The purpose of this essay is to identify an ethical dilemma in the case of end of life patient. The essay will focus on the case scenario of Harry Nelson, who is suffering from the end stage cancer. He has exhausted all the treatment options and currently he is receiving palliative care at his home. Harry has not prepared his advanced care directives. Harry’s condition is significantly deteriorating and he finds difficulty in swallowing food and fluids. Harry is alert and completely aware about his condition and it is his wish to die at his home. However, his daughter Stacy believes that her father’s life can be longer if he receives further treatment in the hospital. The ethical dilemma in this case scenario is that Stacey calls the ambulance. The crew arrives but the conflict between Stacey and her father could not be resolved and crew transports Harry despite of his objection. The ethical dilemma is that patient has been transported to hospital against his wish, even when he fulfills the criteria for the treatment. Therefore, this essay will discuss this ethical dilemma in detail and will provide the legal and ethical defensible approach with the support of relevant principles of health care ethics, professional code of ethics and code of professional conduct.
The ethical dilemma identified in the given case scenario I the Harry do not want to receive further treatment in his last stage cancer and wants to peacefully die at his home. But, his daughter is under stress and wants to send his father to receive end of life care in the hospital. The ambulance crew was called by Stacey, as she believed that her father could live longer if he receives further treatment. However, the actions taken by Stacey and ambulance crew were against the wishes of Harry and ethical dilemma occurred when crew transported Harry even after his objection. The case scenario also explains that harry was alert and completely aware of his condition. This means that patient is competent to take his own decision. The patient is responsible for taking their own decision till the time court has not announced the patients is incompetent to take his decision and had not appointed any decision maker for patient (Willmott et al, 2014). Patient has also not shown any suicidal intentions behind not continuing the treatment. Therefore, he is not even considered under the Mental Health Act of Australia.
Competency is considered as the key component of the patient’s consent (Sweet, 2014). The law surrounding the competency of the patient in end of life may be difficult to establish, but it is the duty of the health care professionals to respect the right and decision making of the patient (Mason, 2013). The condition of the patient is not treatable and the further treatment can ineffectively prolong the process of dying. According to the s 36(2) of the Guardianship and Administration Act 1986, a person is considered to be incapable of giving the consent, if they are incapable of understanding the nature of the treatment and if they are incapable of indicating about their consent. However, in the case of Harry, he has been alert and aware of his condition, and he already had been exhausted all the treatment options. Further treatment will only remain as the life prolonging treatment which will not improve patient’s condition.
According to the definition of a competent patient, “a person should be considered competent to make a health care decision if they appear able to comprehend, retain, and weigh up the relevant information and then make a choice” (Roth, 2014). The common law also states that a person should be presumed to have the decision making capacity unless there are evidences of the incompetency of the patient or the court has declared the patient as incompetent.
Harry’s daughter Stacey is also not appointed as the guardian or administrator for her father. Therefore, the decision making power remains in the hands of Harry. The patient cannot be transported without his or her consent, as forcefully removing the patient and transporting them is considered as assault. The common law of Australia supports the rights of the older patients, who have the capacity to make decision about their health and body (Mason, 2013). It is unlawful to treat the patient or force the patient without their consent. Disrespecting the consent is considered under the law as the crime and a tort. According to the Medical Treatment Act 1988, 2010), the competent adults can refuse the medical treatment even if the refusal of the procedure or the treatment can pose the serious risk to their life. This act significantly supports the provision of informed consent.
According to the study Steer (2015), consent can be defined as the “to give assent, permission or agreement”. From the ethical perspective and ethical healthcare practice consent is considered as the fundamental element of care. Consent is universally associated with patient’s autonomy and self determination (Steer, 2015). The consent of the person is important for respecting the rights of the patients and exercising their will for decision making. Consent of the patient is also important from the legal perspective. The role of the ambulance crew and the paramedics is to treat and transport the patients, it is very important that they receive the consent of the patient. However, in the case of Harry, his consent was not respected that significantly disrespected the autonomy and self determination of the patient. According to Steer (2015), “It is a fundamental principle that to treat someone who is capable of giving consent to treatment, but has not done so, is an assault.”
Due to this ethical dilemma the principle of autonomy of the patient has been challenged. It is the duty of the health care professionals to respect the decisions of the competent patients till the time he has not provided advanced care directives. The end of life treatment can be futile for the patient and may only cause more suffering and pain. Advanced care directive can be considered as the “A document that describes one’s future preferences for medical treatment in anticipation of a time when one is unable to express those preferences because of illness or injury (has also been called a ‘living will’” (Roth, 2014). Advanced care directives are very important for maintaining the dignity of the patient, through which people make future treatment decisions and can make arrangements for future, so that they can die with dignity (Richards, 2010).
According to the study of Ashcroft et al (2007) respect for the autonomy has been deeply rooted in the political and moral traditions. It also displays the absolute freedom and choice of the individual. The principles of bioethics also provide the moral framework for decision making in the health care system. Autonomy means freedom from the external pressure and constraints, personal self governance, and staying free from the control and interference of others (Beauchamp, 2007). Respecting the common autonomous choices of the people is a moral principle, which in health care system is determined through informed consent and refusal of the treatment (Bingham, 2012). The autonomous individual is free to make their personal choices regarding the treatment or refusal of the treatment. Informed consent and respecting the autonomy of the patient is a very important ethical principle.
From the ethical perspective, the right to refuse displays the principle of autonomy. The ethical principle of autonomy is equal for all the individuals and every patient must be allowed to withhold their autonomy. The freedom to disagree or refuse should be accepted till the time patient has been in permanent vegetative conditions, or have provided the advanced care directives for certain treatment options. National Patient Charter of Rights supports the rights of the patients to safe and quality care. The charter provided the 8 key rights to the patients, which also includes the respect, dignity and consideration of the patient choices. Patient should be respected and dignity should be maintained for the patients who are terminally ill, those who are receiving palliative care and those who are competent. The services provided to such patients should be dignified, supportive and comforting (Draft National Patient Charter of Rights, 2008).
According to the Australasian Competency Standards for Paramedics (2011), the paramedics have to work in accordance to legal and ethical boundaries of their profession. They have to practice according to their code of conduct and their code of ethics. According to this code or the competency standard, the ambulance crew including the paramedics must acknowledge the rights of the individuals for autonomy and for self determination towards care (Good Medical Practice, 2009). They are also required to indentify and resolve the conflicts through personal initiatives. Paramedics are also required to understand the principle of consent and how it can be applied to emergency services (Australasian Competency Standards for Paramedics, 2011).
In case of the family members, it must be understood that a right claimed by a person is not a right that they own. The people should be able to distinguish between the rights that are enforceable by the law, such as maintaining the confidentiality, and the right, which is not enforceable by the law, which includes the right of providing the second opinion (Crigger et al, 2015). Relative or family members have no right to determine the medical treatment against the wishes of the patient, who has the legal capacity to provide consent. The relatives cannot dictate that how they cast the vote. The relatives can be consulted to provide the clear picture for the patient, but can’t make decisions on their behalf till the time they are legally authorized to do so.
They can provide their view and can make a decision in the case where patient is unable to do so. Only the authorized person can make decision on the behalf of the incompetent adults otherwise it is unlawful to force the decision on the competent patients (Steer, 2015). In this case it is important to understand that wishes of the patient should be the main priority and it should be assumed that all the conditions for informed consent have been fulfilled. Australian Human Rights Commission also provides the right to self determination to people. In the case of Harry the professionals do not have any duty to provide the life prolonging futile treatment. Therefore, the self determination of the patient provides the right to refuse or disagree with any treatment.
According to the given condition of the patient, any kind of treatment is futile. However, professionals do have the duty of care towards the treatable conditions. It is because the provision is futile treatment provides no benefits to the patient, but increases the unnecessary harm (Willmott et al, 2016). In this regard The Medical Treatment Act can be considered to be important that provides the provision of declining the treatment for terminally ill people. In the given case scenario there has been a conflict among the values and belief of the patient and her daughter. Resolving the value conflicts among the relatives and the patients is not the practice provision of the paramedics; however, the neutrality is impossible in this scenario. The paramedics must have made the choice between the competing values of relative and patient. It can be seen that patient is merely being removed and not helped. He has been harmed or uselessly being bothered, which is in contrast with the ethical principle of Non-Maleficence (‘do no harm’). The paramedics must perform the practice conduct and should focus on helping patient and not their relative (Sweet, 2014). Paramedics also have the right to refuse to serve the third person other than the patient, because the primary duty of care is towards the patient.
This paper is based on the case study of Harry Nelson and provides the detailed discussion regarding the legal and ethical principles associated with the ethical dilemma in the case. Discussion in the paper has been supported with appropriate evidences, laws and ethical principles.
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Futility and the law: Knowledge, practice and attitudes of doctors in end of life care.
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