A recently enacted policy, however, enforces the use of a dogmatic and uncompromising ideological speech as a standard replacement of informed consent (Minkoff & Marshall, 2009). The policy requires a list of statements, considered "facts," which discuss risks, benefits and alternatives. These focus largely on risks, misinformation and implied government disapproval. The use of this script compels the physician to commit an ethical and professional wrong, deceive his patient with false information and withhold genuine evidence-based data. These clearly amount to a violation of the physician's First Amendment rights to protection for scientific speech and information in the informed consent process. The lack of protection for doctors by the appellate courts has produced situations of direct collision between medical ethics and the law (Minkoff & Marshall).
A doctor judges a case as medical futile when care is unlikely to produce benefits for the patient (Eskildsen, 2010). However, determining "significant benefit" is difficult because of the moral and ethical implications involved in the judgment on the patient's autonomy. A determination of medical futility puts professional autonomy above patient autonomy. It presumes that the patient's family or caregivers do not have the appropriate knowledge and experience to make an informed decision. Presumed medical futility encounters problems. One is pits the doctor against the patient or his caregiver rather than collaborates. Another is that the withholding or withdrawal of a supposedly useless treatment may hasten the patient's death and lose the last chance at cure and survival (Eskildsen).
The lack of a unified jurisprudence on medical futility and Supreme Court decisions as guides to physicians tending terminal patients prompted the American Medical Association to come up with guidelines (Eskildsen, 2010). A Texas law also represents an attempt to resolve disputes on end-of-life decisions. These two approaches are currently working towards an agreement on what constitutes benefits and harms before asserting a decision on medical futility (Eskildsen).
Nurses' Role and Advocacy
A patient's perspective is influenced by factors in making sense of his illness, suffering and dying as well as making use of medical services at the end of his life (Pat et al. 2009). A nurse should be aware of, and sensitive about, her patient's need when he needs to make a decision about DNR. She should establish good communication with him in order to eliminate all useless anxiety, misunderstanding and stress (Jevon, 1999 as qtd in Pat et al.). Proper communication, decision-making about DNR and public education should clearly be promoted. She can even function as an advocate in decision-making (Street et al., 2000 as qtd in Pat et al.).
It is a professional imperative for a nurse to practice advocacy (McSteen, 2006). She must apply the concept of advocacy in an intimate and interpersonal way according to her relationship with the patient. She should function as a guide, liaison, and supporter to a dying patient. She will be able to make the patient and his family better understand what they want by helping them discern their own values. In a deep way, she helps them examine themselves and reach a decision from that self-examination of their own values. It is only through a genuine self-examination can the patient actually achieve a truly self-determined decision (McSteen) on a matter as significant and ultimate as a DNR.
Problems, Solutions and Projection
Recurring conflicts on the ethics of futility between patient advocates and healthcare providers require guidance from the law (Eskildsen, 2010). Scholars argue that unilateral withdrawal of end-of-life care should be resorted to only in rare situations. AMA made a significant step in coming up with a clear recommendation for physicians. However, it has yet to determine what to do in case of irreconcilable differences between patient families and providers (Eskildsen).
When a patient's personal autonomy clashes with the physician's "therapeutic privilege" to reveal or withhold information, the solution is informed assent (Curtis & Burt, 2007). Some clinicians remain wary about the legal aspect of informed assent, which does not require a signed form from the patient or family. This can be solved by providing for an adequate document by other means like a medical record entry by the attending physician (Curtis & Burt).
Some hospitals are not yet equipped with protocols to adequately deal with end-of-life issues (Fields, 2008), A DNR order does not mean no care will be given. It can extend alternative care such as liberalized visiting hours, educational materials, pastoral and counseling services (Fields). There will be more ethical dilemmas to expect. But critical care nurses and other health professionals can anticipate them by taking a proactive position at present and seek out answers in preparation for these dilemmas (Ethical dilemmas will increase in the future. Critical care nurses must take a proactive approach to obtain answers to these problems (Pat et al., 2009). #
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