Decision making in an ethical dilemma circumstances could be difficult at time as one is prone to use similar past experience as a yardstick to analyse the circumstances. McGhee and Perrin (2008), define ethical dilemma as a situation that gives rise to conflicting moral claims resulting in disagreements about choices of action. Therefore using a framework as a tool to guide one through the ethical dilemma would aid in arriving a client-centred decision. This paper aims to look into Ranjit’s decision to die in his own home instead in a hospital as requested by his children using the model for ethical decision making by Kerridge, Lowe and McPhee (2005).
Clearly state the problem
Ranjit, a 77 year old man diagnosed with Parkinson’s disease lost his motor functions. He prefers to be cared and die at home however his children are concerned about not being able to meet his needs as they do not possess with necessary skills to handle his disease if he deteriorate.
Ranjit may have Parkinson’s disease however it does not limit his freedom to make his own decision. Therefore the ethical issue is raised in contradiction of his autonomy.
No one is able to care for Ranjit when his condition required more attention, therefore a caregiver is required if Ranjit wish is passed through.
Ranjit is of a legal age in the eye of the law; he is capable to make sound decision for himself. His diagnosis may lead others to make baseless assumption about his capability to make a decision.
Get the facts
Parkinson’s disease is defined as chronic neurodegenerative disorder, which is related to loss of dopaminergic neurons in the substantia nigra. Symptoms such as tremor, brandykinesia and rigidity present in early stage and later stage non-motor features including autonomic dysfunction, falls, and sleep disturbances as loss in non-dopaminergic areas (Ministry of Health, 2007). According to Hoehn and Yahr (1967), Parkinson is classified into five stages, from stage one tremor over one limb to stage five confinements to bed. The prevalence rate in Singapore was found to be 0.3% for the population aged 50 and above (MOH, 2007). People with Parkinson do not only experience distress with their own movement, but the increasing motor deficit also diminishes their ability to express, communicate and interact with others (Doyle Lyons, Tickle-Degnen, Henry, & Cohn, 2004). Disability is seen more prominent as the disease progresses, caregiver may experience strain, burnout or financial burdened (Tan 2013). Therefore communication is critical for patient and caregiver to discuss openly about the disease, understanding their frustrations will help them to live with the disease (Chiong-Rivero et al., 2011).
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Although with pharmacotherapy can improve the quality of life ancillary approach in managing disease cannot be overlooked. Utilisation of rehabilitation services for Parkinson patients will go a long way to keep them active within the community to prevent isolation and depression. Occupational therapy can be involved in teaching client and care givers in coping with activities of daily living. Physiotherapist can be involved in gait training and strengthening muscles to prevent falls. Caregivers can consider sending Ranjit to various alternative services such as Agency Integrated Care (AIC), day care centre or respite care.
Consider the four principles
Autonomy is defined as the freedom and ability to exercise one’s choice and the ability to decide for oneself. The principle in autonomy is to respect a person’s decision, privacy and confidentiality and receive full disclosure (Staunton and Chiarella, 2008, p. 31; Butt and Rich, 2008, p. 42). His children are against Ranjit decision to be cared and die at home, despite his disease his right to choose should not be stripped off. As healthcare provider it is important to respect and promote client’s autonomy (Singapore Nursing Board (SNB) Code of Ethics and Professional Conduct, 1999, p.4).
Beneficence is described as taking action to help other; the desire to do good (Butt and Rich, 2008). The nurse would advocate client’s interest accordance to SNB Code of Ethics and Professional Conduct (1999, p.8) value statement 7, to promote client’s best interest by ensuring desires are acknowledge and considered by the healthcare team. The team shall consider Ranjit’s decision to be cared at home as it is deemed good for him.
Non- maleficence is defined as “above all, do no harm’ (Staunton and Chiarella, 2008). (ANMC) Code of Professional Conduct (2008) conduct statement 4 stated nurses to ensure the safety and quality of care are not compromised. If Ranjit’s decision was granted, a caregiver should be nominated to prevent harm at home such as fall.
Justice is based on the concept of fairness (Hendrick, 2000, p. 121). This suggests that one shall be treated fairly and be given equal chance to make decision.
Statement 2.3 under Australian Nursing & Midwifery Council (ANMC) National Competency Standards for Registered nurses (2006), to demonstrate respect for client’s legal right in relation to health care.
Identify Ethical Conflicts
Beneficence versus Autonomy
The first conflict to be addressed her is whether Ranjit should be cared at home or die in hospital. No doubt hospital is well equipped with equipment and healthcare team to provide a care plan for him till he die but however Ranjit has the right to refuse admission, treatment or care from the hospital. Therefore his primary treating doctor should provide a full disclosure on the disease process, risk and potential problems to allow him to make an autonomous choice.
Beneficence versus Non Maleficence
The second conflict here is his children perceived hospital is the best place for him as they do not have the necessary skills to look after him. However what seem to be best may not be as it place Ranjit at risk for acquiring infection or develop depression to his wish rebuked.
Non Maleficence ethical principle here is involved if Ranjit’s decision is approved by his children. Due to the lack of care at home, he may be faced with potential issues such as falls, pressure sores and chest infection.
Consider the law
Mr Ranjit has the mental capacity to take consent as evidenced by his active commitments with various activities. His consent may be deemed valid if he is able to understand and retain information and communicate his decision as stated in Mental Capacity Act (2008).
Right to refuse treatment
As the children wanted him to be institutionalised, Ranjit can refuse admission to a hospital or a nursing home.
An advance medical directive (AMD) an Act to provide for, and give legal effect to, advance directives to medical practitioners against artificial prolongation of the dying process and for matters connected therewith (Advance Medical Directive Act, 1996). Mr Ranjit may consider AMD to safeguard his wishes, case he became unconscious or terminally ill.
Making the ethical decision
Ranjit’s decision to be cared at home should be granted as he is competent to make his own decision and what is deem best for his interest. Family conference involving patient’s treating doctor, patient and his family may be helpful in this circumstance to hear from individual’s perspective to reach a conclusion that may benefit all. However the ultimate decision is still on Ranjit thus his children should respect his decision and look for alternative revenue to provide care for their father.
Document the decision
In accordance to statement 6.3 of ANMC National Competency Standards for the Registered Nurse (2006), Documentation must be written clearly and concise to provide accurate assessments. Therefore it is important for nurses and doctors to document all discussion shared as evidence to prevent unnecessary miscommunication.
Evaluate the decision
Ranjit’s care plan will need to be evaluated when there is a change in his condition or needs (ANMC National Competency Standards for the Registered Nurse statement 8.2, 2006). As Ranjit is able to make an autonomous decision to be cared at home, his children can employ a caregiver to be home to look after the father, the care plan will need to be evaluated every three months to better support and meet his needs.
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