End-of-Life Decision Making and the Advanced Practice Nurse

Introduction to End-of-Life Ethical Challenges

End-of-life decision making has undergone significant changes in the last 50 years. These changes relate to societal attitudes about death, dying, and healthcare at the end of a person's life, and how those attitudes have evolved due to new innovations in healthcare — technological, pharmacological, and surgical (Daly, 2006a). With these new innovations have come very difficult challenges for patients and their families, as well as for those who provide care at the end of life: nurses and doctors (Wilkie et al., 2001). The ability to prolong life in patients with grave injuries or in advanced stages of terminal illness has raised tough and important questions about the moral acceptability of stopping or forgoing treatment (Daly, 2006a). One only has to look back at the highly publicized case of Terri Schiavo to recognize just how controversial and rife with moral and ethical dilemmas end-of-life decisions are — not to mention the legal issues they raise.

Some very specific challenges that Advanced Practice Nurses (APNs) may face include deciding to withhold treatment that could sustain life, deciding against resuscitation, and avoiding tactics that are both unethical and dishonest. The principle of autonomy — patients' rights to accept or forgo medical interventions — has been widely accepted as the basis for decision making. The ethical dilemma with end-of-life decision making is that issues such as malfeasance, dishonesty, and "playing God" in the sense of deciding who has the chance to live and who does not are very much at stake (Daly, 2006b).

Advanced Directives and Communication Failures

Other ethical dilemmas arise when patients or family members ask nurses to aid them in the dying process — assisted dying or assisted euthanasia. Studies within the last ten years have shown that nurses are commonly asked by both patients and family members to aid in the process of death (Matzo, 2006). There are many boundaries — legal, moral, and professional — that are oftentimes unclear to the APN, which is what makes end-of-life decision making so fraught with dilemma.

Daly (2006b) notes that during the 1990s, advanced directives appeared to offer a solution to end-of-life decision-making problems. Advanced directives are essentially living wills that document a person's wishes regarding treatment when they reach the end of life, particularly when they are no longer able to express those wishes themselves. The purpose of these directives was to get people talking about what they would want "just in case." However, in the 21st century it has become clear that advanced directives are not working as once hoped. The fact that they have not performed as expected means that greater communication between healthcare workers and family members is now vital (Ahrens & Kollef, 2003).

Withdrawing Treatment and Passive Euthanasia

There are major discrepancies in end-of-life decision making when comparing people's religious, philosophical, and cultural worldviews. Returning to the Schiavo case, we can see "the extent to which persistent misunderstandings of complex disease states, human physiology, treatment options, and prognostic probabilities interfere with attempts to reach consensus" (Daly, 2006b).

Daly (2006b) highlights how important APNs are in end-of-life decision making, given how intimately involved they are in providing care to patients at the end of life. However, helping to make decisions about end of life can be very stressful for APNs. APNs can help make the decision not to initiate life-saving treatments. Matzo (2005) found that many nurses are more comfortable with not initiating life-saving treatments if they believe they will have to stop them once begun. Withdrawing life-saving treatments — or "letting die" (Matzo, 2005) — can be considered a form of "passive euthanasia," which carries its own moral dilemmas. Others may view the withdrawal of life-saving treatments as an act that feels equivalent to causing death or killing (Matzo, 2005). Withdrawing life-saving treatments may be morally problematic for some APNs — especially those who believe in the sanctity of life regardless of the burdens of illness and pain. APNs must nonetheless be aware of the legal and moral consensus that recognizes no moral distinction between withholding and withdrawing life-saving treatments (Matzo, 2005).