Ethical dilemmas in end of life care
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By :
Mary Brown
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Introduction
Time and time gain, nurses are faced with a substantial number of issues that need to be addressed when dealing with end of life treatments. However, for purposes of this essay, special attention will be given to ethical dilemmas in administration of care. Before addressing those ethical dilemmas, it is essential to clarify the meaning of the term so as to eliminate any ambiguity in the rest of the essay.At some instances, patients’ wishes may be against the issue or in other situations, family members may be violent or emotionally incapable of handling the trauma associated with family presence. Consequently, nurses should examine the issue on a contextual basis as asserted above. (Kelly, 2008, p 90)
The role of the nurse during advanced directives or living wills
Advanced directives refer to mechanisms utilised by hospitals or hospices to note what patients prefer in the event that the would require life sustaining treatment. Consequently, nurses should ensure that end of life treatment falls in line with the most recent documentation of patient’s wishes. In cases where no written documentation is available, then nurses need to incorporate family members in the process. In cases where the latter group or representatives may not be available, then nurses need to exercise their own judgment. At such a time, nurses should still consider the values and beliefs of their patients. This is why it is necessary for nurses to establish relationships with them so as to determine their preferences and choices.
Ethical issues about the existence of written directives may not necessarily be restricted to the patient alone. In the absence of written directives, it is imperative for nurses to note any illegal practices and report them to authorities. Nurses must realise that their obligations are also extended to other health care professionals as they have the opportunity to change pre-existing laws and methods of handling end of life treatment.
Ethical dilemmas in offering artificial hydration and nutrition
Many practising nurses oppose withdrawal of life sustaining treatment claiming that this is unethical. Such nurses assert that offering artificial hydration and nutrition is a symbol of offering care and taking it away is a sign of neglect. However, there are special circumstances in which taking such actions may be very necessary. (Finucane & Harper, 2001, p 126)
It may sometimes be difficult decide whether a patient should be put on artificial hydration or not. For instance when a patient does not desire to live very long and has expressed that desire to practising nurses, then it may be difficult choosing whether to place that patient on artificial nutrition. Besides that, some patients may be in a position where their conditions are deteriorating and administration of artificial hydration may not achieve tangible results. Sometimes, some nurses have to cope with a situation where artificial hydration may present more risks than benefits to the respective patients. Consequently, it becomes necessary for that nurse to come up with a solution. (Thacker, 2008, p 180)
In such circumstances, a number of factors have to be incorporated into the decision making process. First of all, a nurse needs to examine the potential benefits of the care given against the background of the risks that it will pose to the patient. For instance, when patients have severe dementia, using artificial hydration may actually be detrimental to them. This is because artificial feeding increases a patient’s discomfort and it does not prevent some of the major problems that artificial nutrition ought to prevent. These include; pressure sores, malnutrition and survival. Nurses need to plan ahead instead of waiting for a crisis to occur. At that point, it may be difficult trying to establish the most sound decision. For instance, nurses need to look at the medical history of the patient and establish whether or not that patient would benefit from the provision of life sustain treatment. In certain circumstances, family members may misunderstand the prevailing situation and nurses need to clarify this to them by giving clear and simple statements. Some family members may assume that it is the lack of artificial nutrition that is making their patients weak. Nurses must clarify this out to the family by telling them that it is in fact cancer/another disease that is causing such difficulties. (Hospital Authority, 2002, 1440)
In instances where life sustaining treatment causes extreme discomfort, it may be difficult for nurses to establish the way forward. In cases where the treatment would offer greater benefits to the patient, then nurses should administer it regardless of the discomfort. Research has show that artificial nutrition can cause some or all of the following symptoms
• Vomiting
• Incontinence
• Diarrhoea
• Breathlessness
• Edema
• Etc (Finucane, 2002, p 1919)
When nurses are not sure about the effect of treatment; some practitioners suggest the use of trial treatments. For instance, nurses can try artificial nutrition and observe the effects on the respective patient. If it does not seem like the patient is improving and the artificial nutrition is causing them pain, then it may be advisable to avoid it.
Conclusion
End of life decisions present numerous moral conflicts to practicing nurses because they have to cope with various obligations. However, the most important thing that nurses should keep in mind is that modern medicine has its limits. Sometimes, nature may decide to take its course and it becomes pointless prolonging life when no benefits are foreseeable and when patients have to go through excessive discomfort. Consequently, nurses must ascertain that their decisions comply with patient’s long term goals. These goals should be informed through assistance from the respective nurse. (American Association of Nursing Colleges, 2000, p 148)
Reference
Reichel ,W. (2000): End-of-life care and family practice; Am Fam Physician Journal, 59, 7, 138
Finucane, T. & Harper, A. (2001): policy considerations for attempting resuscitation in nursing homes; Am Geriatr Soc, 47, 34, 126
Emanuel, E. et al (2002): Assistance from friends, family members, volunteers and paid care givers in the care of terminally ill patients; Engl Med journal, 341, 12, 256-63
Finucane, T. (2002): Tube feeding for patients with advanced dementia, JAMA Journal;28, 6, 70
Keay, T. & Schonwetter, R. (2002): Hospice care in the nursing home; Am Fam Physician, 57, 24, 191
American Association of Nursing Colleges (2000): Peaceful Death: Curriculum Guidelines and Recommended Competencies for End-of-Life Nursing Care, Open University Press, 148
Salisbury C. & Bosanquet N. (2003): Providing Palliative Care Service; Oxford University Press, 65
Canadian Nurses Association (2000): Nurses’ Moral Constraints; Ethics in practice, 34, 12, 56
Casarett D. (2000): Special Ethical Guidelines for Palliative Care; Journal of Symptom and Pain management, 20, 2, 136
Seymour J. & Clarks D. (2000): Reflections on Palliative Care; Open University Press, p 200-267
Hospital Authority (2002): Guidelines on Life-sustaining Treatment in the Terminally ill; British Medical Journal, 319, 23, 1440
Thacker, K. (2008): Nurses' Advocacy Behaviours in End-of-Life Nursing Care; Journal of Nursing Ethics, 15, 2, 180
Garros, D. et al (2003): Circumstances Surrounding End of Life in a Pediatric Intensive Care Unit; Pediatrics, 8, 37, 112
Kelly, J. (2008): Nurses' and Doctors' Perspectives on Slow Codes; Nurse Ethics, 12, 15, 90
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