Ethics to Practice: Analysis of 'end of life' decision making
The foregoing discussion is an incursion into nursing ethics. Implication(s) to 'omission' of information as a customary practice within our healthcare institution is reviewed in relation to best practices pertaining to 'informed consent,' and hospital policy is not definitive. Directed at the evolution of ethical decision making, the general query to the study focuses on the parameters of informed consent where individual practice is concerned.
In the nation of Canada where I am a nurse the number of situations where patient informed consent decisions might be subject to our national code of nursing ethics is many. We face critical ethical dilemmas every day, as emergency procedures and critical care interventions are standard practice. Complexity in decision making is furthered in the conduct and approaches made by international colleagues on contract in our institution by way of exchange.
The primacy of informed consent and the serious staff shortages faced by our hospitals are of course linked. The ranks of foreign nurses graciously contracting to fulfill Canada's quotas, engenders a climate of continuous knowledge sharing and training. Lessons learned from those mutually beneficial workshops and training forums is that taken for granted assumptions about internal 'policy' are, in fact, not reliable at all when legal stipulations or other mandated practice frameworks are not present.
I begin with a brief case study of a 31-year-old cancer patient, whom was admitted to our hospital with inoperable cancer of the tongue and throat, the tumor was around the carotid artery. During the course of treatment, the patient continuously engaged nursing and physician staff with queries of "how was he going to die?"
In the Canadian hospital institution environment, medical teams may chose not to forewarn patient of the process of by which he would face extreme morbidity, and ultimately mortality by bleeding to death. 'Omission' it is thought, is superior to disclosure, as it precludes informed consent to treatment, and is not at all mandatory. In the case study, exercise of our professional expertise determined that there was no benefit to the patient to tell him how he would likely die.
We are also covered by immunities. Exception is made when it is perceived that knowledge of non-consensual information, where not part of the treatment intervention, may induce more harm than benefit. The 'benefit' element of our decision served as the pivotal point to quality of life discussion amongst the Team.
In retrospect, I would argue that the decision was consistent with policy, and obviously protected the integrity of our institution from reactionary liability in case that the patient responded with misapprehension or self-abuse. After all, the patient had already been exposed to the near fatal state of his condition, and there was little we could do beyond upholding professional 'duty to a standard of reasonable care' as understood in Canada's adherence to informed consent guidelines.
Concern over the protocol of conduct within our hospital institution has never overshadowed confidence in our practice. Personal conduct is necessarily measured against evidence-based practices, and continuous training is integral to the design of our service framework. Collaboration reinforces the competency of our patient treatment model, and synergy is in essence our prospectus to fulfilling professional standards and ultimately our 'duty' to care.
Still, nurse-patient synergy is a core competency that is meant to be refined over time. Each step in the intervention process model is intended to improve methods of caring for patients, and the structural aspect to our Team management approach includes unstated rules about adherence to physician oversight in cases where an ethical dilemma might present itself. Omission was at issue when our patient pressed for details to his devolving physical condition. In instances where there is even an element of doubt, and our patients express worries about what he/she may 'feel,' we are exceptionally protective...
Distress, even where not warranted in terms of urgent condition is, however, possible wherever perceptions of ethical engagement are cloudy.
In a study on the phenomenon of moral distress in nursing practice, by Pauly et al. (2009), the researchers look at Registered nurses' perceptions of moral distress and ethical climate. In this replication study, a random sample of registered nurses was surveyed with Corley's Moral Distress Scale and Olson's Hospital Ethical Climate Survey (HECS). Outcomes to the study reveal that each HECS factor (i.e. hospitals, managers, patients, peers, and physicians) had correlation with moral distress. Recommendations were targeted at the nurse-patient relationship, where the prevalence of psychological discomfort is likely to affect procedural intervention. This includes sustained communications between nurse and patient, up to point of informed consent. In Canada, there are four (4) elements to informed consent that are also composite to any claim of physician malpractice mentioned in Table 1.
1. There must be a duty of care owed to the patient;
2. The physician must fail to meet the standard of care reasonably to be expected in the circumstances;
3. The patient must suffer harm;
4. The physician's shortcoming must be causally related to the harm.
Table 1. 'Duty to a reasonable standard of care' in Canada.
Source. CMPA 2010. Web.
In spite of the relative immunities to medical practice in Canada, there is still potential that any procedure done without consent and outside of an emergency situation might affect a practitioners licensure; hence the custom of reservation of right to not explain 'technical details' where not requested directly by patients. Learning our rights and responsibilities as nurses and physicians helps us to inform patients of their own protections and obligations to their own care. Ethical decision making constitutes the grey area in the rights to self, responsibilities to patient matrix, and a number of scholarly works in the area of nursing law in the last three decades has been dedicated to thorough going articulation of the relationship of national nursing ethics and the laws upon which they are founded.
If contemporary nursing practice is called upon to articulate ethical codes of conduct in detail, delineating 'where' the right to omit information is relevant, in doing so Canada's practitioners are also quick to acknowledge that professional obligations to patient safety may be conceded in such a rigorous policy environment. Once policy mandate overrules independent professional discernment, respective 'duty' to patient protections may not be achieved in the process. I
In Hoey (1998), review of The CMA's Health Information Privacy Code: Does it go too far? looks at a policy that the Canadian Medical Association (CMA) has adopted which severely limits the use of health information arising from the physician-patient relationship. The article cites 'ethical precepts that govern physicians' interactions with patients as rationale to the Health Information Privacy Code (HIPC). A requirement to Canada's informed consent guidelines, the Privacy Code furthers strictures by mandating modes of dissemination and exactitude in interpretation.
Opponents to the HIPC cite the 'legal and ethical development of informed consent' as the official model to healthcare institution decision making (Whitty-Rogers et al., 2009). According to arguments in support of full disclosure, a true patient-centric model may only be realized through auto-decision, and that includes self-advocacy through independent voice. The assumption to the argument sees choice as formative to participatory wellness; promoting patient dignity and quality of life. This includes communication in support of patient decision at the end of life.
The complexity of the ethical decision making framework presented by the CMA involves practitioners in the scope of policy mandated criteria to practice. When not strictly defined within official policy, or institutional protocols, the authority of 'custom' as a mechanism of consensus between professionals serves as substitute to those instruments. In O'Connor, Legare and Stacey (2003) Risk communication in practice: the contribution of decision aids an investigation of the practical and effective approaches to patient consultation used by medical professionals captures the dynamic between informed consent policy, and institutional decision making. The study's goals address decision making of select health services that stand to increase the chances of value added health outcomes, while minimizing the risk of undesired consequences in the scope of scientific options.
In general, decision support should be synergistic to individual 'patient values, personal resources, and capacity for self-determination' argue O'Connor, Legare and Stacey. Patient centred are the maxim for practice setting interactions in the Canadian healthcare institution. Knowledge sharing is power sharing. Patients want to participate in responsibility based therapeutic alliance more and more. According to O'Connor, Legare and Stacey patient inclusion in the decision model actually facilitates agreements on problems, treatment options, and the future role in decision making.
Utilizing Decision aids had comparable effect to usual care interventions on patient satisfaction, anxiety, and health outcomes that were not linked to patient values, the O'Connor, Legare and Stacey study revealed that by conveying patient participation in their own health is not only a 'right,' but a viable method for all stages of the patient journey. Patients involved in deliberation, planning, and implementation of the negotiated option had more positive…
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