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Autor: anton 30 October 2010
Words: 2082 | Pages: 9
Running Head: Ethical Analysis Paper
When Patient Care Conflicts with Moral, Ethical, and Legal Boundaries
Ethical Analysis Paper
Trends and Issues
Austin Peay State University
Gregory A. Wood
March 18, 2005
When Patient Care Conflicts with Moral, Ethical, and Legal Boundaries
There are many situations that cause ethical dilemmas in the scope of nursing practice. One such situation that is encountered repeatedly is that in which a patient has no living will or advance directive to designate when extraordinary life saving measures will be stopped and the patient will be allowed to die. This becomes a dilemma in many cases because there is so much uncertainty in outcomes for individuals. This uncertainty stems from the fact that some people recover from profound states of illness while others do not. It is in these cases in which many subjective criteria tend to be added to the equation when trying to decide on the plan of care for the patient (Oberle & Hughes, 2001)
A 78-year old man who has not had any significant health problems in his life except for a myocardial infarction (MI), which was the reason for his admittance to the hospital emergency room. After the acute issues of the MI had been resolved a battery of tests, including: cardiac catheterization, electrocardiogram, echocardiogram, and serum enzyme tests were performed to determine the extent of the damage and the best course for treatment. It was determined that there were two blockages and that the patient would be a good candidate for coronary artery by-pass graft (CABG) surgery. During surgery, the patient sustained another MI and developed ventricular fibrillation which was corrected by electro-cardioverter defibrillation and the use of anti-arrhythmic medications. After surgery the patient was taken to the post-anesthesia care unit where it was found that after the effects of the anesthesia should have dissipated, the patient was unable to sustain spontaneous respiration and his blood pressure continued to fall when trying to wean from the ventilator and vasopressor medications. This is when the patient was admitted to the surgical intensive care unit (SICU) so that the pressors could be titrated to maintain blood pressure and the ventilator could be monitored. During the 6 weeks in the SICU, the patientâ€™s status continued to decline. Several attempts were made to try and wean the ventilator and vasopressors but each attempt was unsuccessful. The patientâ€™s condition had worsened to a point that the family, including the son, daughter-in-law, and wife began questioning the nurse about trying to get an order to withdraw the life supporting measures. They began asking about the withdrawal after the third week in the SICU when the patient began developing sores on his heels and sacrum and two of his toes turned black because of the lack of circulation in the extremities caused by the vasopressors. He was experiencing renal failure as a result of the low blood pressure and his arterial blood gas values include oxygen saturation levels below 60mmHg and carbon dioxide levels above 50mmHg. The attending doctor was asked by the family on several occasions about issuing a do not resuscitate order (DNR) and to withdraw life support, but the doctor proceeded to convince the family to wait even though there were no signs of improvement. The doctor also during this time had told some of the nursing staff, who had taken care of the patient and talked to the family, to not do a â€œfull blown codeâ€ even though there was no written DNR. The patient remained in the SICU for six weeks until he went into cardiac arrest and resuscitative efforts, with every measure available, were performed unsuccessfully.
The main ethical issue involved in this case revolves around the wishes and feelings of the patientâ€™s family and the opinion of the doctor who has the ultimate power to issue a DNR or agree with the wishes to withdraw life sustaining measures. There was also an issue with the doctor saying to only perform a partial code which was not documented by orders. This was not only an ethical issue but also a legal issue that could jeopardize a nurseâ€™s career if the verbal orders were followed.
According to the 2001 revision of the American Nurses Association Code for Nurses, there are four provisions that pertain to this situation. The main provision is Provision 1.3 that states:
â€œNurses are leaders and vigilant advocates for the delivery of dignified and humane care. Nurses actively participate in assessing and assuring the responsible and appropriate interventions in order to minimize unwarranted or unwanted treatment and patient suffering. The acceptability and importance of carefully considered decisions regarding resuscitation status, withholding and withdrawing life sustaining therapies, forgoing medically provided nutrition and hydration, aggressive pain management and advance directives are increasingly evident. The nurses should provide interventions to relieve pain and other symptoms in the dying patient even when those interventions entail risks of hastening death. However, nurses may not act with the sole intent of ending a patientâ€™s life though such actions may be motivated by compassion, respect for patient autonomy, and quality of life considerations. Nurses have invaluable experience, knowledge, and insight into care at the end of life and should be actively involved in related research, education, practice, and policy development.â€
According to this provision, as well as provisions: 2.1, â€œPrimacy of the patientsâ€™ interests;â€ 2.2, â€œconflict of interests for nurses;â€ and 5.1, â€œmoral self respect,â€ there are many issues involving in the ethical care of this patient. These issues are all of ethical concerns, but are also legal concern according to the fact that is illegal to not completely attempt resuscitative efforts in the absence of a DNR.
The ethical principles involved in the care of this patient include beneficence, nonmaleficence, autonomy, and paternalism.
Beneficence states that â€œthe actions one takes should promote good.â€ This principle was used in the care given by the nurse to continue with all measures to promote the comfort of the patient as well as talking with the family. Nonmaleficence states that â€œone should do no harm.â€ The nurse performed all activities to try and provide comfort and dignity to the patient even with the knowledge of the grim prognosis. Autonomy is doing what the patient would wish to be done and paternalism is decisions being made for one person by another. Autonomy was in a way not upheld since the family had voiced that the patient would not want to live in this way, but the resuscitative effort was necessitated by law since there was no DNR order written by the doctor (Yoder-Wise, 2003).
The ethical agents involved in this situation include, the patient, the wife, the son, and the daughter-in-law asking for a DNR and to withdraw life support and the doctor not willing to issue a DNR even though the family had requested it to be done. The family membersâ€™ rights during this situation were the same with the wife and son having just slightly more authority than the daughter-in-law to request that life supportive measures be removed. The patient also had rights but could not say whether or not he wished to continue with the life supportive measures and had no advance directive to determine his plan of care. This decision then fell to the wife and son who were beginning to get frustrated with the doctor since it was the doctor who had the ultimate power to write a DNR order in the absence of an advance directive. The key decision makers were the wife and the doctor, but no decision supporting the familyâ€™s wishes was reached prior to the patientâ€™s less than dignified death. The nurse in this situation had no choice but to perform the resuscitative effort regardless of the ethical considerations because of the doctorâ€™s unwillingness to write a DNR and giving a verbal order for a partial code. The performance of a partial code or allowing the patient to die without resuscitative efforts could have jeopardized the nurseâ€™s career in the absence of any written orders for either measure.
Options/Reconciliation Facts and Theory
There were basically four options: follow the orders in a patientâ€™s living will, withdraw life supportive measures, issue a do not resuscitate order, or perform a full code on the patient. The first option is impossible in this situation since it must be performed in advance to the patientâ€™s loss of competence. This has become more of an issue as technology has advanced to be able to sustain life in spite of the patientâ€™s inability to live unassisted. Because of the Patient Self-Determination act of 1990, all nurses are required to educate patients about advance directives in order to prevent such situations (Taylor, Lillis, & Lemone, 2001). This option offers the patient to exercise the principle of autonomy.
The second option of withdrawing life supportive measures or what some call passive euthanasia involves the removal of all technology, save that used for pain relief, and allowing the patient to die with the dignity which is supported in the ANA Code for Nurses. This supports the principle of nonmaleficence since there was no direct action which caused the patientâ€™s death.
The third option of the issuance of a do not resuscitate order would have also upheld the principle of nonmaleficence. This option would have been an acceptable option in this case because it does not harm and all life sustaining measures being used were considered to be palliative to the patientâ€™s situation thus maybe prolonging the patientâ€™s suffering and pain although the patient could not respond (Taylor, et.al, 2001).
The last option of performing a full code on the patient which was the one that eventually took place, happened not because of choice by the family or the patient, but because of the lack of an advance directive, the lack of cooperation of the doctor with the familyâ€™s wishes, and the absence of a DNR order in the patientâ€™s chart. This option seemingly disregards the principles of beneficence and nonmaleficence in this situation.
The deontological theory supports option one because this option focuses not on the consequences of the action but on the intention of the action which is to prevent the problems that may occur in the absence of the advance directive. This type of ethics has been divided into situation ethics in which decisions are made based on the characteristics of the individuals (Yoder-Wise, 2003).
The teleological or utilitarianism theory supports options two and three. This is so because this theory is based on the performance of actions that promote the greatest amount of good in the end and not just the action. It is characterized by actions that bring about the least harm and suffering to a single person and the greatest amount of good for the most people, including the patient.
The fourth option is not supported by either theory. Unfortunately, this was the ultimate outcome of the situation based solely on legal issues without taking into account the ethical or moral issues involved because of the non-existence of an advanced directive or a DNR order written by the doctor.
In an ideal situation, option 1 would have been chosen because it would have prevented all the suffering that the family had to endure due to the length of time they had to wait for their loved one to die in an undignified resuscitation attempt. This would have alleviated the concern of whether or not to issue a DNR order by the doctor or whether or not the family needed to request that supportive measures be discontinued. The most evident benefit of this decision would be that the patient would have been able to maintain the principle of autonomy during the days of his life in which he was incompetent to make decisions.
American Nurses Association (2001). ANA Code for Nurses. Retrieved March 15, 2005 from http://www.nursingworld.org/ethics/ecode.htm.
Oberle, K. & Hughes, D. (2001). Doctorsâ€™ and nursesâ€™ perceptions of ethical problems in end-of- life decisions. Journal of Advanced Nursing, 33,6. Retrieved March 15, 2005 from Tennessee Health and Wellness Resource Center Database.
Taylor, C., Lillis, C. & LeMone, P. (2001). Fundamentals of Nursing: The Art and Science of Nursing Care (4th ed.) Philadelphia: Lippincott.
Yoder-Wise, P. (2003). Leading and Managing in Nursing (3rd ed.) St. Louis: Mosby.
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