Nurse Ethics: Dignity and End-of-Life Care for Elderly

Introduction

Healthcare professionals, particularly nurses, are guided by a Code of Ethics that obliges them to show compassion, respect for human dignity, and regard for the rights of their clients or patients — especially those at the end of life. How nurses manage the inherent needs of elderly or end-of-life patients for that compassion and respect has a significant impact on the outcome and quality of care they provide. There may be resource limitations in hospital or care settings that incline nurses toward inappropriate behavior or remarks, but a patient's interests and rights always take primacy over other workplace considerations.

Nurses also need to understand and properly apply two important legal documents: the Patient Self-Determination Act of 1991 and a Durable Power of Attorney for Medical Care. Familiarity with these documents prepares nurses for the difficult end-of-life event and its consequences. Surveys have also shown that African American elderly individuals and others nearing the end of life are among those most in need of compassion and respect — yet they often feel these are denied to them in care settings due to racism and discrimination.

Dignity and Older People: The Voice of Professionals

Arino-Blasco (2005) writes about a study conducted on the views of 424 health and social care professionals in six European countries regarding dignity in elder care and how these professionals can provide better dignity-enhancing care for older clients. The surveyed professionals expressed their views on dignity, on older people, on working with older people, and on dignified versus undignified care, as well as on the system, guidance, and education related to dignity.

According to participants, dignity is particularly important to older people because of their vulnerability. Patient-professional relationships that focused on individual dignity produced positive effects on patient care and cooperation. Participants generally painted a difficult picture of the frailest elderly and found that those who violated the dignity of older patients created barriers to dignified care. They noted that a care sector characterized by low value, a lack of respect, and a lack of funding tends to become an impoverished and unsuitable environment for elderly patients — a condition that, in turn, reduces the workforce and increases its workload.

The majority of participants also said that personal skills, professional values, communication, and behavior all had an impact on the dignified care of the elderly. While they acknowledged this, they also emphasized that the system and the scarcity of resources often pushed them to their limits and at times led some of them to become insensitive to the needs of elderly patients, whose dignity and self-respect could be damaged as a result. All participants reported having little or no education on providing dignified care, yet were expected to know how to provide it automatically.

As the aging population requiring this type of care continues to grow, healthcare professionals are challenged to seriously consider specific concepts — such as dignity, ageism, values, communication, holistic care, and human rights — in their practice. Existing guidelines, rules, and protocols, participants noted, touched on dignity only in relation to etiquette. They pointed to the lack of resources, more than the lack of education or other measures, as the greatest source of stress, which tended to affect the type of care they provided to elderly patients who were most sensitive to dignity as they neared the end of life.

The indignities associated with old age stemmed from ill health, dependency, vulnerability, frailty, loss of competence, and being left behind by current technological advances. The professionals surveyed identified promotion of autonomy and independence, a person-centered and holistic approach, maintenance of identity, encouragement of involvement and empowerment, effective communication, and respect as the essential factors in dignified care. Undignified care, by contrast, was associated with invisibility, depersonalization, treatment as an object, humiliation, abuse, and narrow or mechanical approaches to care.

The Nursing Code of Ethics and End-of-Life Care

The Code of Ethics for Nurses with Interpretive Statements establishes that the nurse, in all her professional relationships, is to show compassion and respect for the inherent dignity, worth, and uniqueness of each person — particularly the patient or client — irrespective of social or economic status, personal attributes, or the nature of the illness. She must show compassion and respect in her relationships with all patients, whatever their human needs and values, lifestyle, value system, or religious beliefs, whether or not she approves of these or of the patients' individual choices. She must respect them as persons.

That respect extends to the supportive care needed by the elderly and the dying. Nursing care is particularly vital for patients and their families at the end of life, in preventing and relieving the symptoms and suffering that are common at that stage. The nurse must actively participate in the assessment and assurance of the responsible and appropriate use of interventions in order to minimize unwarranted or unwanted treatment and patient suffering. She should provide interventions to relieve pain and other symptoms even when they may carry risks of hastening death — but she may not make choices to end a patient's life based on compassion, respect for autonomy, or quality-of-life concepts.

The code establishes the nurse's duty to recognize the patient's moral and legal rights to self-determination and to assess only the patient's understanding of information and the implications of their decisions. It also establishes the primacy of the patient's interests over all other interests, and requires nurses to collaborate and cooperate with other members of the care team in a shared effort to meet the patient's health needs and the needs of the public.

Conclusion

Nurses and other healthcare professionals are bound to a Code that obliges them to treat every patient with compassion and respect so as to elicit patients' cooperation and assure the best outcome of care. While these professionals confront personal and workplace strains and resource limitations, their patients' interests must always take precedence. Nurses may or may not agree with patients' preferences and beliefs, but they are ethically required to respect those preferences and beliefs and to communicate that respect in all their professional activities and dealings.