Ethical Issues in Long-Term Care End-of-Life Decisions

Introduction: The Ethical Dilemma

Mrs. Beaudoin faces a serious ethical dilemma given that she does not have a formal power of attorney and her husband, who also resides in the same facility, has moderate dementia and is very frail. The central ethical issue is that Mrs. Beaudoin's health is failing steadily. She is known to have cancer throughout her body, a failing heart, moderate dementia, and Type II diabetes. Following a cardiac arrest and a brief stay in the intensive care unit, she suffered a severe brain injury caused by insufficient oxygen. Because she cannot make healthcare decisions on her own, and her husband's condition is equally compromised, the critical ethical question becomes: who will make healthcare and end-of-life decisions on her behalf?

Mrs. Beaudoin's brain injury and inability to consume enough calories to sustain her body weight mean her health continues to decline. A further ethical dilemma arises because the presumptive substitute decision-maker — her eldest daughter — disagrees with the assessment of the care team. She objects to a treatment plan focused solely on comfort care and the exclusion of CPR. Mrs. Beaudoin does not appear to be leading a meaningful life, and there is a real concern that the team's efforts to keep her alive are causing her suffering. The ethical issues at stake broadly include the patient's capacity to make decisions, the right to refuse treatment, the withdrawal and withholding of life-sustaining treatment, hydration and nutrition, assisted suicide, and no-code decisions (McCabe & Coyle, 2014).

It is the responsibility of the acting long-term care (LTC) administrator to maintain an approach consistent with ethical decision-making and to implement decisions that are morally sound (Thorns, 2010). The administrator must possess sufficient facts, knowledge, and experience regarding Mrs. Beaudoin's condition and the expected prognosis. Moreover, the administrator must be willing to collaborate and communicate effectively with colleagues in order to arrive at decisions that serve the patient's best interests (Thorns, 2010).

In order to deliver medically and ethically appropriate healthcare decisions for patients without surrogates and for patients who lack decision-making capacity, several factors must be considered. Any decision made without knowledge of what the patient would specifically have wished for must be made in that patient's best interest (Santa Clara University Markkula Center for Applied Ethics, 2019). Appropriate care decisions are defined by the provision of beneficial ethical interventions and the avoidance of interventions that offer no benefit or that would impose a burden on the patient. Interventions that contravene generally accepted healthcare standards or that are medically ineffective must be avoided (Santa Clara University, 2019).

Core Ethical Principles in End-of-Life Care

According to Holt (2017), medical interventions are increasing in both number and sophistication, as is the human lifespan. This dual increase has generated numerous ethical concerns at the end of life. The basic principles of bioethics — including justice, the doctrine of double effect, beneficence, non-maleficence, and autonomy — must form the foundation for all end-of-life decision-making (Holt, 2017). The proliferation of new medical interventions and life-extension technologies has created situations in which patients may seek to end their own lives through physician-assisted suicide, and in which healthcare professionals may employ euthanasia to relieve patient suffering (Holt, 2017). Various medical organizations have produced ethical guidelines on these subjects (Macauley, 2018), which can assist in resolving the complex clinical and ethical dilemmas that arise at the end of life.

Providing good care for a dying patient requires that those involved have a sound understanding of the ethical issues surrounding end-of-life healthcare. Advance care planning can preserve patient autonomy even at moments when the patient is no longer able to make decisions independently. If a patient has expressed the wish that artificial hydration and nutrition be withheld, this can be honored without violating any ethical code. In Mrs. Beaudoin's case, there is no legal surrogate to assist in decision-making because she had no formal power of attorney. Although her eldest daughter disagrees with the medical team's recommendation — comfort care only, with no CPR — it is important that the physicians' integrity as the moral agents within the clinical setting be honored and recognized. The healthcare team bears the moral imperative to ensure that a dying patient receives good care. The dilemma here is whether to follow the expert opinion of the oncologist or to defer to the wishes of the eldest daughter.

One of the principles of ethics in public healthcare, according to Schroder-Back et al. (2014), is the non-maleficence principle. This principle requires the healthcare professional to act in a manner that avoids harm, even when the patient or client requests otherwise. It has historical antecedents in the renowned Hippocratic Oath in medical ethics. The second key principle is beneficence (Schroder-Back et al., 2014), which speaks to the obligation to act in the benefit of clients and patients. It is the physician's obligation to assist and heal the patient to the best of their judgment and abilities. While non-maleficence involves the omission of harmful actions, beneficence calls for active promotion of the welfare of others. The health-maximization principle addresses the gap that neither beneficence nor non-maleficence fully fills: both principles do not, by themselves, ensure that the health outcomes of the population are maximized. Improving health outcomes and the quality of care is fundamental to the success of any healthcare system (Schroder-Back et al., 2014).

On the matter of efficiency, there is a global need for better health outcomes despite scarce available resources. For this reason, those resources must be utilized efficiently — a moral duty of health professionals, because efficiency enables greater health benefits. The autonomy of the patient must also be respected (Schroder-Back et al., 2014). The principle of justice in health equity must be observed: every patient has equal moral value, and any unequal treatment requires justification.

Identifying the Appropriate Substitute Decision-Maker

The appropriate substitute decision-maker (SDM) for Mrs. Beaudoin is her eldest daughter. Her husband, also a resident of the long-term care facility, has moderate dementia and is quite frail, making it impossible for him to make healthcare decisions on her behalf. It would also be unwise for the acting administrator to rely on the husband as a surrogate. The only logically capable surrogate who can act in Mrs. Beaudoin's best interests is therefore the eldest daughter, as she is the only one in a position to make informed healthcare decisions on her mother's behalf.

Conclusion

The case of Mrs. Beaudoin illustrates the complex intersection of clinical judgment, family dynamics, and bioethical principle that long-term care administrators must navigate. The core ethical principles of non-maleficence, beneficence, autonomy, and justice provide a framework for making decisions when patients lack decision-making capacity and have no formal legal surrogate. The eldest daughter serves as the appropriate substitute decision-maker, but where surrogates disagree, the best-interest standard — informed by the treating clinician's expert judgment — must prevail. Finally, a patient's expressed desire to prolong life does not obligate clinicians to pursue interventions that impose suffering without meaningful benefit. Ethical end-of-life care demands that the patient's welfare, dignity, and quality of life remain at the center of every decision.

References

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Holt, J. (2017). Ethical issues at the end of life. In Key concepts and issues in nursing ethics (pp. 129–143). Springer International Publishing. https://doi.org/10.1007/978-3-319-49250-6_10

Macauley, R. C. (2018). Ethics in palliative care: A complete guide. Oxford University Press.

McCabe, M. S., & Coyle, N. (2014). Ethical and legal issues in palliative care. Seminars in Oncology Nursing, 30(4), 287–295. https://doi.org/10.1016/j.soncn.2014.08.011

Santa Clara University (2019). Healthcare decisions for incapacitated patients without surrogates. Markkula Center for Applied Ethics. Retrieved 21 March, 2019 from https://www.scu.edu/ethics/focus-areas/bioethics/resources/healthcare-decisions-for-incapacitated-patients/

Schroder-Back, P., Duncan, P., Sherlaw, W., Brall, C., & Czabanowska, K. (2014). Teaching seven principles for public health ethics: Towards a curriculum for a short course on ethics in public health programs. BMC Medical Ethics. BioMed Central Ltd. https://doi.org/10.1186/1472-6939-15-73

Shulman, R. (2016). Consent for treatment and conflicts between substitute decision makers: Options for resolution. Retrieved 21 March, 2019 from https://www.allaboutestates.ca/conflicts-substitute-decision-makers/

Thorns, A. (2010). Ethical and legal issues in end-of-life care. Clinical Medicine, Journal of the Royal College of Physicians of London. Royal College of Physicians. https://doi.org/10.7861/clinmedicine.10-3-282