Introduction
An ethical dilemma arises when the clients and health care providers differ in their understanding of what is right or wrong (Narrigan, 2004). As nurses we often deal with ethical dilemmas in our everyday clinical practice; and as professionals we have the responsibility to analyse and examine any ethical problems that may arise. Any decision should be based on ethical principle that protects the best interest of both the patient and the health care provider. This paper will outline a critical incident which occurred in one of my clinical experience in intensive care unit (ICU).It presents the clinical case, identifies the ethical dilemma, and discusses the principles that apply to this situation.
The Case
Mrs G was a 76-year old woman who was brought to emergency department (ED) after her carer found her in respiratory distress. The ED doctor noted that the patient was minimally responsive to verbal stimuli, afebrile, normotensive, tachycardic to 130 bpm, and tachypneic to 30 breaths/min.A chest radiograph revealed a right lower lobe consolidation. Based on her old notes it was found out that she had been recently admitted for investigation of significant weight loss and it was found to be a result of advanced bowel cancer ,with lungs, bone and brain metastases. While in ED Mrs G’s respiratory functions deteriorated and a referral for ICU was made. She was then seen and reviewed by our junior registrar and after discussion from the ICU consultant, Mrs G was admitted to ICU for closer observation. I was then tasked to look after this patient for that shift. After knowing the brief history of the patient from my team leader, I was then asking the doctor of what do we do for this coming admission? Are we going to intubate and ventilate this patient in case she developed respiratory failure? And what are the chances of her recovery from this critical illness? Has it been discussed to the next of kin before the plan for ICU admission? The doctor then replied that it was his consultant’s decision, and so we will just have to wait when this patient will arrive in the unit.
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Within 24 hours of being transferred to the ICU, Mrs G’s condition deteriorated rapidly and a decision was made to talk with the family of what we should do in the event of cardiac arrest. Relatives need to be involved in discussions about end-of life issues so that they are fully aware of the appropriate decisions to be made; and that all parties involved understand the situation (McDermott, 2002).The son was immediately informed about his mother’s condition and it was revealed that Mrs G had previously stated to him that she does not want any heroic measures in the event of cardiac arrest. The conversation with Mrs G’s son over the phone resulted in the decision to initiate a not for resuscitation (NFR) order. The purpose of the NFR order is to deliberately withhold life-saving measures when the patient’s respiratory or cardiac function suddenly stops (Costello, 2002).
The next day the patient’s daughter arrived. During my conversation with her she mentioned that she had a distant relation with her mother and not had been in contact with the patient over the past 3 years. But despite of all that she still wanted that everything done for her mother. At this point in time I am not sure whether the daughter was aware of the condition of the patient before admission (especially her mother’s diagnosis of bowel cancer and the chance of survival is slim knowing it has metastasised to other organs). I then told her the need to speak the medical staff and the meeting was arranged for her later that day.
In this case, a clinical ethical dilemma has been identified. The daughter’s request for care conflicts with the patient’s advance directive and places us in a difficult position of either honouring the patient’s wishes or satisfying the daughter’s request. The doctor decided to call the patient’s son, the health care proxy and legally appointed decision maker for the patient. He was able to reach the son by phone and discussed to him the planned course of treatment. The son emphatically agrees with the ICU team’s plan to continue the current supportive treatment regimen. He (son) stated that his mother would not want any aggressive measures, and he agrees to comfort care for the patient. He said he will speak to his sister about her concerns and will join the arranged meeting later that day.
In analysing a clinical ethical dilemma, the first step is to further characterize the situation in terms of the underlying ethical principles that apply and the possible related ethical concepts that may be involved for example advance directives (Alfandre, 2007). To understand the decision-making process in this case, one must consider the ethical principles of autonomy, beneficence, normaleficence, and justice. These principles can guide primary care physicians and nurses to implement the care of the dying patients in general (Rousseau, 2001; Basket, 2006; Beauchamp & Childress, 2001). The healthcare team consultation meeting held prior to the family conference regarding Mrs G’s status provided the opportunity for healthcare team members to agree that Mrs G was dying. Even if more treatment was attempted for his individual systems, death was the expected outcome for Mrs G. Therefore the aim of good critical care medicine should be to establish a meaningful tension between the aim of preserving life and making a peaceful death possible (Callahan, 2003). At the meeting later that day, I could feel the emotional tension between the son and daughter, and being the nurse that involved in the care of their dying mother I was overwhelmed with 27-11-116feelings of uncertainty. I also felt that because of the disagreement with the plan of care, it could compromise my moral obligation which is to support the patient’s wishes and respect her preference for treatment.
As we are all aware that the patient’s condition was failing, the conflicts of reciprocal autonomy (cooperation in a decision or action) should be resolved (Mick, 2005).
Autonomy
It defines the freedom to make decisions of oneself without interference from others (Urden, Stacey, & Lough, 2006).The ethical dilemma presented in this case is whether to respect the patient’s autonomy or ignoring her wishes by giving in the demands of her daughter. In this situation the ICU consultant was concerned about providing additional medical treatment that the patient may not have wanted. Respecting patient’s autonomy “yields satisfaction for that person ( the patient) directly” while interfering with an individual’s autonomy may be experienced as “a form of pain or suffering” (Ozar & Sokol, 2002). I believe that without compelling reasons to override the patient’s prior stated wishes, respecting the patient’s autonomy takes precedence over beneficence, as the care the patient would have chosen is the care that has been proposed. Thus the team aims to continue with comfort care including oxygen, frequent suctioning, and pain relief for respiratory distress. However, to do otherwise would be uneasy without the cooperation of the patient’s daughter.
Beneficence
This principle directs the doctor to act in the patient’s best interests (Alfandre, 2007). As the nurse that looks after Mrs G, I also wanted to provide the care that is in her best interest as possible. Making her more comfortable and free of pain is an example of this principle During the end-of-life dilemmas, the stress of illness and dying can create a tension that makes barriers to communication even if there was an advance directive (Tulsky, 2005). The consultant suspects that part of the daughter’s concern may have been related to a sense of grief and loss and its associated guilt and regret. Being mindful of one’s emotions in complicated ethical dilemmas can help the health care professionals have more empathy for patients and thereby improve the therapeutic alliance (Halpern, 2007).
During the meeting, since both the son and daughter were present, the consultant starts the dialogue about the value of comfort care and its importance with dying patients. Emotional statements about end of life are difficult to express yet provide crucial information to family members that can help create consensus around the next medical decisions and course of action. In this case, it would be appropriate to also consider the extent of Mrs G’s illness (metastatic involvement to major organs) and its impact on her quality of life. But what are the doctor’s obligations when one of the family members disagree about the prior stated wishes of the patient? This is the ethical question raised in this case scenario.
Non-maleficence
The decision of not resuscitating Mrs G was influenced by this principle. Instituting full cardiopulmonary resuscitation measures to a patient who is terminally ill could have a devastating effects and contributes to poor care at the end stage of their illness (Edmonds,2003).
According to a recent study by Redman and Fry (2000) on ethical issues in nursing practice, prolonging the living-dying process with inappropriate measures is one of the most profoundly disturbing experiences that we nurses face and witness. I do feel that aggressive treatment to the patient is a violation of this principle as what exactly what the daughter wanted.
The consultant returns to Mrs G’s room the following morning and finds the patient with more laboured breathing. Mrs G’s daughter, who is at the bedside, appears distraught. The doctor decides to quietly observe. Few minutes passed as he is evaluating the patient’s general condition, when the daughter says, “The last time I saw her she was so strong”. The doctor decides to remain silent. After a few moments, the daughter says, “I didn’t visit her as often as I should have”. The doctor turns to the daughter and says, “I imagine it’s hard to watch a parent so sick”. The doctor realizes the daughter’s sorrow for her mother’s imminent death. “Your mother is very sick- that’s why she’s not talking- but I want to reassure you that she’s not uncomfortable. She is getting morphine to relax her breathing and manage her pain.
This is part of the dying process and we are making her comfortable.” The tension in the daughter’s shoulders releases and says, “I know you are doing what she would have wanted. I guess I’m scared of losing her…This is so hard for me. Thank you for listening.”
The next day the consultant schedules a joint meeting with the son and the daughter. At the meeting, he allows time for the family’s grief to be expressed, for the son and daughter to come to agreement about the plan of care, and have all their concerns addressed. The son and daughter together agree to proceed with comfort care.
After the meeting, the consultant returns to the station and places an order to titrate Mrs G opioid infusion for comfort. The patient dies 7 hours later in no acute distress, with the family at the bedside. I felt that without careful and effective communication techniques with the doctor, it would not have resulted in a “good death” of my patient.
Justice
It implies that all people should be treated fairly and available resources should be used equitably (Cohen, 2006).
The application of this principle was not implemented right at the beginning of this incident. Failure to facilitate this ethical principle has contributed to the conflict situations of this case. When patient is admitted to ICU the use of high technologies often may have the effect of unrealistic expectations (by family members) of what should be achieved at end-of life care. The respect for autonomy did not empower the patient’s right at the start and this leads to a breach in the justice principle. However, the doctor also has the right to apply that autonomy to exercise ethical belief in responsibly handling requests for inappropriate treatment (Fisher, 2004).
Outcomes of Reflection
Clinical situations that raise ethical questions are a challenge to navigate. Often, there are multiple clinical facts to consider. In addition, patient preferences and the concerns and values of family must be taken into account (Schumann & Alfandre, 2008).
Analyzing this scenario I am pretty sure that events on this specific case have some contributing factors which were not under my control. I felt it extremely difficult to be in a situation I know is hopeless but all available measures are being implemented to prolong a patient’s life and I am powerless to do otherwise. It is very distressfull for me especially if the patient that I cared for is a terminally ill patient. I can always relate it to my father who had liver carcinoma and died 3 months after the diagnosis. I know in my heart and how I wish I could turn back the time, that I would be able to look after him the way I look after my patient nowadays (I was still a student nurse by then). I can’t help but cry reading this lines. In the study by Wilkinson(1988) of situations in patient’s care that were associated with moral distress, prolonging life and performing unnecessary tests and treatment on terminally ill patients were mentioned and experienced more often by nurses. The feeling of dissatisfaction and distressed in providing end- of- life care includes the overuse of life-sustaining technologies, a profound sense of responsibility for patient’s welfare, and a desire to relieve suffering (Asch, 1996).The kind of care which I provided for this client was not influenced by her age or social status. In my quiet thoughts, I was convinced that this patient could have better and appropriate care if there was a proper referral system in place like getting in contact with the palliative care. This should have been done during her previous hospital admission as there was already a clear diagnosis at that time.
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The admission to ICU I believed was inappropriate as getting a NFR order could have been done in emergency department and comfort measures in place as soon as possible. The goal is to improve patient’s condition by alleviation of pain and suffering and we could reach this by working together and supporting each other. My practice is not perfect and there is always room for improvement. If I would approach this situation again for sure I would be more assertive. I think it is beneficial to explore other alternatives and encourage other coworkers or professionals to discuss the possibilities of different actions plus to decide together what would benefit our patient. After all, we are the most responsible for the care which we give to our client and if there is an indication that the care is not appropriate we shall make attempts or steps to provide better and more satisfying care.
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