End of Life Decision Making Ethics

Introduction
When a family has to decide how much is too much, as Plakovic (2016) puts it during end-of-life care, there is a clear ethical dilemma that crops up for family members and care providers. That dilemma is related to the issue of how to approach end-of-life treatment. For instance, some individual have strict preferences when it comes to whether or not they want to be resuscitated or kept alive by a machine. Others have no instructions set aside before hand for care providers and family to go by. The ethical dilemma is complicated by the fact that care providers have an oath to care for all life—but at the end-of-the-life, what is the line between postponing the inevitable inhumanely and giving as much humane care as is possible? That blurred line is a complicated one to walk. The two major points that this paper will address when it comes to end-of-life care and the “do not resuscitate” (DNR) clause are related to the principles of nonmaleficence and autonomy and the ethical theory that is discussed in relation to this issue is deontology, also known as duty ethics.
What is the Ethical Dilemma?
The ethical dilemma associated with end-of-life care and the DNR clause is whether life of a patient should be prolonged just because it is mechanically possible to prolong it even though there is no hope for improvement and there will be an extremely low quality of life—basically the person will be unresponsive or in a terminal state. Should the care provider continue to recommend that the life of the patient be prolonged? What should the care provider advise to the patient’s family? How should the issue of DNR be approached?
As the example of Mary attempting to ensure that the best care is provided to her father CJ, who the health care team believe is in a terminal state, shows the complexity of the ethical situations (Plakovic, 2016). On the one hand, it is understandable that the daughter wants to see her father get better; on the other, it is understandable that the son sees the writing on the wall and does not want to prolong the father’s suffering unnecessarily. Yet the health care providers have to respect the family’s wishes and in the case of conflict, with the son bowing out and the daughter taking charge, the health care providers have to continue to provide care even though—as the case shows—the patient would be dead in a matter of days no matter what. Sometimes it is difficult to communicate that reality to the patient. Emotions cloud reason, and loved ones do not want to say goodbye without first attempting to do all they can do to see if the loved one improves. As Yuen, Reid and Fetters (2011) explain, even in cases where there are DNR orders (as in Mary’s father’s case) there are still ethical issues—because it is not always a clear case of the patient needing resuscitation. Weissman (1999) notes that DNR orders are in need of reform because there is no clear way to navigate the subject—or, as one of the participants in Weissman’s (1999) study put it: “We know it’s required under hospital policy to ask patients their preference about resuscitation, but these cancer patients . . . well . . . you know . . . they’re dying . . . it doesn't make sense” (Weissman, 1999, p. 149). This confession from a health care professional shows the extent to which the issue can become complicated.
Main Moral Issues
The main moral issue regarding end of life care is that health care providers who try to tell a patient’s family members about the facts of terminal decline can come across as seeming uncaring, insensitive, and not open to doing their jobs to save lives. The exact opposite is typically the case, however: the health care professional sees everything that could and will go wrong as the patient slips into further decline and delaying the end of life just so a family member can feel better about giving the patient every chance to improve can cause stress to other family members, to health care professionals and to the patient himself. This unnecessary stress goes against what the health care professional aims to do when providing quality care—yet at the same time the health care professional has to abide by the wishes of the patient’s family if there are no clear DNR instructions regarding end-of-life care that clearly express the patient’s interests.
From a deontological perspective, the health care provider has a duty to abide by the patient’s instructions regarding DNR. However, in lieu of these the provider must go by what the patient’s family wants—even if it goes against what the provider knows to be in the best interest of all stakeholders. Defining what is right in every instance is not always easy or even agreed upon by various people—which makes the moral issue in this case all the more difficult to understand and even simply to define (Karnik & Kanekar, 2016; Sen, 1983).
Two Bioethical Principles
Nonmaleficence
The principle of nonmaleficence focuses on doing the least amount of harm (or no harm) in order to achieve a beneficial end (Bronzino & Peterson, 2016). This principle relates to the issue of end of life care and decision-making because the goal should be to do the least amount of harm in order to benefit the patient. The problem is that it is difficult to determine among patient’s family members and care providers what is really in the best interests of the patient. The care providers can explain a terminal situation to a family member but this does not mean the family member will accept the reality or even want to think about it until all options have been exhausted—which can mean that the final days of the patient’s life can end up being incredibly painful and tortuous. The principle of nonmaleficence should really be guiding actions with respect to addressing this issue.
Autonomy
The principle of autonomy refers to the idea of being in charge of one’s own decisions (Marijic, Buss & Strupeit, 2017). This principle relates to this issue because the patient is clearly not in charge of making his own decisions at the end of his life. Thus, either the family has to be informed explicitly about the loved one’s wishes or the loved one should have a clear and explicit DNR on file that the family and care providers will have to respect (Garrido et al., 2015).
A Value of My Own Personal Morality
A value of my own personal morality is that care providers should not be expected to provide unreasonable care and in the case of DNR and end of life treatment, care providers should be honest with loved ones and tell them clearly what the reality is. I do not believe that assisted suicide is moral—but I also do not believe that DNR is immoral or akin to assisted suicide. It is rather the acceptance of reality—i.e., that the patient is in terminal decline.
I believe that every patient should be given the utmost quality care—but in the cases of end of life situations, quality care takes on an added context regarding how to make the end of life process easy and comfortable for all without adding unnecessary or undue strain onto the patient or the patient’s family. The reality of the situation needs to be told to the patient’s loved ones and expressed clearly. If there is no DNR and the loved ones want to continue with treatment in hopes of the patient improving, care providers should respect but they should continue to try to make it clear to the patient is as sympathetic and sensitive terms as possible the fact that the patient is terminal or entering into a terminal phase.
The Value’s Relationship with the Morality of a Society I am Currently Living In
In my society, assisted suicide is still not accepted as a moral solution, so I am in the majority in the sense that I believe it to be immoral. However, in terms of DNR and end of life care much of society is still confused about the issue and so there is a lot of uncertainty regarding what it means to advise a patient’s family that the end of life is near for the loved one (Garrido et al., 2015). Care for patients who are at the end of their life is not something that many people want to discuss because death is an issue for them that is unpleasant. However, it is an issue that all family members should discuss because a DNR can help to make it easier for all when that time comes.
Conclusion
The ethics involved in end of life care and how to go about addressing that situation can be complex particularly for family members who disagree about what the best course of action is in the case of a loved one not having a clear DNR on file. Care providers should try to communicate the situation to the patient’s loved ones in an effective but respectful way; however, if loved ones do not accept the reality and want to hold out hope for improvement, the care providers can continue to give treatment. It is in everyone’s best interests, however, to continue to speak to the loved ones to try to get them to see the reasons why prolonging the inevitable is more painful.
References
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Yuen, J. K., Reid, M. C., & Fetters, M. D. (2011). Hospital do-not-resuscitate orders: why they have failed and how to fix them. Journal of General Internal Medicine, 26(7), 791-797.