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Telehealth: Ethical and Legal Challenges in the Healthcare System
Hooman Heydary, Shakila Belkafeh, Mohammadreza Dinmohammadi,
Volume 17, Issue 0 (12-2024)
Abstract
Telehealth has emerged as a rapidly expanding method for delivering healthcare services, especially during the COVID-19 pandemic. This approach has opened new avenues for accessing medical care and contributed to reducing healthcare costs. However, the growth of telehealth has introduced significant legal and ethical challenges that warrant thorough investigation. This review study employed keywords such as "telemedicine," "telehealth," "ethical challenges," "legal challenges," and "healthcare system" to search scientific databases including PubMed, Scopus, CINAHL, and Google Scholar. Articles published in English and Persian between 2010 and 2024 were reviewed. Eligible sources included research articles, systematic reviews, and case reports focusing on legal and ethical issues related to telehealth. Following an initial screening, articles were assessed based on quality and scientific credibility, and the selected works were analyzed for the final synthesis. Telehealth presents several critical challenges that must be addressed to ensure safe and equitable care delivery. One of the foremost concerns is patient privacy and data protection; the exchange of sensitive health information necessitates robust security protocols and adherence to data protection regulations to uphold patient confidentiality and trust. Another key issue is informed consent, which must be adapted to the virtual context to ensure patients are adequately informed of both the benefits and potential risks associated with telehealth services. While telehealth enhances healthcare accessibility, it may also deepen existing health disparities due to unequal access to digital technologies. Therefore, investments in communication infrastructure and digital literacy are essential to promote inclusivity and equal access to care. Although telehealth offers substantial benefits—including improved access, convenience, and enhanced coordination of care—its legal and ethical implications must not be overlooked. To fully realize its potential, stakeholders must collaborate in developing comprehensive regulations and ethical frameworks. Addressing these challenges is imperative to advancing telehealth in a manner that ensures patient safety, protects rights, and promotes health equity.

The Impact of Professional Ethics Training on the Spiritual Care Competence of Emergency Nurses
Milad Kazemi Najm, Tahereh Toulabi, Abbas Abbaszadeh, Rasoul Mohammadi, Nasrin Imanifar,
Volume 17, Issue 0 (12-2024)
Abstract
Nurses, as the largest group of healthcare workers globally, are responsible for providing holistic care to patients. Holistic care encompasses physical, mental, social, and spiritual dimensions. This study aimed to determine the effect of professional ethics training on the spiritual care competence of emergency nurses. This two-group field trial study with a pre-test and post-test design was conducted with 84 nurses working in the emergency departments of Lorestan University of Medical Sciences. Participants were selected through stratified random sampling. The intervention group participated in four workshops. The study tool was the Spiritual Care Competency Questionnaire. Data analysis was performed using SPSS, employing descriptive statistics (mean, median, and percentage) and inferential statistical tests, including repeated measures ANOVA, independent t-tests, and Fisher’s exact test.
The study included two groups: intervention (n = 42) and control (n = 42). Most participants in both groups were women. A significant difference was observed in the average total spiritual care competence scores and its dimensions (excluding the self-knowledge subscale) over different time points in the intervention group (P < 0.001). However, for the self-knowledge subscale, no significant difference was found in the average scores between the control and intervention groups at different time points. The results of this study demonstrated that professional ethics training improves nurses' spiritual care competence. By conducting workshops, training programs, and in-service courses on professional ethics and spiritual care, the quality of nursing care can be enhanced, ultimately improving patient safety. It is recommended that healthcare policymakers and nursing managers prioritize professional ethics as the foundation of all nursing practices. Employing innovative and engaging methods, such as the scenario-based approach used in this study, can further support the development of professional ethics in nursing.

Investigating the Ethical Challenges of Nurses in End-of-Life Care at Home for Elderly Patients: A Review Study
Nayereh Baghcheghi, Zahra Maddah,
Volume 17, Issue 0 (12-2024)
Abstract
With the increasing elderly population and the growing demand for home healthcare and end-of-life care services, nurses are facing expanded duties and responsibilities. This intensification of responsibilities can expose them to significant ethical challenges. This study aimed to investigate the ethical issues nurses encounter in providing end-of-life care at home for elderly patients. This review study involved a comprehensive search of databases including PubMed (Medline), Google Scholar, ISI Scopus, ProQuest, Science Direct, SID, IranDoc, IranMedex, and Magiran. The keywords used were: nursing ethics, ethical challenges, end-of-life care, and home care, along with their Persian equivalents. The search covered literature published between 2000 and 2024. The review identified several prominent ethical challenges faced by nurses in home-based end-of-life care, including: lack of attention to patients’ rights and independence, disrespect for the dignity of elderly patients, inadequate empathetic care, poor communication, and unsafe home environments for nurses. These challenges may lead to moral distress, as well as psychological and emotional consequences for both the care providers and the elderly patients. Given the serious ethical challenges nurses face in end-of-life home care for the elderly, it is essential for them to be well-versed in ethical principles relevant to this context. Enhancing awareness and competence in ethical practices can help nurses uphold patient rights, promote autonomy, and provide high-quality, compassionate care through effective communication and support.

Attitudes Towards Euthanasia Among Intensive Care Nurses
Maryam Ghaffari, Reza Shabanloei, Mozhgan Behshid,
Volume 17, Issue 0 (12-2024)
Abstract
Euthanasia, often referred to as mercy killing or an "easy death," remains a deeply controversial issue, particularly in Islamic countries where it is both ethically and legally prohibited. Nurses working in intensive care units (ICUs) are more likely than other healthcare professionals to encounter situations related to end-of-life care, given the critical condition of the patients they serve. Consequently, their attitudes toward euthanasia hold significant ethical and professional implications. This descriptive-analytical study was conducted to explore the attitudes of ICU nurses toward euthanasia in a context where it is culturally and legally forbidden. A total of 194 nurses from eight hospitals affiliated with Tabriz University of Medical Sciences participated. Data collection instruments included a demographic questionnaire and Holloway’s Attitudes Toward Euthanasia Scale. Data were analyzed using descriptive statistics, t-tests, and ANOVA. The mean attitude score towards euthanasia was 71.95 ± 4.99 out of a possible 120. Overall, 74% of participants scored below 75, reflecting a generally negative attitude toward euthanasia, while 26% scored above 75, indicating a more favorable view. No statistically significant association was found between attitudes toward euthanasia and any demographic variables (p ≥ 0.05). Despite the legal and religious restrictions against euthanasia in Iran, a portion of ICU nurses demonstrated a positive attitude toward the practice. Given the potential impact of these attitudes on patient care, nursing managers and educational authorities should address even minimal levels of support for euthanasia. Targeted training and ethical guidance are essential to ensure that patient care remains aligned with legal and moral standards, particularly in ethically sensitive clinical situations.
 

Ethical Considerations in Healthcare Policy-Making and National Planning: A Qualitative Study
Peyman Parvizrad,
Volume 17, Issue 0 (12-2024)
Abstract
Healthcare policy-making and national planning are complex processes that require the integration of ethical principles to ensure fairness, effectiveness, and public trust. This qualitative study explores the key ethical considerations that should guide the development and implementation of healthcare policies and plans. A qualitative research design was utilized, incorporating semi-structured interviews with key stakeholders in the healthcare sector, including policymakers, healthcare providers, and patient representatives. A total of 15 interviews were conducted until data saturation was achieved. The interviews were transcribed verbatim and analyzed using thematic analysis. Thematic analysis identified seven key ethical considerations in healthcare policy-making and planning: (1) Equity and Justice – ensuring equitable access to healthcare regardless of socioeconomic status, race, or other demographic factors; (2) Autonomy and Informed Consent – respecting individual autonomy and ensuring informed decision-making in healthcare interventions; (3) Beneficence – prioritizing actions that maximize benefits and minimize harm; (4) Non-Maleficence – preventing harm to patients and communities; (5) Confidentiality and Privacy – safeguarding patient information and ensuring data protection; (6) Resource Allocation – making fair and justifiable decisions regarding the distribution of limited healthcare resources; and (7) Transparency and Accountability – promoting openness in policy decisions and ensuring accountability for outcomes. Ethical considerations play a critical role in shaping healthcare policies and national planning efforts. By integrating ethical principles into decision-making, policymakers and healthcare providers can foster policies that enhance public well-being, equity, and trust in the healthcare system. A structured ethical framework can help ensure that healthcare policies align with societal values and promote justice in health service delivery.

Home-Based Care Ethical Issues and Solutions: A Review Study
Shima Yadegar Tirandaz, Azam Shirinabadi Farahani,
Volume 17, Issue 0 (12-2024)
Abstract
In recent decades, care delivery has shifted from hospital settings to community and home-based care due to factors such as an aging population, cost control, patient preferences, and advancements in technology. While home care offers advantages like patient independence and care aligned with individual values, it also presents unique ethical challenges. These challenges arise from the home environment, which may not be designed for medical care, as well as potential conflicts between the values of patients and care providers. This study aims to explore the ethical issues in home-based care and propose solutions. This review was conducted by analyzing original articles from PubMed, Scopus, WOS, and Google Scholar, using the keywords "Home-Based Care" and "Ethical Issues" until November 2024. A total of 10 studies relevant to the study’s focus were included. The studies identified several ethical challenges in home-based care, including: respecting patient autonomy, establishing trust, managing patient resistance to care, balancing autonomy with benevolence, the risk of harm, justice concerns, limited resources, managing patient expectations, decision-making capacity, disagreements on treatment, access to healthcare providers, caregiver roles, maintaining professional relationships, providing truthful information, conflicts between families and patients, self-medication, medication access, sudden changes in condition, care coordination issues, inadequate treatment due to resource limitations, insufficient psychosocial support, life-saving decisions, communication problems, ineffective care, and cultural conflicts. To address these challenges, the following solutions were proposed: respecting patient values, beliefs, and preferences; supporting patient rights in family conflicts; promoting independence; building trust through respectful communication, empathy, and encouragement; ensuring patient dignity; maintaining healthcare workers' moral obligations; avoiding coercion; adhering to legal and ethical principles; facilitating patient participation; reducing caregiver burden; providing adequate resources; and educating and guiding patients and families. Ethical challenges are inherent in home-based care. If not properly identified and managed, these issues can negatively impact the quality of care. Home care organizations and providers must implement ethical strategies to uphold patients' independence and dignity within their home environment.
 

Ethical Challenges of Nurses in Caring for Patients with Chronic Mental Illness
Alireza Zare, Mohammad Hossein Taklif, Alireza Javid, Zahra Amadeh, Negin Farid,
Volume 17, Issue 0 (12-2024)
Abstract
Nurses, as key members of the healthcare team, face complex ethical issues when caring for patients with chronic mental illnesses. These challenges include maintaining confidentiality, obtaining informed consent from patients with limited cognitive abilities, managing conflicts between patient rights and safety requirements, and addressing social stigma. Inadequate attention to these challenges may lead to reduced care quality and psychological stress for nurses. A better understanding of these challenges and the provision of appropriate solutions is essential. This study was conducted through a simple review approach. A comprehensive search was first conducted in PubMed, Scopus, PsycINFO, and Google Scholar databases. Combined keywords such as "ethical challenges," "nursing," "chronic mental illness patients," and "ethical care" were used. Inclusion criteria included studies published in English and Persian from 2010 to 2023, including research, review, and qualitative articles related to the topic. A total of 150 articles were identified, and after evaluating their quality and relevance, 30 articles were selected for final analysis. Data were analyzed using thematic and comparative analysis methods. The findings revealed that nurses face multiple challenges, including maintaining confidentiality when interacting with families, obtaining informed consent from patients with cognitive disorders, and managing ethical conflicts between patient safety and individual freedom. Additionally, a lack of specialized ethical training, the absence of clear protocols, and the pressure from the social stigma of patients were identified as key challenges. The ethical challenges faced by nurses in caring for patients with chronic mental illness require special attention from relevant organizations. Providing continuous education, developing ethical guidelines, and creating psychological and legal support can help mitigate these challenges. Further studies on practical, experience-based solutions to address these issues are recommended.

Nursing Ethics in the Care of Elderly Patients: A Review of Challenges and Solutions
Alireza Zare, Mohammad Hossein Taklif, Alireza Javid, Zahra Amadeh, Negin Farid,
Volume 17, Issue 0 (12-2024)
Abstract
As the global elderly population continues to rise, nursing care for this demographic faces increasing ethical challenges. The elderly are particularly vulnerable, requiring specialized care that addresses their physical, psychological, and social needs. However, these needs often present ethical dilemmas, including issues related to autonomy, informed consent, fairness in resource allocation, and managing conflicts between patients and their families. This systematic review aims to identify the ethical challenges nurses face in caring for elderly patients and to propose solutions that enhance the quality of care. A comprehensive search was conducted across several reputable databases, including PubMed, Scopus, CINAHL, and Google Scholar, using keywords such as "nursing ethics", "elderly", "ethical challenges", and "ethical care". Articles published between 2010 and 2023 in English and Persian were considered for inclusion. After an initial screening, 40 eligible articles were selected for final analysis, and thematic analysis was used to interpret the data. The findings reveal several key ethical challenges for nurses in elderly care, including respecting patient autonomy, navigating decision-making processes in cases of cognitive decline, ensuring confidentiality, and managing family pressures. Additional difficulties include resource shortages, high workload, and limited access to ethics training. Proposed solutions to address these challenges include continuous ethics education, the development of comprehensive ethics protocols, and the formation of interdisciplinary teams to facilitate more informed decision-making. Addressing ethical challenges in elderly care requires robust planning and action from health systems. By establishing clear ethical guidelines, promoting ongoing education, and fostering a supportive work environment, the quality of care for elderly patients can be significantly improved. Further research should evaluate the effectiveness of these strategies in mitigating ethical issues within nursing practice.

The Importance of Patient Autonomy in Home Care: A Systematic Review
Mohammadreza Jalilfar, Hedayat Jafari, Fatemeh Roudi, Seyed Tohid Hoseini, Soodabeh Eslami, Seyed Mohammad Mirshafiei,
Volume 17, Issue 0 (12-2024)
Abstract
With the increasing need for home nursing care, patient autonomy emerges as a crucial ethical principle in delivering care services. Therefore, this study aimed to investigate the importance of autonomy and individual independence in home-based patient care. In this systematic review, articles from PubMed, Scopus, ScienceDirect, Magiran databases, and Google Scholar search engine, published within the last 10 years, were used to search for articles related to autonomy and independence in home nursing care. The keywords used in the search were: "patient autonomy", "home nursing care", "nursing ethics" and "autonomy in nursing home care".  After reviewing and filtering the articles based on the study's objectives, 20 articles related to autonomy in home nursing care were included in this systematic review. The findings of these studies indicated that various factors can influence patient autonomy at home-care, including: · Individual factors: age, gender, physical and mental health status of the patient; · Family factors: family support, family relationships, family culture; · Social factors: social support, access to social resources; · Organizational factors: care policies, organizational structure, organizational culture.  Considering these findings and their comparisons, it can be concluded that to promote patient autonomy at home, all the mentioned factors should be considered. Some of the suggested solutions to promote patient autonomy are: · Educating the patient and family about patient autonomy; · Strengthening family support for the patient; · Providing social support services to the patient; · Developing care policies that support patient autonomy; · Improving organizational structure and culture.  Patient autonomy is one of the essential ethical principles in home nursing care. Considering the factors affecting patient's autonomy, comprehensive solutions should be considered to promote it. Patient and family education, strengthening family support, providing social support services  and improving organizational structure and culture are among the effective solutions in this field.

Moral Sensitivity Among Nurses in Cardiac Critical Care Units of Selected Hospitals Affiliated with Isfahan University of Medical Sciences in 2024
Safoura Dorri, Seyed Ali Rasooli, Hamideh Hakimi,
Volume 17, Issue 0 (12-2024)
Abstract
Moral sensitivity, defined as the ability to recognize and assess the ethical complexities of clinical situations and make appropriate ethical decisions, is a crucial skill for nurses. Despite its importance, various studies report varying levels of moral sensitivity among nurses, suggesting a gap in this competency. Nurses’ continuous exposure to ethical dilemmas can lead to adverse outcomes, including psychological and moral distress, decreased job satisfaction, and compromised care quality. As moral sensitivity can differ across healthcare settings and may change over time, studies assessing its levels across different periods are essential. This study aims to assess the level of moral sensitivity among nurses in hospitals affiliated with Isfahan University of Medical Sciences in 2024. This cross-sectional descriptive study was conducted with 200 nurses working in cardiac intensive care units (CICUs) of four large hospitals affiliated with Isfahan University of Medical Sciences. Participants were selected using a random sampling method. Data were collected using a demographic information form and the Lutzen Moral Sensitivity Questionnaire. Data analysis was performed using SPSS version 26, employing descriptive statistics such as means and standard deviations. The findings revealed that the average moral sensitivity score among the nurses was moderate (60.17±13.04). When analyzing the different dimensions of moral sensitivity, the highest score was observed in the dimension of "honesty and benevolence" (15.30 ± 4.48), while the lowest score was found in the dimension of "professional knowledge" (3.25 ± 1.88). The mean scores for the remaining dimensions were as follows: "respect for patient autonomy" (7.44 ± 2.13), "awareness of how to communicate with patients" (15.18 ± 3.41), "experiencing ethical problems and dilemmas" (7.74 ± 2.03), and "applying ethical concepts in ethical decision-making" (11.95 ± 3.35). The study revealed that nurses demonstrated a moderate level of moral sensitivity, with the lowest scores in the dimension of professional knowledge. This suggests that nurses may not be sufficiently involving patients in their treatment and care decisions. Given these findings, it is critical for healthcare policymakers and nursing managers to implement continuous assessment and feedback systems to accurately evaluate nurses' moral sensitivity and professional knowledge. By identifying the weaknesses and educational needs of nurses, targeted training programs can be developed, ultimately enhancing nurses' moral sensitivity and improving the quality of care.
 

A Review of Ethical Challenges in the Care of Elderly Patients
Fatemeh Ghonoodi, Zahra Amrollah Majdabadi , Sahar Keyvanloo Shahrestanaki,
Volume 17, Issue 0 (12-2024)
Abstract
This study emphasizes that adherence to medical ethics principles by healthcare professionals is essential for improving the quality of care for elderly patients. With the aging population in Iran, the importance of this issue continues to grow. Therefore, integrating all care infrastructure to address healthcare challenges and identifying ethical issues in elderly care, along with efforts to resolve them, aligns with the practical application of medical ethics and meets the current and future care needs of this population. The present study aimed to identify and examine the ethical challenges in the care process of elderly patients. Using a systematic review approach based on Aveyard, databases such as PubMed, CINAHL, Web of Science, Scopus, Ethics Share, and Google Scholar were searched for articles published between 2017 and the present. The search used keywords including “ethical challenge,” “care,” and “elderly patients.” Inclusion criteria were articles published in English or Persian that were relevant to the research objective; studies without available full texts were excluded. Thirty articles that systematically analyzed ethical challenges in elderly care were included. The results indicated that the primary ethical challenges are respect for elderly patients’ autonomy, preserving their dignity and privacy, insufficient education and awareness regarding professional-patient communication, and a lack of elderly-friendly activities in healthcare settings. Additionally, the emotional difficulties caused by complex chronic conditions necessitate expanded access to appropriate psychological support for the elderly. This study highlights that these ethical challenges are influenced by cognitive, educational, practical, and structural factors. Consequently, integrated care approaches that prioritize elderly patients’ independent preferences and ensure strong physician-patient relationships in clinical decision-making are needed. To mitigate these challenges, appropriate educational programs aimed at enhancing both the quantity and quality of medical ethics education for healthcare professionals—including students, staff, and faculty—are essential. Given the significance of this issue, continuous educational programs should be developed for nurses and other healthcare professionals to familiarize them with existing ethical challenges and improve the quality of care provided to elderly patients.

Association of Moral Reasoning with Clinical Belongingness and Their Influential Factors among ICU Nurses
Simin Kokabi Asl, Sareh Zekavat, Somayeh Rostamkhan, Abolfazl Dehbanizadeh, Mahsa Ghaemizadeh, Milad Amiri,
Volume 17, Issue 1 (3-2024)
Abstract
The intensive care unit (ICU) is a challenging and stressful environment where nurses encounter difficult ethical decisions daily. Therefore, this study aimed to determine the correlation between moral reasoning and clinical belongingness among Iranian ICU nurses. This cross-sectional, descriptive-analytical study was conducted on 126 nurses working in the adult ICUs of hospitals in Yasuj, Iran in 2023 using census sampling. Questionnaires measuring clinical belongingness and moral reasoning were used to collect data. Data were analyzed using independent samples t-test, ANOVA, regression, and Pearson’s correlation coefficient via SPSS-26 software. The findings revealed that the mean scores for clinical belongingness and moral reasoning among the nurses were 109.68 ± 13.75 and 36.07± 5.50, respectively, indicating good clinical belongingness and moderate moral reasoning. Moreover, a statistically significant relationship was identified between the place of service and clinical belongingness (p = 0.02), while no significant relationship was found between clinical belongingness and moral reasoning (p>0.05). Although no significant relationship was established between clinical belongingness and moral reasoning, certain demographic characteristics showed a significant predictive relationship with nurses' clinical belongingness. Accordingly,  it is recommended that nursing officials and managers utilize these findings to improve moral reasoning and the sense of belonging to the clinical environment among nurses.

Is it Possible to apply an Advance Directive in Iran’s Health System?
Amin Arman, Mina Mobasher, Mohammad Aminizadeh,
Volume 17, Issue 1 (3-2024)
Abstract

Deciding on whether to continue life-prolonging treatments for terminal patients is a major challenge in healthcare. Advance directive emerges as a proposed solution to this issue in the world. The patients record their preferences regarding the continuation of life-prolonging treatments while they still are able to make decisions. Although advance directive is morally justifiable from the perspective of principlism, respecting the patient’s right to autonomy and assessing the benefits and drawbacks of providing such services, the religious beliefs of patients, their families, and healthcare providers always exert a significant influence on this matter. In Islam, preserving human life heavily affects these decisions. Several juridical and legal rules can culminate in different decisions on the continuation or termination of life-prolonging treatments including the absolute legal power of the owner to exercise dominion[1] or control over property and permission of intervention in their body[2], the rules of prohibition on causing the death[3], the sanctity of human killing[4], the rule of prohibition of detriment[5], the concept of unstable life[6] in Article 372 of the Islamic Penal Code and the rules of preventing losses[7], and the rule of sanctity of idle[8]. Nevertheless, given various types of will in Islamic Jurisprudence and according to the contract of agreement[9], it is possible to record the patient’s request regarding how to continue the treatment. This study indicated that implementing advance directives in Iran’s health system requires a more accurate analysis of moral, legal, and jurisprudential foundations.

 
[1] (tasli¯t)
[2] (ezn dar tasarof)
[3](nafy al-d.arar )
[4] (Hormat Ghatl)
[5] (la¯ d.arar wa la¯ d.ira¯r fi¯ al-isla¯m)
[6] (Ghayr-Mustaqarr)
[7] (‘usr wa al-h. araj, al-)
[8] (hormat laghw)
[9] (agde solh)
[1]. (tasli¯t)
[2]. (ezn dar tasarof)
[3]. (nafy al-d.arar )
[4]. (Hormat Ghatl)
[5]. (la¯ d.arar wa la¯ d.ira¯r fi¯ al-isla¯m)
[6]. (Ghayr-Mustaqarr)
[7]. (‘usr wa al-h. araj, al-)
[8]. (hormat laghw)
[9]. (agde solh)

A Comprehensive Practical guideline for Breaking Bad News to Patients and Their Families in Intensive Care Units: A Qualitative Study
Sooreh Khaki, Masoud Fallahi -Khoshknab, Farahnaz Mohammadi-Shahboulaghi, Gülbeyaz Can, Mohammad Ali Hosseini,
Volume 17, Issue 1 (3-2024)
Abstract
Conveying bad news to patients and their families is a process that requires team collaboration. Different countries have taken into consideration providing suitable solutions. This study aimed to develop an practical guideline, according to the experiences of patients, families, and healthcare providers in intensive care units across three phases. In the first phase, in-depth interviews were conducted with 31 participants selected through purposive sampling, and the initial draft of the practical guideline was created. In the second phase, the initial draft was discussed and reviewed by experts in two focus group meetings, and a secondary draft was developed. In the third phase, the practical guideline compiled by the Delphi method was validated by 43 experts in policymaking and decision-making. Finally, an practical guideline to deliver bad news to patients and their families was developed with 8 main steps and 43 sub-steps. The main steps included before delivering bad news (assessment, planning and preparation, coordination), during delivering bad news (announcing bad news, emotional support, summary and documentation), and after delivering bad news (referral, follow-up). This practical guideline is intended to facilitate the process of delivering bad news in intensive care units to achieve the desired outcomes and reduce the resulting consequences and harms. Accordingly, healthcare providers are recommended to consider the importance of patient and family preferences, adhering to scientific and standard methods for delivering bad news, and upholding the principles of professional ethics.

Ethical Considerations in Decision-Making for an Elderly Alzheimer's Patient: A Case Report
Maryam Modabber, Mojtaba Parsa, Shiva Khaleghparast,
Volume 17, Issue 1 (3-2024)
Abstract
In the current era, the alarming increase in the number of patients with Alzheimer's disease has led to greater attention to issues related to care and alternative decision-making for this special group in society. The four ethical principles of "beneficence", "non-maleficence", "respect for autonomy", and "justice" serve as fundamental guidelines in medical decision-making. This study presents a case report of an elderly Alzheimer's patient and the ethical issues related to medical decision-making in the absence of a substitute decision-maker. Typically, for individuals lacking decision-making capacity, decisions are made by a substitute decision-maker and, in some countries, an advance care directive. In the absence of these, the medical team may make decisions in the best interest of the patient, considering the individual's cultural and social conditions, while taking into account the aforementioned ethical principles.

Assessing Responsiveness to Non-Medical Needs of Inpatients in Educational-Therapeutic Hospitals in Gorgan, 2022
Alireza Heidari, Seyed Hamed Atashi, Farideh Kouchak, Zahra Khatirnamani,
Volume 18, Issue 1 (3-2025)
Abstract
Addressing patients’ non-medical needs reflects the desires of patients and their families to engage more actively in decision-making and treatment processes. The present study aimed to assess the level of responsiveness to the non-medical needs of hospitalized patients. This was a cross-sectional study conducted using a descriptive-analytical approach. A total of 392 patients hospitalized in Shahid Sayad Shirazi and 5 Azar educational-therapeutic hospitals, affiliated with Golestan University of Medical Sciences in Gorgan, were included in the study. Participants were selected through systematic random sampling. Data were collected using the validated and reliable responsiveness questionnaire developed by the World Health Organization (WHO). The mean (±SD) age of participants was (45.17 ±16.92) years, with 55.1% being male. The mean (±SD) overall score for the importance of responsiveness was (33.37 ±4.45), which was above the average. The majority of patients (over 65%) rated all dimensions of responsiveness as very important or extremely important. The most important dimension from the patients' perspective was the quality of the surrounding environment (95.9%), while the least important was the confidentiality of personal information (34.7%). The mean (±SD) overall score for responsiveness performance was 54.54 (0.70 ± 8), which was above the average. The overall score of the responsiveness performance and importance in Sayad Shirazi and 5 Azar educational hospitals was above average. Dimensions deemed important by patients but with weaker performance should be prioritized, and educational and therapeutic centers should pay more attention to patients’ non-clinical expectations.

Ethical Challenges in Elderly Care: A Narrative Review
Zahra Khalilzadeh-Farsangi, Samaneh Fallah-Karimi,
Volume 18, Issue 1 (3-2025)
Abstract
With increasing life expectancy and a growing elderly population worldwide, elder care has become a major priority for health systems. These care services are accompanied by numerous ethical challenges, and neglecting them can negatively affect the dignity, rights, and quality of life of older adults. This study aimed to address the question: “What ethical challenges are faced in elder care?” Accordingly, a systematic review was conducted guided by PRISMA guidelines. To identify relevant studies, PubMed, Scopus, Web of Science, SID, and Google Scholar were searched for the period 2013–2025, using the keywords “Ethical Challenges”, “Elderly Care”, “Nursing”, and their Persian equivalents. Inclusion criteria were original articles (qualitative, quantitative, experimental, or quasi-experimental) with a direct focus on ethical challenges in elder care, written in Persian or English, and with full-text availability. Exclusion criteria included letters to the editor and conference abstracts. The quality of the studies was assessed using the appraisal tool proposed by Gifford. In total, 31 eligible articles were included in the final analysis. The results indicated that ethical challenges in elder care can be classified into four main categories, including autonomy, justice, beneficence, and non-maleficence. Subthemes included privacy preservation, shared decision-making, end-of-life care, equitable resource allocation, and the prevention of physical and psychological harm. The findings underscored the necessity of strengthening ethics education and informing policymaking in elder care.

The Effect of An Intervention Based on the Knowledge-to-Action Model on Moral Distress in Critical Care Nurses
Mohammadmahdi Pazhavand, Maasoumeh Barkhordari-Sharifabad, Khadijeh Nasiriani,
Volume 18, Issue 1 (3-2025)
Abstract
Identifying an effective coping strategy for moral distress, as an important and common phenomenon among intensive care unit nurses, seems essential. The knowledge-to-action model aims to identify effective methods for implementing evidence into clinical practice. The present study sought to determine the effect of an intervention based on the knowledge-to-action model on moral distress among nurses working in intensive care units. This was an experimental study, and the statistical population included nurses working in the intensive care units of Namazi Hospital in Shiraz, Iran. A total of 100 eligible nurses were selected through convenience sampling and then randomly assigned to intervention and control groups. For the intervention group, the knowledge-to-action model was implemented. Data were collected using the Hamric Moral Distress Scale before and one month after the intervention. Both groups completed the questionnaire at these time points. Data were analyzed using descriptive and inferential statistics with SPSS version 19. The findings showed that the two groups were similar in terms of demographic characteristics and mean moral distress scores before the intervention. After the intervention, the mean scores of moral distress in the intervention group were significantly reduced in the frequency dimension (2.12±0.34) and severity dimension (2.32±0.46) compared to the control group (frequency: 2.51±0.43; severity: 2.57±0.55) (p<0.001). The results indicated that implementing the knowledge-to-action model reduces moral distress in intensive care unit nurses. Therefore, it is recommended that nursing managers adopt this model to improve the quality of care.

The Relationship Between Moral Injury and Moral Courage in Nurses Working in Intensive Care Units
Samaneh Fallah-Karimi, Zahra Khalilzadeh-Farsangi, Azizollah Arbabisarjou, Fatemeh Etemadinia,
Volume 18, Issue 1 (3-2025)
Abstract
Nurses working in intensive care units are frequently exposed to complex ethical issues and difficult decision-making, placing them at high risk for moral injury. Such injury can negatively affect their professional performance and mental health. Accordingly, this study aimed to explore the relationship between moral injury and moral courage among nurses working in intensive care units. This descriptive cross-sectional study was conducted in 2024. The study population consisted of 150 nurses working in intensive care units. Data were collected through Sekerka’s Moral Courage Questionnaire and the Moral Injury Symptom Scale for Health Professionals. Data were analyzed using descriptive statistics, Pearson’s correlation coefficient, and the independent samples t-test via SPSS software version 22. The findings revealed a significant inverse relationship between moral injury and moral courage (r = -0.64, p < 0.001). Moreover, moral courage levels were higher among registered nurses compared to nurses in the compulsory service program. Besides, a direct relationship was observed between age and moral courage, suggesting that moral courage increases with age. The results of this study highlight the importance of designing and implementing effective educational programs to reduce moral injury and promote moral courage among this group of nurses.

Is the Use of Video Recording Important in the Intensive Care Unit?
Parsa Farmahin Farahany, Zahra Torkashvand,
Volume 18, Issue 1 (3-2025)
Abstract
 One of the key ethical-legal concerns in the medical profession is patients’ trust in the quality of care and adherence to professional standards. This viewpoint explored the ethical-legal dimensions of using surveillance cameras in Intensive Care Units (ICUs), focusing on a specific legal-ethical case. In this scenario, the patients’ family caregivers express doubt about the quality of care and request access to recorded footage. From an ethical-legal perspective, documenting events by the medical team—provided that privacy, data protection regulations, and visual monitoring standards are respected—can help safeguard patients’ rights, clarify staff performance, and prevent legal misunderstandings. While acknowledging the potential benefits, this study also outlined legal considerations, such as patient notification, access limitations, and data management protocols. The key conclusion is that the use of cameras in ICUs, if aligned with legal and institutional requirements, can enhance trust, demonstrate ethical compliance, and reduce legal complaints.

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