Imagine this scenario: a patient has end stage heart failure, coronary artery disease, peripheral artery disease, chronic obstructive pulmonary disease and sleep apnea. She has refused any invasive treatments for many years, ignoring potential consequences, and has opted for medical management. She has an advance directive stating her preference for no cardiopulmonary resuscitation, no artificial hydration or nutrition, and only desires comfort measures to allow for a pain-free and natural death. This patient has developed shortness of breath, leg edema, and chest pain, and is rushed to the emergency room. Upon admission, she is diagnosed with pulmonary edema and renal failure. Medications are administered to treat pulmonary edema, but she is not responding to the medications and starts to decompensate. The patient mentions that she does not want to have dialysis or a respirator. Her family is informed of the critical status of the patient and that the chances of survival are minimal. The family insists on multiple treatments that the doctor has recommended, and wants her to be put on a respirator and have dialysis. Only one sibling has medical durable power of attorney and has a copy of the advance directive, and informs the family of the patient's wishes per the advance directive. The family disregards the advance directive, insisting on keeping the patient alive, regardless of the patient's wishes or the severe decline in quality-of-life.
The above scenario is not uncommon today, since current technologically advanced medical treatments can keep patients alive longer. This development has made end-of-life care one of the most controversial issues in health care. Medical advancements have set the stage for ethical and legal dilemmas not only about patients' and family's rights, but also about health care professionals' roles.
In 1991, the U.S. Congress passed the Patient Self-Determination Act (PSDA). The purpose of this law is to inform patients of their rights regarding their medical care, including the right to accept or refuse treatment and the right to make an advance directive and ensure that these rights are communicated by the health care providers, especially when a patient becomes incapacitated (Duke et al., 2009). The dilemma surfaces as a result of conflicting desires between the patient and his or her family. The nurse's challenge is to completely support the patient's wishes, while supporting the family to do the same. The nurse is the advocate for the patient, educator of the family, and liaison to the interdisciplinary team.
The ANA Code of Ethics requires nurses to respect the autonomy of each patient and his or her decision to choose the healthcare options that he or she believes are correct for them, based on religious views and socio-cultural values, as well as personal desires for end-of -- life care (ANA Code of Ethics 2001). Nurses are also obligated to participate in advocating for the patient to avoid unnecessary treatment if the patient does not want treatments that doctors and/or family members may be pushing for. (ANA Code of Ethics 2001). Nurses must be familiar with the end-of-life wishes of their patients; otherwise, the patient loses a valuable advocate for assisting in achieving their goals for end-of-life care. Nurses must also recognize their own personal values and beliefs surrounding end-of-life care for their patients' choices to advocate adequately. They cannot be judgmental or biased, but must follow the wishes of the patient and make sure that everyone involved in the case does so as well.
Conflicts during end-of-life issues arise when there are differing opinions between the doctor, the family and the patient about the care to be received during this time. When faced with difficult ethical dilemmas, it is best to have a plan of action to assist in decision-making. A step-by-step approach often works best because it allows the decision-maker to breakdown a stressful choice into workable parts. Purtillo cites six steps to follow to resolve ethical dilemmas. These steps are: assessing the problem, identifying the ethical problem, analyzing the problem, exploring the options, implementing the action, and evaluating the outcome (Purtillo, 2005). Once the ethical conflict is addressed and/or resolved, nurses must not allow their personal feelings to interfere with professional decisions.
Assessing the problem:
To begin assessing an ethical dilemma, the nurse needs to collect the medical, social, psychological, and legal facts pertaining to the case, in some cases the nurse needs to take into consideration the patient's psychological state, prognosis, knowledge of treatment and quality of life. It is also important to evaluate the family's understanding of a patient's illness, as well as his or her wishes. The nurse must also consider the patient's cultural and religious beliefs, the organizational policies of the healthcare institution, and other available resources that can aid in resolving the dilemma. Identifying ethical dilemmas can be challenging at times, and nurses may need guidance and support from professional resources such as patient advocates, risk management, palliative care, and the ethics committee, if available (Cohen & Erickson, 2006).
Identifying the ethical problem:
If a conflict emerges, it is important to identify whether the problem is truly an ethical one, or whether the nurse is letting his or her feelings intervene with the ethical dilemma, when in question check with other colleagues and other recourse team members. If your moral issues interfere with ethical issues ask other colleague to take care of the patient. It is also important for nurse to look at ethical theories based on the ethical dilemmas to help identify solutions to the problem (Cohen & Erickson, 2006).
Analyzing the problem:
This step involves studying the problem to see the different sides of the issue, in particular, the perspectives of the patient, his or her family members, and those of the medical team. There are multiple theoretical methods that can be used to aid nurses to analyze the dilemma. Ethical theories can be consequential, duties, individual rights, and communal or intimate relationships (Beauchamp & Childress, 2001). When dealing with ethical issues, nurses might have a tendency either to look at consequences or duty-based mythologies to accomplish the result. When using consequential theory, nurses feel that is very important to tell the patients the truth about diseases so patients can make informed decisions about their care. When using the duty-based approach, health care professionals feel forced tell the truth to patients, although this can cause patients mental stress and pain. In analyzing the problem, it could also be helpful to interview each of the parties and research previous similar cases. It could also involve communicating with different resource people and/or organizations that could help the nurse to solve the problem, or help advocate for the patient.
Exploring options for resolution:
After analyzing the problem and having identified that the dilemma is indeed an ethical one, step three is to brainstorm possible solutions. It would be helpful for nurses to work with colleagues at this stage, in order to maximize creative ideas. In addition, nurses should try to anticipate reactions of the parties involved in the conflict, in order to be prepared with adequate responses.
Implementing the plan of action:
When making ethical decisions, nurses might tend to use their morals and opinions to guide them. One thing nurses need to recognize is that the opinions and ideas of all the team members are important, and the morals of the patient and family members have priority in end-of-life decisions (ANA, 2001). So when beginning to implement a plan of action, it is important for nurses to get buy-in from all parties involved. It helps to be prepared with adequate research and to anticipate questions that the patient and family members might have.
Evaluating the outcome:
After an attempt has been made to resolve the dilemma, all parties should evaluate the result and make any necessary revisions to the plan, if possible. If the patient has passed away, an attempt should be made to interview the family members and medical team involved in the case to find out their perspectives on the outcome. This process could be difficult, depending on the emotions of those involved, but it would perhaps be helpful to explain to the family members that their reflections on the situation would potentially help future patients and their families.
When giving support and advice to patients and families at the end of their lives, one needs to understand how overwhelming and emotional this issue is. If the patient or family member is struggling with end-of-life decisions, they should consult someone they trust to them help think about the implications of their decisions. Clergy members, counselors and medical ethicists can help patients, family members, and caregivers think about end-of-life issues and answer questions about care. A grief and bereavement counselor can help him or her work through the emotional difficulties associated with these decisions. Doctors or health care providers can provide access to these resources.
Making decisions about end-of-life care can be a difficult and emotional experience for patients and loved ones. Terminal illness and old age present numerous medical and ethical…