Introduction
An ethical dilemma is “…the need to choose from among two or more morally acceptable options or between equally unacceptable courses of action, when one choice prevents selection of the other” (Ong, Yee, & Lee, 2012). Everyday nurses face ethical dilemmas, but with each patient’s situation being different, their course of action must be based on what is best for that patient specifically. An ethical dilemma that interests me is the challenges that nurses face during end of life care when withdrawing life sustaining treatment. Throughout this paper I will identify this ethical dilemma involved in end of life care, people who are involved, my personal experience and beliefs, resources to assist nurses, and solutions to the dilemma.
Ethical Dilemma and People Involved
End of life care is a difficult time for patients, their families, and even health care workers who are involved. There are a lot of different opinions that surface when a loved one is dying and not everyone always agrees on what they think is best for the patient. During this time, it is important for the health care providers to have solid communication skills and be motivated in making decisions. Patient centered care and autonomy is an ethical priority when tending to a dying patient. From a medical and ethical standpoint, withdrawing and withholding life sustaining treatment may be in the best interest for the patient who is nearing the end of their life. For instance, if an intervention will not benefit the patient or achieve the planned goal, it is pointless and not required medically, legally, or ethically for the patient to receive this intervention. The medical goal needs to be practical for the specific patient and something that they can reasonably accomplish. The healthcare providers, patient, and family typically put a time period to an intervention so if it works then they will continue to use it, but if no positive outcomes are shown then it is withdrawn or withheld. On the other hand, it is pertinent for a patient to be withdrawn and withheld from treatment if they or their healthcare power of attorney no longer want it to be administered.
According to, Ethical Issues at the End of Life, “The most frequent issues that are encountered in the management of patients near the end of life is the decision to withdraw or withhold cardiopulmonary resuscitation, elective intubation and mechanical ventilation, and artificial nutrition and hydration” (Cavalieri, 2001). When withdrawing and withholding artificial nutrition and hydration (ANH), it becomes difficult and tricky legally and ethically. Some healthcare workers view it as a required mandatory care, where others may view it as another medical intervention for patients. As stated in, Ethical Decision Making With End-of-Life Care: Palliative Sedation and Withholding or Withdrawing Life-Sustaining Treatments, some people think that it is essential for patients during end-of-life care that cannot eat or drink to receive ANH and that terminating it may be the reason of the patient’s death (Olsen, Swetz, & Mueller, 2010). On the other hand, some people believe that pursuing ANH is an unwanted tribulation that has shown no evident aid. All of these interventions are ethically justifiable to withdraw once the medical goal can no longer be accomplished and this decision is compatible with the patient’s desires.
My Personal Experience
My experience with withdrawing and withholding life-sustaining treatment is related to my great grandfather who had skin cancer and was taken into hospice care. My great grandmother is still alive and was his healthcare power of attorney. My great grandparents had talked about what they wanted for themselves in life or death situations, but I know that those decisions are still hard to make no matter what. When my great grandfather initially found out about is cancer, he wanted every life sustaining treatment done if a situation arose. Although, as the months passed he became sicker and eventually changed his mind and did not want any life sustaining treatment like cardiopulmonary resuscitation (CPR), ANH, or mechanical ventilation. This was a hard pill to swallow for my family because we were watching him degrade in front of our eyes. My great uncles and my grandma were not happy with the decisions that my great grandparents were making, but they new that it was what they both wanted for each other. When he was placed at a hospice care facility, the only intervention he received was a PCA pump to help with the pain. His appetite decreased and eventually he stopped eating and drinking, which decreased his output. Within a week of him being at the facility, he began sleeping majority of the day and ultimately passed away.
My Personal Beliefs
I personally believe that everyone has the right to his or her own decision and it is important to respect it even if you don’t agree. I use and value ethical principles in my everyday life and I believe it is essential to always have them in the back of your mind, especially with this ethical dilemma. I believe that nurses need to ensure patients are staying autonomous by making their own decisions and not being coerced by healthcare professionals or family. I feel as though nurses should provide equal and fair care to every patient by advocating for their patients dying wishes. A major core belief that I have is that nurses should provide care in the best interest of what will benefit the patient the most. They need to do this in a way that is not conflicting with the patient’s rights to self-determinate because as I stated before, it is their life and at the end of the day they should make their own decisions.
Resources to Assist Nurses
Nurses need to know that resources are available to them during ethical dilemmas and that they are not alone in making decisions. Examples of resources include:
- Accustomed to the American Nurses Association’s code of ethics
- Reviewing legal material and hospital guidelines correlating to the dilemma
- Schedule an ethics consultation
- Ask mentors or supervisors for their perspective
- Contact professional ethics associations and/or committees
- Participate in employee counseling services if available
When a nurse is dealing with an ethical dilemma, they need to assess and evaluate the situation. As stated before, each patient is different so the nurse needs to understand the circumstances and background that make up why the patient is deciding this. A nurse’s role is very powerful when handling an ethical dilemma. The nurse should put their personal beliefs to the side, respect the patient’s wishes, and provide the best patient care. When communicating to patients and their family, staying professional is key during times of distress because it allows them to create a trusting relationship. The nurse should advocate for their patient by helping them make informed decisions by breaking down the medical terms and explaining in a way they will understand. Also if a patient’s family opposes the patient’s choices, the nurse needs to make the patient a priority and assist their needs.
Solutions to the Dilemma
I don’t believe there is one right solution to this ethical dilemma, but I think that we can steer clear or decrease the amount of issues that come along with it in the future by the choices we make today. A way that can be done is by the nurse recognizing the issue and collecting as much pertinent information about the ethical dilemma. After dissecting the information, the nurse should determine if additional resources are needed to help with the problem. The nurse should distinguish who has the authority and dominance in the circumstances and what the nurse can and cant sway. It may help the nurse to formulate a list of potential steps they plan to take and the pros and cons that follow. The nurse should conduct a plan and take action that shows professionalism medically and ethically. Throughout this whole process, good communication with healthcare professionals, patients, and their families is needed. Also educating and talking to patients and their families about ways to plan end of life care in advance can alleviate some of the ethical issues when the time comes (Nyman & Sprung, 2000).
Conclusion
In end-of-life care, withholding and withdrawing life sustaining treatment has shown to be an ethical dilemma nurses face often. It becomes a complicated and heavy situation when the patient, family, and health care providers do not all see eye to eye on decisions. The most common life sustaining treatment that is withdrawn and withheld is cardiopulmonary resuscitation, elective intubation and mechanical ventilation, and artificial nutrition and hydration (Cavalieri, 2001). In my personal experience, my great grandfather denied all life sustaining treatment and not everyone in my family agreed with this choice. I believe that you have to put your opinions to the side and listen and respect what someone plan to do with their end-of-life care. There are multiple resources for nurses to turn to when in an ethical dilemma and the way they react to the situation is very powerful. I think that the steps to find a solution in this ethical dilemma may be similar for all patients, but I do not believe that every patient’s results will be the same.
References
- Cavalieri, T. A. (2001). Ethical Issues at the End of Life. JAOA Special Focus
- Section, 101(10), 616–622. Retrieved from https://jaoa.org/article.aspx?articleid=2092415.
- Nyman, D., & Sprung, C. (2000). End-of-life decision making in the intensive care
- unit. Intensive Care Medicine, 26(10), 1414–1420. Retrieved from https://www.atsjournals.org/doi/full/10.1164/rccm.201001-0071CI?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed.
- Olsen, M., Swetz, K., & Mueller, P. (2010). Ethical Decision Making With End-of-Life
- Care: Palliative Sedation and Withholding or Withdrawing Life-Sustaining Treatments. Mayo Clinic Proceedings, 85(10), 949–954. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2947968/.
- Ong, W. Y., Yee, C. M., & Lee, A. (2012, January). Ethical dilemmas in the care of
- cancer patients near the end of life. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/22252176.
