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Nutrition: Ethical or Unethical?
Should nurses withhold or withdraw nutrition & Hydration from terminally ill patients? This is a question that boggles the mind. Some feel that withholding anything from any patient is unethical, while others feel it is acceptable because we must promote quality of life. Furthermore, who decides within this issue the outcome of the patient? Nurses? Nurses? The Court? Recently, we have decided on a combination of the two. However, in order to discover what is actually best for patients, it is important to exmaine this paper.
What care is 'futile'? Throughout the years, the question of whether or not to withhold certain treatments to terminally ill patients has been addressed. Do we continue to treat people who are still alive, even if we know that there is no hope? This is a question that has been asked over and over again by various parties. This notion is an ethical dilemma because it involves the notion of ending a life by witholding medical attention. Some religious groups feel that patients should be treated at all costs up until the end, while other people disagree with the notion and say this is immoral; these people have such a low quality of life, they should be relieved of their pain and suffering as fast as possible. Much like abortion, another ethical dilemma, it is difficult to say which side is right or wrong. Hence, an analysis into the situation must be consiered.
This ethical debate, although around for years, has recently heated up in the last decade or so. Several court cases have occurred in which nurses are asking the courts to allow their patients to be put out of their misery. Hence, more and more nurses are desiring not to treat these suffering, near-dead patients. Historicaly, one question has developed two trends in this battle:Who is to judge futility; nurses or the courts? As a general rule, nurses are advised to seek a declaration from the High Court before terminating treatment to patients in a persistent vegetative state, but this leaves open the question of the grounds on which the decision should be based. The Courts do believe cases provoking moral and ethical issues are appropriate for the court to decide. They were not exclusively for nurses. Nor, would the profession be grateful to the court for leaving the full responsibility for such decisions in its hands.
The medical profession can tell the court about the patient's condition and prognosis and about the probable consequences of giving or not giving certain kinds of treatment or care, including the provision of artificial feeding. But whether in those circumstances it would be lawful to provide or withhold the treatment or care is a matter for the law and must be decided with regard to the general moral considerations. As to these matters, the medical profession will no doubt have views which are entitled to great respect, but some would expect medical ethics to be formed by the law rather than the reverse. These people feel that this is a purely legal (or moral) decision which does not require any medical expertise and is therefore appropriately made by the court. This opinion feels that there should not be a belief that what the nurse says is the patient's best interest is the patient's best interest and the court should retain the ultimate power and duty to review the nurse's decision in the light of all the facts (Shroeder 2000).
However, others feel that decisions concerning the best interests of patients in continuing to receive treatment should be governed by the views of reasonable nurses. This side argues that a medical practitioner is under no duty to continue to treat such a patient where a large body of informed and responsible medical opinion is to the effect that no benefit would be conferred by continuance. Existence in a vegetative state with no prospects of recovery is by that opinion regarded as not being a benefit, and that, if not unarguably correct, at least forms a proper basis for the decision to discontinue treatment and care (Ackermen 2000).
The Pros and Cons
Different nurses may take different views both on strictly medical issues and the broader ethical issues which the question raises. The nurse's answer may well be influenced by his own attitude to the sanctity of human life. In cases where there is no strictly medical point in continuing care, if a nurse holds the view that the patient is entitled to stay alive, whatever the quality of such life, he can quite reasonably reach the view that the continuation of intrusive care, being the only way of preserving such life, is in the patient's best interests (Ferrell, 2001). But, in the same circumstances another nurse who sees no merit in perpetuating a life of which the patient is unaware can equally reasonably reach the view that the continuation of treatment is not for the patient's benefit. Accordingly, on an application to the court for a declaration that the discontinuance of medical care will be lawful, the court's only concern will be to be satisfied that the nurse's decision to discontinue is in accordance with a respectable body of medical opinion and that it is responsible. In the end it is a matter of personal choice, dictated by his or her background, upbringing, education, convictions and temperament. Legal expertise gives no special advantage here (Huffman, 2001).
Given this latitude, one would expect pressure to extend the concept of 'futility' and the decisions contemplate the possibility of a similar approach being taken in other cases in which the damage is less severe, for example 'the very poor quality of the life which may be prolonged for the patient if the treatment is successful'; or those suffering the advanced stages of GuillainBarre syndrome, in which the patient retains some measure of consciousness, but whose brain stem is so damaged that the patient loses all power of movement, including the autonomic reactions of the heart and lungs. Reasoning of this kind has been applied to a baby who was not terminally ill but, whilst retaining some intellectual capacity, suffered spastic quadriplegia, blindness, and deafness. He was unable to react to his environment, and would suffer pain, especially from the mechanical ventilation which was needed from time to time. His life would be so afflicted as to be intolerable, and therefore the court could order, on the recommendation of a consultant, that the local authority responsible for the child be free not to resuscitate the child if he went into crisis. On the other hand, Down's syndrome would not be so awful as to fall into this category, nor the life of a seven-year-old victim of meningitis who suffered profound brain-damage as a baby and was unable to interact with his environment.
Clearly, judgments of this nature are highly intuitive and often defy rational analysis. Is it futile to continue to treat those suffering from the advanced symptoms of Alzheimer's disease who are conscious but whose memory and personality have largely been destroyed? Is it futile to treat a ten-year-old suffering leukaemia when the chance of a successful outcome is around 2 per cent? What if the chance of success had been 22 per cent? A line must be drawn somewhere. No doubt, nurses will be available to support both sides of the question. Is it proper that so much discretion sbould be given to nurses in matters which are not primarily concerned with clinical discretion? This brings us to 'do not resuscitate' orders and the way in which they have been used in practice.
Is it ethical, however, to allow a nurse or a nurse, backed by the decision of the court, to end the life of a terminally ill patient? According to James Whitten (1998), the answer would be no; doing something along these lines to a terminally ill patient would be like breaking one of the ten commandments of the Bible; it is completely immoral. Nancy Trotto (2000) agrees and suggests that other forms of help, besides nutrition, should be applied to helping these patients -- technology should also be used.
Of course, not everybody agrees with this notion. Betty Ferrell (2000) gives examples of nurses who feel that there should be some sort of limit to how much nurses and nurses assist terminally ill patients. If we know that they are going to pass, and that if we prolong their lives will be awful, why do we continue to force them to live? Grace Huffman (2001) agrees. Her article points out the notion that nurses and nurses need to be respectful of patients' wishes; hence, if a terminally ill patient wishes to have these items withheld, then so be it.
2. Do Not Resuscitate Orders
When are 'do not resuscitate orders' (DNRs) issued and to what procedures are they subject? Decisions to use DNRs in hospital are not uncommon and nurses have candidly identified a number of factors they…[continue]
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