Ethical dilemma in aged care setting can be very challenging for the healthcare professionals. There are many situations where healthcare professionals find themselves stuck in ethical and moral complication. This essay is going to discuss the ethical dilemma in the given case scenario of Elsie Lee. She is an 88 years old woman, who has been shifted to residential aged care setting. She has impaired physical mobility due to severe rheumatoid arthritis. She also suffers from vision impairment and short term memory. Such patients are more dependent on nursing professionals and may have specific care needs.
Elsie also considers making an advanced care directive (ACD). Patient desires to make advanced care directive, so as to indicate that what kind of treatment should be given if her health deteriorates. Elsie was waiting to meet her family on Sunday and discuss it advanced care directives with her family, as she was keen to make it clear to the staff that she does not require any aggressive treatment and does wanted o be resuscitated. But, on Friday she suffered a serious chest pain and RN called the ambulance, and even after refusal from the patient, unsuccessful attempt of resuscitation was made. In the hospital the patient was declared as dead. The ethical dilemma aroused for RN and paramedics that resuscitation should be given and patient should have been shifted without consent or not.
The stakeholder involved in the ethical dilemma re nursing professionals and paramedics, because they had to decide whether aggressive treatment be given to end of life patient to fulfill principle of beneficence or to respect the autonomous decision of the patient. Ethical dilemmas can leave the nursing staff in a situation where they have to decide in moral obligation and dignity of patient. Thus, end of life care becomes very complicated, but his may not be in the mind of the healthcare professionals when patient is admitted to residential care setting, but it can provide a way for future interventions.
Case scenario of Elsie, puts the nursing professionals and paramedics in the ethical dilemma, and they are accused for assault and battery. Advanced care directives can help the person to plan their future personal and healthcare needs, if they may not be able to communicate their needs in severe health conditions. Advanced care directives, work as the important document that designates a person to make decision of behalf of patient in sever conditions. However, in the case of Elsie, advanced care directive had not yet been signed and thus, RN believed that transferring the patient to the hospital would be in best interest for her. There are also many ethical issues associated with providing treatment to older people, as some of the aggressive treatments could increase their suffering and withdrawal of such measures can result in quality death.
Elsie did not wanted to bother her family members and wanted to have peaceful death, thus she wanted to refuse aggressive treatment measures. However, the ethical issue arises due to communication barrier. Elsie was not able to communicate her needs to the professionals. Advanced care directives had worked as a important factor in providing care to Elsie, if it has been signed, but the situation still questions the autonomous decision of patient. At the end of life, treatments could be inconsistent and patient can refuse aggressive measures. Here the principle of autonomy contradicts with principle of beneficence and ethical dilemma for the healthcare professionals arises.
The nursing code of ethics states that rights and dignity of the patient should always be respected and preserved. Before making any clinical decision, the rights of patients must be considered. Every intervention or treatment must be taken in accordance to patient’s decision. The Australian Healthcare system is based on providing patient centered and family centered approach, which state that personal values, belief and choices of patients and their family members must be respected. Legal rights and human rights allow a person to make their own choices for their treatments. The patient and the care givers equally have the right to dignity. The dignity of the patients can be safeguarded, when nurses have the responsibility and accountability of applying appropriate professionals ethics (Code of Ethics for Nurses, 2008).
The responsibility of resuscitation on patient depends upon the doctor. They are in correct position to decide whether patient should be resuscitated or not. But, prior to performing any kind of medical treatment, healthcare professionals and nursing staff must take the consent of the patient. This process must be done considering ethical, legal as well as all cultural paradigms (Hewitt, 2011). In case the patient has refused for the measure being taken, it is important to consider their request and to apply alternate measures for fulfilling their duty of care. Significant importance must b e given to the family members and care givers, and decision should be made according to their concern. Decisions should be considering professional code of conduct and duty of care (Bollig et al, 2015). Communicating accurate needs are also important to take proper decisions. In case of Elsie, she had not informed the professionals about her concern and RN did not considered her request due to many clinical, communication and ethical barriers.
The virtues and principles of healthcare ethics are associated with four main principles of ethical practice. These four principles provided various bases for making ethical decision in nursing profession (Adams et al, 2011). The four principles of healthcare ethics are autonomy, beneficence, non- maleficence and justice. The first principle of autonomy is the main ethical principle, which implies that rights and dignity of patient are very important and for providing quality care, these rights must be respected (Sutrop, 2011). The model of decision making in clinical nursing practice is based on ethical principles. These principles are not legally defined, but they are meant to enhance quality of care (Beauchamp, & Childress, 2012).
The principle of autonomy must be respected to value the choices of patients. The principle of beneficence states that every intervention should be done to provide maximum benefit to the patient. The nursing practice requires making ethical decision to justify the quality of care (Suhonen et al, 2010). Thus informed decision making is considered to be important for benefit of the patient. Non- maleficence states that no harm should be done to the patient, or least harm should be inflicted by the treatment measures. This principle requires to be considered in decision making process. Family members must be involved in decisions and patient, who is competent to make choices, must be considered (Beauchamp, & Childress, 2012).
There could be conflict between the two ethical principles of autonomy and beneficence. A person is considered as competent to make decision about his or her health and to take part in decision making process, till the time they are not declared by the court as incompetent and proxy decision maker is designated (Crispin, Bestic, and Leditshke, 2015). In the case of Elsie, she was competent to make her choice about her treatment and was not completely unconscious. In the absence of the advanced care directives in case of Elsie, RN chose to make her own decision for the benefit of patient, considering the ethical principle of beneficence. Due to this situation, the autonomy of the patient and family members was challenged. Ethical dilemma aroused, when RN took her own decision and could not respond to needs and request of patient. Here autonomy and beneficence could be seen in conflict (Johnstone et al, 2015).
Shifting the patient to hospital without her wish may have created the stressful situation for Elsie, but as she was in severe pain the correct measure was to transfer her to emergency department. The decision making in such situation requires considering the principles of bioethics and referring to the evidence based studies (Crispin, Bestic, and Leditshke, 2015). However, as patient has already refused the treatment, nurse could have tried to make her comfortable in the residential care only and try to take alternative measures.
Code of professional conduct and code of ethics are meant to pave the way towards more enhanced quality care for patients, and to promote skills based practice for nurses. The code of professional conduct is the way in which the professional behave, while providing care to patients. The professional conduct states that “Nurses practice and conduct themselves in accordance with laws relevant to the profession and practice of nursing” (Code of Professional Conduct for Nurses, 2008). Thus, every decision must be in accordance to law and ethics, which saves patient’s dignity, values, belief and rights.
According to study of Deasy et al (2012) “paramedics are authorized to perform endotracheal intubation and can administer a wider range of cardiac drugs” (p. 59). They can also take telephonic assistance from other professionals regarding carrying out resuscitation. But, in the case of Elsie, paramedics conducted resuscitation, even when patient had requested to leave her as it is. Decision making can be very complex in such situations, as there are many uncertainties associated with resuscitation in older patients. The code of ethics, nurses must value the moral and legal rights of the patients and must respect their choices in decision making (Code of Ethics for Nurses, 2008). Cardiac arrest can occur in the patients with serious illness and history of cardiovascular problems. The pain can occur, even before the discussion about the resuscitation or other aggressive measures has been made between professionals and patient. The healthcare professionals have to decide that resuscitation must be given with patient’s concern or not. But, in absence of advanced care directives, it must not be assumed that resuscitation is the default measure for cardiac arrest. Thus,“Clinical judgment should be used, where resuscitation is manifestly inappropriate and or the patient is deceased” (Using Resuscitation Plans in End of Life, 2014, p. 7).
Ethical and legal consideration of all the invasive and aggressive measures in case of older patients should be significantly considered by professionals. End of life treatment for older patient may have different care needs and may prefer to die peacefully. The decision of the patient must be respected to avoid any kind of ethical conflict. It will be considered as unlawful to ignore the needs and desires of the patients (Bossaert et al, 2015). The nursing staff and paramedics can use alternate methods and measures to fulfill their duty of care. However, in absence of advanced care directives and resuscitations plans, the decision of aggressive treatment must be taken in best interest of the patient. The clinical decisions should consider the values, belief and request of patients to work n accordance to ethical principle of autonomy. According to Using Resuscitation Plans in End of Life, (2014) “planning end-of-life care is an iterative or cyclic process based on assessment, disclosure, discussion and consensus building with the patient and or their family and the treatment team (p. 4). Thus, involving family decision is very important and considering the patient’s refusal under Adult Refusal to Treatment Act (1993) must be considered to avoid legal conflicts (Herring, 2014).
Providing care to older patients in residential aged care setting can be very challenging and complex for professionals. This paper has focused on the case study of Elsie Lee, who is an 88 years old woman, who has been shifted to residential aged care setting, due to her increased demands for care. She has physical impairment and vision impairment and has the history of AMI. Nurse care manager suggested that Elsie wants advanced care directives to be so signed, but before that she suffered cardiac arrest. In spite of requesting RN to leave her as it is, she was transferred to hospital and paramedics applied resuscitation. Ethical and legal dilemma of ignoring patient’s autonomy arises and Family accused the services and professionals for assault and battery. However, the essay provides a legal and ethical resolution for the problem in future cases.
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