Ethical Decision-Making in Nursing: An End-of-Life Case Study

Introduction

This report describes an ethical predicament encountered by a nurse working in an emergency department. The predicament is analyzed using Catalano's (2009) algorithm for ethical decision-making, and a theoretical perspective is applied throughout the analysis. Several likely solutions to the predicament are discussed, and research instruments for solution evaluation are identified.

There are many moral situations faced by people working in the nursing profession, particularly in relation to a growing technological and scientific environment involving the development of advanced treatment methods and diagnostic equipment (Range & Rotherdam, 2010). Many conflicts arise from the manner in which professionals handle patients in hospital environments or in basic care networks. Workers face difficulty when trying to resolve conflicts due to being overlooked by their leaders or due to a lack of sufficient support while executing their duties and exercising professional autonomy. This can produce feelings of anger, guilt, outrage, sadness, frustration, hopelessness, and impotence toward conflict situations (Corley, 2002).

There are four crucial responsibilities for any nurse: promotion of health, prevention of illness, alleviation of suffering, and restoration of health. These duties require a nurse to promote health, coordinate patient care, administer medication, carry out medical examinations, and perform other essential duties. The nursing process entails assessment, planning, diagnosis, evaluation, and implementation (Parse, 1999).

A working nurse encounters conflict and moral issues in many different situations. It is not possible to separate conflict from a nurse's professional life. Among the many conflicting situations are the absence of consent prior to a procedure, extension of a patient's life without attention to quality of life, questionable or inhumane professional conduct, resource allocation inequalities, and fragmented decision-making. Moral distress can become a persistent burden for nurses given the many conflict situations they face (Lunardi et al., 2009).

Problem Statement

The ethical dilemma encountered by the nurse working in the emergency department involves a 93-year-old patient transferred from an extended care unit. This patient is suffering from Alzheimer's disease. Due to her declining health, she is unable to eat or drink, threatening her life. The patient is also unable to respond to touch or voice and is non-verbal. The physician in charge has concluded that she is unable to thrive. The patient's granddaughter has been granted power of attorney over her grandmother, and there is no advanced directive from the patient. The patient's family insists that their loved one must be taken to the emergency department to receive a feeding tube. The family has been informed that there is a chance their loved one could survive with nutritional support.

The ethical dilemma for the nurse is to identify the patient's right to a dignified death while balancing that right against the desires and wishes of the patient's family members (Heiser, 2014).

Literature Review

Nurses must make critical decisions throughout their practicing careers. The decision-making process must be informed by ethical principles. Ethical decisions involve the education and practical experiences of nurses, as well as the influence of culture and personal beliefs. Motivations, expectations, and different value systems also impact the decisions nurses make. The code of ethics for nurses and the framework of professional mission statements support nurses in their decision-making. Nurses employ ethical standards during decision-making in light of prevailing circumstances (Silva et al., 2014).

Nurses must have the professional capacity to examine various situations and arrive at well-considered decisions having explored all possible alternatives — a hallmark of ethical decision-making (Silva et al., 2014). Nurses must be able to support their actions and decisions. For this reason, a nurse must be confident in their ability to make sound judgments in any situation, quickly distinguishing between right and wrong actions. Nurses must have sound moral perception, courage, sensitivity, and imagination (Holt & Convey, 2012). According to Grundstein-Amaro (1992), a nurse must place great value on the care perspective during decision-making — meaning that a nurse must be responsible and highly sensitive to the wishes of the patient throughout any decision-making process.

Corley, Elswick, Gorman, and Clor (2001) argue that a nurse experiences high levels of moral distress when staffing is so low that adequate care becomes impossible. A nurse will experience twice as much distress when there are staffing problems than when facing other issues. Woods, Rodgers, Towers, and La Grow (2015), however, contend that moral distress arises primarily from situations in which optimal care is compromised by cost-cutting measures, poor care continuity, and working alongside incompetent colleagues. In circumstances where a nurse disagrees with a physician's orders and is required to conduct unnecessary treatments and tests — making the nurse feel as though the dying process is being prolonged unnecessarily — moral distress can result. Futile care is also considered a significant source of moral distress. Molloy, Evans, and Coughlin (2015) suggest that nurses frequently suffer moral distress when supporting distressed families of critically ill infants. When a nurse's concerns are dismissed, they become emotionally distressed and feel powerless to effect change.

Moral distress can predict burnout. A nurse experiencing higher levels of moral distress is more likely to leave their institution for a less stressful environment or to abandon the nursing profession altogether. Corley et al. (2001) found that 15% of nurses had left their positions due to moral distress. Hamaideh (2014) associated high levels of moral distress with an insufficient knowledge base and inadequate skills for handling morally challenging situations. Pye (2013) suggests that experience level may positively influence a nurse's ability to manage moral distress effectively.

Ulrich et al. (2010) found that nurses are sometimes unaware of the options available to them when confronted with an ethical dilemma, and that nurses are often inadequately prepared for handling such situations. Musto and Schreiber (2012) found that nurses experience moral distress when they question their own decisions and doubt their practice — doubts that surface when nurses overthink solutions to difficult situations.

Theoretical Perspective and Case Analysis

Catalano's (2009) algorithm for ethical decision-making is applicable to the description and analysis of the current ethical dilemma (Blais & Hayes, 2011). The algorithm proceeds through four steps:

Step 1: Highlight the ethical dilemma, collect data, and interpret it.
Step 2: State the ethical dilemma.
Step 3: Gather necessary facts.
Step 4: Identify potential solutions.

Catalano (2009) asserts that decision-making begins with an assessment of the ethical dilemma situation. First, it is important to identify the likely ethical dilemma, collect data, and interpret it. Decisions entail determining which party will be most affected by the outcome. Step 2 involves stating the dilemma — in this case, the nurse must meet the wishes of the family while also ensuring the patient is allowed a dignified death. Step 3 entails gathering facts, including potential risks to the patient's life. The information gathered is essential for generating a sound outcome (Deshpande, 2009).

In accordance with Step 1, the wishes of the family were evaluated. Information available to the nurse indicates that the person with power of attorney wants her grandmother to receive a feeding tube. The granddaughter believes that the feeding tube at the emergency department will help her grandmother recover. The nurse's assessment reveals that the family is unaware that Alzheimer's is a progressive, irreversible disease — a form of dementia that cannot be reversed (Porth, 2010). The family did not have information indicating that Alzheimer's effects on the patient's quality of life at this stage would not be improved through nutrition. The nurse must consider the patient's physical condition: the patient is incapable of making decisions or communicating and is suffering from a stage 3 decubitus coccyx ulcer. Placing a feeding tube would not improve the patient's quality of life.

Step 2 presents the dilemma of whether to honor the desires of the family or to support the patient's right to a dignified death. Step 3 presents several possibilities: having a surgeon fit the patient with a feeding tube; offering hospice care for the patient and family; or clearing the patient medically and returning her to the extended care facility (ECF). All gathered information must be carefully considered to allow the nurse to arrive at a resolution. Any further decision will depend upon the outcomes and solutions generated from this analysis.

Conclusion

It is naïve to assume that any single method or system can resolve all moral situations. Principles are general in nature and definition, while ethical disputes are unique and specific. In the field of bioethics, the presence of tradeoffs can delay decision implementation. Moreover, in nursing, every case is unique, and the correct decision may not be apparent before the situation arises. For every situation, it is essential to examine relevant data carefully, because the variables in any new situation cannot be predicted in advance. Consequences must be considered throughout the decision-making process.

Ethics are important for the analysis, study, and assessment of relationships between empirical data drawn from unique situations in which a person's life or death is at stake. Sound professional ethics calls for systematic formulas resulting in morally sound and successful decisions, offering a fitting framework for adoption in ethical situations. This ensures that decisions are made with consideration of relevant data and with clarity about duties and rights. It is also crucial for patients and their families to reflect carefully on every decision in order to avoid consequences arising from mistrust or misunderstanding (Trout & Rivkin, 2000).

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