Ethics PresentationAmy, Ashli, Clarissa, Jen

N362, Fall 2014

VIEW POINTS

Patient Physician Family Nurse

Ethical Dilemma Case 5

Tom is a 56-year-old man with a history of chronic renal failure and diabetes. He suffered a respiratory arrest and was on a mechanical ventilator for 3 weeks. He was successfully weaned from the ventilator but he suffers irreversible brain damage due to hypoxia. He currently receives tube feeding with some water four times a day to maintain hydration and nutrition. He has an advanced directive that is in his private physician's medical record. A niece confides to the nurse that her uncle did not want to survive being a “vegetable” and "unable to do anything for himself." She believes this is expressed in his directive. However, the primary physician who is a personal friend of the family is reluctant to discuss this as the immediate family (wife and children) wants all measures to keep him alive. Wife has durable power of attorney for medical decisions. The niece asks you to help adhere to her uncle's wishes.

1. IDENTIFY ETHICAL ISSUE AND PROBLEM

2. IDENTIFY AND ANALYZE ALTERNATIVES FOR ACTION

3. SELECT ONE ALTERNATIVE.

4. JUSTIFY THE SELECTION

Ethical Decision Making Model(Cherry & Jacob, 2008)

ETHICAL ANALYSIS

PATIENT● Autonomy: Personal freedom and right to make choice ● Patient Self Determination Act 1990: required to inform pt

of right to make healthcare decisions and to have an advance directive to state wishes.○ Durable Power of Attorney: make decisions when pt incapable

to do so.

FAMILY ● Struggle with personal emotions and pt’s wishes.

● Guilt of feeling responsible for loved one’s death.● Possible chance of recovery.● Need to preserve family well-being during stressful time

(conflict).(Schenker, Y., Crowley-Matoka, M., Dohan, D., Tiver, G., Arnold, R., & White, D., 2012)

ETHICAL ANALYSIS

PHYSICIAN● Fidelity: keeping promise, truth.

● Integrity: acting in accordance with an appropriate code of ethics.

○ Responsible to determine pt’s medical decision making capacity and when implementation of proxy is needed.

NURSE● Non Maleficence: do no harm. ● Beneficence: doing good

● Autonomy: Pt’s right of freedom to choose. *Should confirm advance directive at physician’s office and should have on file at hospital.

(Cherry & Jacob, 2008)

ANA Code of EthicsProvision 2 The nurse’s primary commitment is to the patient, whether an individual, family, group, or community.

2.1 Primacy of the patient’s interests - The nurse’s primary commitment is to the recipient of nursing and health care services --the patient-- whether the recipient is an individual, a family, a group, or a community. Nursing holds a fundamental commitment to the uniqueness of the individual patient; therefore, any plan of care must reflect that uniqueness. The nurse strives to provide patients with the opportunities to participate in planning care, assures that patient’s find the plan acceptable, and supports the implementation of the plan. Addressing patient’s interests requires recognition of the patient’s place in the family or other networks of relationship. When the patient’s wishes are in conflict with others, the nurse seeks to help resolve the conflict. Where conflict persists, the nurses commitment remains to the identified patient.

Ethical ViolationPHYSICIAN violating ethical principle of Fidelity and Autonomy by withholding information on pt’s advance directive, if advance directive clearly states

A. No I do not want to prolong my life.B. No I do not want artificial nutrition and hydration by tube into stomach or vein.

*Personal friendship shouldn’t interfere with professional obligations

DilemmaIf patient does not fall under above category, wife who has durable power of attorney is able to make medical decisions that may not be in line with patient’s wishes.

ALTERNATIVES

● Assign power of attorney to a trusted person. Sometimes a spouse or son/daughter will find it difficult to comply with your decision not to prolong life.

● Discuss wishes and what is important to you regularly while you are healthy (before a medical emergency occurs).

● Inform doctor, family, and friends that your advance directive is available and you want them to honor your wishes.

● Advance directive:○ copy at home (easy to find place)○ medical records○ designated on Hawaii Driver’s License or State ID○ register at www.mydirectives.com (free, easy to update and

share, own video response available).○ http://www.kokuamau.org/professionals/polst

(Advance healthcare directive form, 2014)

MORE ALTERNATIVES

● Ignore the knowledge of the advanced directive and allow the family/wife (durable POA) to continue to make decisions for the patient.

● Obtain a copy of the advanced directive form from the physician’s office and deliver care based on patient’s wishes as listed in the AD to ensure autonomy.

● Obtain a copy of the advanced directive form from the physician’s office and share the information with the family.

Scholarly Articles - Key PointsCare at the end of life: how policy and the law support practice (Brown & VAughan, 2013)

● “Advanced directives are arguably the best way to ensure personal wishes surrounding care are respected…”

● “A failure to respect a valid advanced directive can result in a claim for battery being made against the clinician.”

● “If not recent, there is a need to ensure the patient’s wishes have not altered” once a terminal diagnosis has been made.

● “An advanced directive optimizes the chances of empowering the patient to make it clear what they would and would not want as they near the end of their life.”

● “All decisions made in the patient’s best interest still have to consider the patient’s values, attitudes, and beliefs.”

● “The Mental Health Act Code of Practice states that any staff involved in care-giving to a patient who lacks capacity should make a record of the process of working out the best interests of the patient for each relevant decision.

Scholarly Articles - Key PointsDoing the Right Thing: A Geriatrician’s Perspective on Medical Care for the Person with Advanced Dementia (Gillick, 2012)

● 62% of American’s have not taken steps to designate a health care proxy to make medical decisions for the in the event of incapacity and they have not drawn up a living will to guide their physician’s care and practice

● Balanced perspective is necessary in ethical decision making….factoring in both the patient’s previously expressed wishes (respecting autonomy) and the current reality (respecting beneficence)

SOLUTION

Nursing responsibilities:

-helping the patient to remain in control.

-facilitating responsible decision making.

-requesting an ethics consultation.

-requesting palliative care consultation.

-thorough documentation of the decision-making process and actions taken.

Dr. gives wife copy of advance directive w/ pt wishes. Carry out patient care according to patient’s desires as listed in the AD.

References

Advance directives. Retrieved on November 3, 2014 from http://www.nlm.nih.gov/medlineplus/advancedirectives.html

Advance healthcare directive form. Retrieved on November 3, 2014 from http://health.hawaii.gov/eoa/files/2013/04/AHCD.pdf.

Brown, M., & Vaughan, C. (2013). Care at the end of life: How policy and the law support practice. British Journal of Nursing, 22(10), 580-583.

Cherry, B. & Jacob S. (2011). Contemporary nursing - issues, trends & management, (5th ed.). St Louis: Elsevier Mosby.

Code of Ethics for Nurses With Interpretive Statements. (n.d.). Retrieved November 2, 2014, from http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics.pdf

Gillick, M.R. (2012). Doing the right thing: A gertiatrician’s perspective on medical care for the person with advanced dementia. Journal of Law, Medicine & Ethics. 40(1), 51-56.

Schenker, Y., Crowley-Matoka, M., Dohan, D., Tiver, G., Arnold, R., & White, D. (December 2012). I don’t want to be the one saying “We should just let him die”: intrapersonal tensions experienced by surrogate decision makers in the icu. J Gen Intern Med. 27(12): 1657–1665. doi: 10.1007/s11606-012-2129-y