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Stakeholders Facing Ethical Dilemma

Discuss about the Ethical Dilemma in Absence of Advanced Care Directives.

Ethical dilemmas are the part of life of healthcare professionals. They may have to make decisions and choices that can lead them to challenge their moral obligation towards their duty of care. Sometimes the wishes of the patient may not be acceptable for the nursing professionals, and to fulfill their duty of care they may have to make their own decisions. Ethical dilemma can also challenge the rights and dignity of the patients. Many ethical issues can come up in the case of advance directives. Many challenging situations can arise in the case of elderly care, and nurses must apply the professional guidelines to resolve the issues.

The essay is based on the case study of Elsie Lee, who is an 88 years old women and have been moved to Residential Aged Care (RAC). She had been facing many physical health issues due to which her mobility has been reduced, eyesight has diminished and also have a short term memory. She wanted that she requires no resuscitation and no aggressive treatments. She has displayed to sign the advanced directives. But, when she suffered severe chest pain, RN on duty sent her to hospital and attempted resuscitation. The ethical dilemma in this case scenario is that patient died and family claimed that due to stress of moving she died. The two main stakeholders involved in this case are RN and paramedics. This essay will discuss the ethical and legal dilemma with reference to given case study.

The main stakeholders involved in this case are RN and paramedics. According to patient’s family they are accused of going against the wishes of the patient and putting her into stressful situation, due to which she died. The ethical dilemmas can be very difficult and challenging for the nursing professionals. They have to maintain many value principles to stick to their duty of care. Advanced Care Directives in Australia are also called as ‘living will’. This kind of directive is a kind of document, which is filled with healthcare steps that patient would requires in certain circumstances (Scott et al, 2013). These directives are for the healthcare professionals, to be followed in the case, when patient is not in condition of making choices. This document can also designate a care giver or a family member to make important decisions.

Providing care to the older patients is very difficult and a complex job. The patient in the condition of end of life often prefers to sign the advanced directives (Heyland et al, 2013). Patients do not want to bother their family members and can deny for the invasive and aggressive treatments at the end of life. The care given at the end of life can be considered as inconsistent and patients may refuse to receive life sustaining treatments (Detering, Arnold and Dizon, 2014). In the absence of the advanced directive, patient’s desire to not employ resuscitation cannot be accepted. The ethical dilemma in the given case scenario for the nursing professionals and paramedics is that, patient requested them to not to transfer her to hospital and not to attempt resuscitation. But, RN said that patient has not yet signed the ACD, due to which she has to take invasive measures at the time of clinical emergency. Ethical dilemma can be choose between patient’s request and professional guidelines at the time of emergency.

Ethical and Legal Conflicts

With the enhancement in the medical and scientific knowledge and technology, the care for older patients has become more complex. The process of decision making about the end of life patients results in complex ethical dilemmas. In the given case scenario, RN made the decision to provide best treatment to the patient and ease her suffering. Perhaps, decision has to be made that whether treatment should be terminated, this is the situation making the case more complex (Detering, Arnold and Dizon, 2014).

Maintaining the dignity and rights of the stakeholders is very important in nursing practice. Older and end to life patients may face many complex situations regarding their treatment. However, according to professional practice, they are also considered as competent individuals, who can make their own decisions. They have the right to be equally valued. Their rights and dignity must be respected throughout their treatment. For the purpose of advanced care directives, it is important to make conversation with patient and family members and decisions should be made, which may be culturally safe and respecting patient’s dignity.

In the given case scenario, advanced care directive had not been signed by the patient, and no conversation about the care plan was discussed among healthcare professionals and family members. Though, patient had already made her choice and had informed her family members. Respecting the autonomy of the patient and family members is very significant, but it is not possible to always consider the choices of patients and professionals have to make conscious decisions about treatment (Detering, Arnold, and Dizon, 2014). Many patients make decision, when they are not capable of making correct decisions, and if the advanced care directive has not been signed till that time professionals have to make the decisions, which are in best interest of patients.

The principles and values of healthcare ethics state that at the end of life care, patient can choose hospice care. “A holistic and philosophical approach to end of life care, hospice brings doctors, nurses, social workers and other professionals together as a care team” (Punjani et al, 2014, p. 15). The goal of such care is to provide comfort to the patient and respect her decisions at the end of life care. The main emphasis of the hospice care is to mange symptoms, control pain and provide comfort to patient. The principles and values of healthcare ethics include the ethical code of conduct and ethical professional conduct. The principle of autonomy states that rights and obligations of the patient must be respected. It includes respecting the right of the patient to make decision about their treatment. This principle also states that rights of the patient also include having the correct information about their health status (Zahedi et al, 2013). Accoding to autonomy, patient can deny the treatment given to them.

Dignity and Right of Stakeholders

In the given case scenario, patient had denied for resuscitation and to be transferred to hospital, which was ignored by the RN in absence of advanced care directives. In the absence of the accurate care directives, professionals have to use their clinical judgment and must involve the family members and care givers and decision in best interest of the patient must be made (Brinkman-Stoppelenburg, Rietjens, and van der Heide, 2014). In this case patient’s autonomy could be preserved, but the best possible decisions are to be carried out. According to the principle of Beneficence states that decisions should be carried out to provide maximum benefit to the patient, which implies to make decisions for protecting their patients (Rajani, 2013). The principle of Non-maleficence states that no harm should be made to the patient. These two principles go hand in hand and decisions should be made in favor of patient and their family members (Punjani et al, 2014).

The principle of autonomy can interfere with the principle of beneficence. If the patient denied the treatment in the acute condition, the principle of autonomy states to respect their decision, but in this case principle of beneficence will be ignored and respecting the autonomy can result in patient’s death. If the treatment is carried out for the benefit of the patient, even after they refused, this situation will challenge patient’s rights and dignity (Punjani et al, 2014). Here is when nursing professionals are required to make decisions about the patient with reference to bioethical principles (Johnstone, 2015).

According to the code of ethics, it is the duty of the nursing professionals to recognize the human rights and dignity of the patients and must safeguard their dignity. For maintaining the quality of care, the nurses are accountable for making the decisions made by them. They must provide safe and competent care (Code of Ethics for Nurses, 2008). According to the given case study, Elsie is an old age patient in residential aged care, she has displayed the desire to sign advanced care directives, however she had not yet signed the directives and before that she suffered from severe attack. RN shifted her to hospital and attempted unsuccessful resuscitation (Rosenwax et al, 2011). This was done even when patient refused for any kind of treatment. However, the decision of RN can be considered as correct towards her duty of care and making responsible decisions.

The Principles and Virtues of Healthcare Ethics

Decision making in acute care setting can be very complex and difficult for the nursing professionals. They may have to make difficult decision, such as resuscitation must be given in the case of cardiac arrest or not (Adams et al, 2011). This is the time when professional code of conduct must be applied for the benefit of the patient, which states that decision making of the family members and care givers must be respected in complex situations. Nurses and healthcare professionals are accountable for practicing competent and safe care for the patient (Code of Professional Conduct for Nurses, 2008).

The ethical principles of nursing practice states that autonomy of the patient must be respected and if the patient is able to communicate the refusal or concern about the treatment then it should be respected. This decision must be respected in the case of interventions that include CPR or resuscitation. The patient is considered to be competent, till the time they are not declared as incompetent by court (Hebert, Moore, and Rooney, 2011). According to the study of Hewitt, (2011), “In Australian Jurisdiction, a doctor responsible for treating a patient in hospital assumes the responsibility for deciding whether  or not the patient should be resuscitated” (p. 195). If the benefit of the resuscitation cannot be seen then resuscitation must not be attempted. Increasing the intensity of the treatment can be harmful for the patient, which happened in the case of Elsie Lee. The nursing professionals and other team members must work towards providing comfort from other means and refusal of the patient must be respected, even if the advanced care directives are not signed.

According to autonomy principal, patient can refuse to treatment. Physical contact with the patient should also ensure that it would not give rise to any legal liability, and thus autonomous decision of the patient must be respected. According to Australia law, where attempting resuscitation and aggressive treatment can be considered as unlawful; it is when the patient has refused resuscitation and when resuscitation is judged as futile. According to Hewitt, (2011) “Re T (Adult Refusal of Treatment 1992), 3 WLR 782; ( 1993)Fam 95 at 116 Butler-Sloss LJ stated that a decision to refuse medical treatment  by a patient capable  of making decision  does not have to be sensible, rational or well-considered” (p.199). Thus ethical and legal resolution for the situation must be to avoid resuscitation in end of life patients and if the patient is competent enough to refuse resuscitation or aggressive treatments. For ethical concern, decision of family members must be asked before making complex clinical decision in such patients.

Conclusion

Applying aggressive treatment and resuscitation in end of life patient can be a very difficult and complex decision. The paper is based on the case study of Elsie Lee an 88 years old woman, who desired to sign advanced care directives, but before that she had a cardiac arrest. RN on duty is accused of applying aggressive treatment against the choice of patient, which resulted in stressful situation for patient; and ultimately in her death. Paper discussed many ethical principles to focus on ethical dilemma. It is important to focus on the quality of care and maintaining the dignity and rights of patients. For this purpose paper also provides an ethical and legal resolution for the conflict.

Adams, J.A., Bailey, D.E., Anderson, R.A. and Docherty, S.L., 2011. Nursing roles and strategies in end-of-life decision making in acute care: a systematic review of the literature. Nursing Research and Practice, 2011.

Brinkman-Stoppelenburg, A., Rietjens, J.A. and van der Heide, A., 2014. The effects of advance care planning on end-of-life care: a systematic review. Palliative medicine, p.0269216314526272.

Code of Ethics for Nurses, 2008. Nursing and Midwifery Board of Australia. Accessed at: 27th October, 2016. file:///C:/Users/Master/Downloads/5_New-Code-of-Ethics-for-Nurses-August-2008.PDF

Code of Professional Conduct for Nurses, 2008. Nursing and Midwifery Board of Australia. Accessed at: file:///C:/Users/Master/Downloads/6_New-Code-of-Professional-Conduct-for-Nurses-August-2008-1-.PDF

Detering, K.S.M.J., Arnold, R.M. and Dizon, D.S., 2014. Advance care planning and advance directives.           

Genuis, S.J. and Lipp, C., 2013. Ethical Diversity and the Role of Conscience in Clinical Medicine. International journal of family medicine, 2013.

Hebert, K., Moore, H. and Rooney, J., 2011. The nurse advocate in end-of-life care. The Ochsner Journal, 11(4), pp.325-329.

Hewitt, J.E., 2011. " Do Not Resuscitate" orders in Queensland; Examining the need to obtain consent.

Heyland, D.K., Barwich, D., Pichora, D., Dodek, P., Lamontagne, F., You, J.J., Tayler, C., Porterfield, P., Sinuff, T., Simon, J. and ACCEPT (Advance Care Planning Evaluation in Elderly Patients) Study Team, 2013. Failure to engage hospitalized elderly patients and their families in advance care planning. JAMA internal medicine, 173(9), pp.778-787.

Johnstone, M.J., 2015. Bioethics: a nursing perspective. Elsevier Health Sciences.

Punjani, N.S., Bhanji, S.M., Mehgani, S.T. and Shah, M., 2014. Health care ethics–am I dying. International Journal of Endorsing Health Science Research, 2(1), pp.28-30.

Rajani, S., 2013. Compare & Contrast The Four Principles Of Healthcare Ethics. International Journal of Innovative Research and Development|| ISSN 2278–0211, 2(8).

Rosenwax, L.K., McNamara, B.A., Murray, K., McCabe, R.J., Aoun, S.M. and Currow, D.C., 2011. Hospital and emergency department use in the last year of life: a baseline for future modifications to end-of-life care. Med J Aust, 194(11), pp.570-573.

Scott, I.A., Mitchell, G.K., Reymond, E.J. and Daly, M.P., 2013. Difficult but necessary conversations—the case for advance care planning. Med J Aust, 199(10), pp.662-6.

Zahedi, F., Sanjari, M., Aala, M., Peymani, M., Aramesh, K., Parsapour, A., Maddah, S.B., Cheraghi, M.A., Mirzabeigi, G.H., Larijani, B. and Dastgerdi, M.V., 2013. The code of ethics for nurses. Iranian journal of public health, 42(1), p.1.

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