Ethical decision making: pressure and uncertainty as complicating factors.

This qualitative study examines social workers' ethical tension as they evaluate decisional capacity of elderly individuals experiencing some degree of cognitive impairment. An interview guide of open-ended questions was used with a convenience sample of 17 home health care social workers. Constant comparative analysis was used to examine factors contributing to ethical tension. Three areas emerged as highly relevant to participants ethical decisions: (1) clinical uncertainty, (2) pressure from other professionals, and (3) a combination of pressure from other professionals and clinical uncertainty. Clinical uncertainty was influenced by partial cognitive impairment, mental health problems, the interplay of health and mental health, and unclear etiology of poor decisional capacity. Pressure from other professionals typically involved issues of compliance and medical safety. Ethical tension was particularly strong when participants experienced both pressure from other professionals and clinical uncertainty.