Individual competency | Even if legally allowed, you must be trained/competent |
| Provider orders / protocols | Many interventions require an order or standing protocol |
| Federal rules (e.g., CMS) | LTC residents’ rights, restraint standards, care planning requirements |
Stay in your lane—and escalate
- Do not independently prescribe, alter controlled regimens, or provide medical diagnoses beyond nursing scope
- Do not ignore unsafe orders—clarify, refuse dangerous instructions, and escalate
- Document objectively: assessment findings, patient statements, notifications, and responses
- Delegate only to personnel permitted and competent; retain accountability for the decision to delegate
GERO-BC specialty knowledge deepens how well you assess and educate older adults; it does not replace APRN/physician authority for diagnosis and prescribing.
Professional Boundaries and Confidentiality
Long-term relationships in clinics, home care, and nursing homes tempt boundary drift:
- Avoid dual relationships (borrowing money, dating family members, becoming informal “favorite child”)
- Gift policies: follow facility rules; small tokens may be acceptable, valuable gifts are not
- Social media: never post identifiable patient information or images
- HIPAA/privacy: share minimum necessary information with the care team; verify authority before discussing with callers
- Truth-telling: older adults generally have a right to diagnostic information unless they clearly delegate “tell my daughter instead” and capacity is considered
Moral Distress and Ethics Resources
Moral distress occurs when you know the ethically appropriate action but constraints (policy, hierarchy, family pressure, staffing) block it—for example, continuing burdensome treatment the patient previously refused, or failing to provide adequate analgesia.
Constructive pathway
- Name the conflict (which principles collide?)
- Gather facts (capacity, directives, prognosis, options)
- Use chain of command and interdisciplinary team huddles
- Request ethics consultation for persistent conflict
- Protect self-care to prevent burnout and compromised vigilance
Ethics consults advise; they do not replace clinical decision-makers—but they structure fair process and often reduce conflict.
Ageism as an Ethical Issue
Ageism is prejudice or discrimination based on age. Ethically, it violates justice and often beneficence when treatable problems are dismissed as “just old age.” Counter ageism by:
- Separating normal aging from pathology (Domain I skill applied ethically)
- Offering evidence-based interventions regardless of chronologic age when goals and prognosis support them
- Using person-centered language (names and roles, not “the feeders” or “bed 3”)
Integrated Exam Approach
When an ethics stem appears, identify: (1) Is the patient capacitated? (2) What does the patient want? (3) What is lawful scope? (4) Which principle is primary? Choose the option that honors informed autonomy, reduces harm, advocates within systems, and stays inside RN authority.
A capacitated 88-year-old declines percutaneous feeding after repeated aspiration. The care team believes a tube would prolong life. Which ethical principle most strongly supports honoring the refusal?
Which action best demonstrates nursing advocacy for an older adult in a skilled nursing facility?
A newly GERO-BC–certified RN is asked by a coworker to independently adjust a warfarin dose based on an INR the RN obtained. What is the appropriate response?
A nurse experiences moral distress when a capacitated patient’s documented preference for comfort-focused care is repeatedly overridden by a demanding relative. What is the best next step after clarifying facts?