Nursing Ethics in an end of life scenario

Ethical Issue
One of the most important ethical issues in nursing is how to approach end-of-life care. Nurses have a duty to provide compassionate care in ways that respects the individual’s autonomy and dignity. As patients live longer due to advancements in medical care, nurses are increasingly being faced with care options that extend life, versus options that do not extend life but which promote quality of life through a greater acceptance of death. A related issue is physician-assisted suicide. When physician-assisted suicide is legal, nurses may have this option presented to them by patients, creating ethical dilemmas. This paper will examine multiple sides of the end-of-life issue, showing that while there is no easy or “right” solution, individual cases should highlight the means by which nurses can always ascribe to their professional duties and the ethical standards of the profession.
Point of View: Quality of Life Over Quantity
Legal Issues
With the exception of physician-assisted suicide laws and liability torts, there are no clear legal guidelines for end-of-life care in general (Pope, 2018). The principles of non-maleficence determine individual cases. However, physicians and other healthcare staff in the United States have been generally opting for life extension in all circumstances, even when doing so conflicts with patient wishes (Pope, 2018). High-profile cases like the Terry Schiavo case should demonstrate that healthcare staff have a far greater legal obligation to honor patient wishes than to extend life without reason. Healthcare workers have recently been acting more out of fear of litigation than out of duty to care, duty to respect patient autonomy, and duty to respect patient dignity (Pope, 2018). From the perspective of providing compassionate and holistic care, nurses need to honor a patient’s wishes even if those wishes are to terminate life and to help patients embrace mortality with a sense of peace and acceptance.
Scope of Practice
Within the general scope of practice, end of life care issues arise in all healthcare settings but primarily in hospice and palliative care environments, including nursing homes. A survey of nine nursing home residents and their relatives showed that residents generally defer to relatives and staff and few have formal advanced care planning directives (Bollig, Gjengedal & Rosland, 2015). Healthcare administrators should start mandating advanced care planning directives to avoid legal and ethical conundrums. Moreover, offering patients the ability to plan helps them to psychologically contend with mortality, which can also improve relationships with family members. Extending life indefinitely and for no reason is not necessarily beneficence, just as physician-assisted suicide and passive euthanasia are not maleficence. As Hogsnes, Danielson, Norbergh, et al., (2016) point out, “more focus must be placed on [patients’] psychosocial and existential needs in the documentation of end?of?life care,” (p. 1663).
Moral Obligation
Nurses can face serious moral distress when they do not have clear guidelines for professional practice (McAndrew & Leske, 2014). End-of-life care brings to light the moral conundrums of providing nursing care that simultaneously recognizes the immanence of death. The obligation of the nurse is to alleviate suffering in ways that are culturally appropriate and desired by the patient. When the patient is unable to make end-of-life decisions personally, those decisions need to be made by the patient’s primary caregiver, to avoid moral complications. Ultimately, the duty of the nurse is to the patient, to provide compassionate care in accordance with ethical duties like autonomy and dignity. These moral obligations far outweigh the more spurious morality of life extension at all costs, the moral duty to prevent costly litigation, or the desire to earn more money for the healthcare organization via life extension.
Counter-Argument
Legal Issues
Without clear legal guidelines instructing nurses as to how to approach patients in hospice, palliative care, or nursing homes, healthcare staff need to rely more on situational variables and ethical principles. Ultimately, nurses need to obey the law and if the law is ambiguous on any matter, the nurse needs to err on the side of caution and preserve the patient’s life even when the patient either expresses a wish for passive euthanasia or prefers to embrace her or his mortality.
Scope of Practice
The healthcare organization and its management may have institutional guidelines that constrain individual nurse decision-making. When the organization, for example, has a policy of life extension at all costs, the nurse is obliged to follow these rules even when the patient or the family members feel otherwise.
Moral Obligation
Whether from a strict interpretation of the Hippocratic Oath or a religious conviction that life is sacred, a nurse may have a moral obligation to preserve life. The nurse has a moral obligation to provide the best quality of care possible under the circumstances, and also a moral obligation to obey supervisor orders.
Conclusions
Like most healthcare ethical conundrums, end-of-life issues can be challenging to resolve. The principles of patient autonomy and dignity should guide all nursing decisions, even when those decisions may conflict with organizational policy driven by a fear of litigation. Compassionate care in end-of-life scenarios does not necessarily entail preserving or extending life without the express consent of the patient or a primary caregiver.




References
Bollig, G., Gjengedal, E. & Rosland, J.H. (2015). They know! Do they? Palliative Medicine 30(5): 456-470.
Hogsnes, L., Danielson, E., Norbergh, K.G., et al. (2016). Healthcare professionals’ documentation in nursing homes when caring for patients with dementia in end of life. Journal of Clinical Nursing 25(11-12): 1663-1673.
McAndrew, N.S. & Leske, J.S. (2014). A balancing act. Clinical Nursing Research 24(4): 357-374.
Pope, T.M. (2018). Legal aspects in palliative and end of life care in the United States. Up To Date. https://www.uptodate.com/contents/legal-aspects-in-palliative-and-end-of-life-care-in-the-united-states