Describe about food and nutrition support refusal at the end of life.
This research paper focuses on the discussion related to the significance of ethical, legal and moral rights and obligations of the nurse practitioners in a professional environment across the healthcare setting. The paper also emphasizes the ethical dilemma, legislative issues and ethical conventions like utilitarianism, deontology, autonomy and justice in relation to the requirement of nutrition administration to patients during the advanced stages of their debilitating and life threatening disorders. The paper discusses the evidence-based findings regarding the results of the violation of human rights and ethical principles and their adverse implications on the healthcare professionals. The significance of NGT (nasogastric tube) administration for accomplishing the nutrition and hydration needs of the patient emphasized in the context of Beauchamp and Childress’ principles of maleficence and non- beneficence. The prospective recommendations regarding the effective resolution of an ethical dilemma related to nutrition administration at the end of life provided for their implementation in the nursing practice. This aspect of confidentiality considered and maintained throughout this assignment in accordance with the Nursing and Midwifery Code of Conduct (NMC, 2015). The pseudonyms “Susan” and “Julie” utilized for indicating the patient and her daughter throughout the length of this research paper.
Evidence-based research literature describes the process of nutrition in terms of the provision of administering nourishment for maintaining the well-being and development of the treated patient (Vander, et al., 2008). McLaren (2006) considers the hydration and nutrition as the basic human necessities warranted for accomplishing the psychosocial, cultural and biological requirements of individuals. Nutritional management is highly effective in providing immunity to patients during the process of infection treatment and surgical intervention and promotes the process of wound healing (Leaker, 2013). The term “nutrition” in the clinical setting attributes to the nutritional solution administered to the treated patient with the effective utilization of NGT (nasogastrictube), IVL (intravenous line) and IGT (intragastric tube).
Great Britain House of Lords (1993) advocates the requirement of administration of ANH (artificial nutrition and hydration) in accordance with the legislative conventions. Contrarily, if the nutritional administration fails to produce a therapeutic effect, it requires removal from the treatment regimen by the healthcare professionals (Griffith, 2014).
In a community home setting, 87-years old Susan experienced the end of the life condition during the progression of advanced stage of chronic lung cancer. Susan lived with her daughter Julie who was single and not accompanied with any relative. Susan opted dying at her home, rather than a hospital while receiving treatment for her terminal condition. Community healthcare teams were given the responsibility of treating Susan and monitoring the intravenous (IV) morphine administration across the residential setting. Susan experienced the symptoms of dysphagia, loss of appetite and signs of hypotension, tachypnea and tachycardia. Her oxygen saturation level, respiratory rate and heart rate recorded at 95%, 23/minute and 90/minute. The comparative analysis of these findings with the previously recorded data revealed the deteriorating health status of the patient (Resuscitation Council, 2015). Susan also exhibited the symptoms of restlessness, confusion and agitation requiring clinical assessment by a healthcare professional (NMC, 2015). The clinical assessment warrants the assessment of patient’s mental ability to participate in and identify the logical decision-making for effective enhancement of her healthcare outcomes (Carroll, 2010). The Mental Capacity Act (2005) evaluates the psychosocial and mental capacity of the patient and accordingly informed consent obtained for administering the appropriate healthcare interventions (Griffith & Tengnah, 2008). The mental capacity test confirmed the inability of the patient in giving her consent for healthcare intervention. The medical decision was resultantly undertaken accordingly for the health promotion and reduction of harm of the affected patient (Chidwick et al., 2013). The medical decision complied with NMC 2015 conventions that warrant the requirement of justification of the decisions of nurses in accordance with the best interest of the patient.
Susan refused to take feed and drink and eventually experienced weakness, debility and dehydration. She therefore, became the subject of ANH administration with the utilization of nasogastric tube. However, Julie did not favor the administration of NGT and advocated her mother’s decision in the context of the fact that she might suffer from dry mouth, aspiration and pain following the NGT intervention. In the absence of lasting power of attorney, Julie could not take a decision of challenging the NGT administration in the clinical setting (Griffith, and Tengnah, 2008). Julie was left with the only option of raising her voice against the NGT administration, while realizing the pattern and intensity of pain and suffering associated with this tubal intervention. This discrepant situation resulted in an ethical controversy that created hindrance in the care taking of the patient in the hospital setting. Nurse professionals in the clinical setting remained obliged with their duty of providing the best care to the patient; however, patient’s daughter consistently opposed this aspect of care. In the absence of an advanced directive, the nurse professionals and members of the medical team remained unaware regarding the previous views and wishes of the patient regarding the NGT intervention. The ethical dilemma resulted in a debate regarding the administration or cessation of NGT intervention while considering the patient’s sufferings as well as the nutritional and hydration requirements.
Indeed, state of dilemma leads to the selection of the difficult option while considering its associated cost and benefits in comparison to the adverse outcomes (Buka, 2014). The detailed discussion between the physicians was undertaken in the context of taking a decision regarding the administration of ANH through nasogatric tube. Some nurse professionals advocated the perspective of administering NGT; however, some of them opposed the same while considering the inevitable death of the treated patient. The other nurse professionals advocated the requirement of taking consent from patient’s family members regarding NGT intervention. This posed a serious question regarding the ethical accountability of the nurse professionals in serving the patient for reducing harm and elevating her wellness outcomes. Nurse professionals utilize conventions stipulated by Nursing and Midwifery Council (NMC) and the General Medical Council (GMC) while practicing morality and ethics and defend their judgments accordingly in problematic situations.
The Human Rights Act (1998) safeguards right of living of humans in accordance with its prescribed legislation. Nurse professionals require prioritizing the benefits as well as care requirements of their patients and need to safeguard their rights while administering best available care interventions for elevating the wellness outcomes. The nurses should administer healthcare interventions while safeguarding the dignity of their patients and monitor their individualized treatment challenges and requirements (Tingle and Crib, 2007). The care and treatment require administration by nursing professionals while preserving the rights of patients and surpassing biased behavior and discriminatory attitudes (Tingle and Cribb, 2007). For accomplishing this purpose, the nurse professionals require practicing compassion and kindness in attitude for reducing the anxiety and suffering of the treated patient (NMC, 2015). Conventions for mental capacity legal test across Northern Ireland, Wales and England stipulated in accordance with the conventions of the Mental Capacity Act (2005). Indeed, while taking the decisions on behalf of patients, the nurse professionals require considering the norms that prioritize the interests of the treated patients (Allmark and Tod, 2009). In the present scenario, the same conventions utilized for administering NGT to the affected patient.
The theories of deontology and utilitarianism signify various ethical dilemmas and considerably influence the healthcare strategies utilized for treating the patient population. Bentham considers utilitarianism in terms of an ethical convention that provides the greatest benefits to the patient population. The concept of utilitarianism defined in terms of “consequentialist theory” that considers the justification for ethical decision in accordance with its consequences rather than the method that resulted in the particular outcomes (Pieper, 2008:319). The theory of utilitarianism utilized in healthcare scenarios where there is a requirement of providing maximum benefits to the patients with limited resources (Wilmot, 2013). The utilitarian convention directly questions the moral basis of the artificial maintenance of the life of terminally ill patients like Susan. This theory advocates the lawful extension of benefits to individuals irrespective of their personal as well as societal constraints. Utilitarianism advocates the administration of fair and legitimate methods for enhancing the wellness outcomes of a larger section of society. This concept might require utilization for raising a question regarding the harm caused by ANH administration to Susan. Contrarily findings by Schwarz (2007) reveal the suffering faced by the patient in the absence of fluids and nutrition leading to the intense episode of hunger and weakness. On the other hand, findings by Stiles and Ella (2013) indicate that the terminally ill patients do not experience the pattern of thirst or hunger and associated manifestations. Ganzini et al. (2003) and Li (2002) advocate the contention in relation to the development of coma and distress among terminally ill patients in the absence of nutritional assistance. Similarly the case report configured by Fisker and Strandmark (2007) confirms the health advantages of nutrition and fluids for the terminally ill patients. Despite the existence of variable perspectives on the scenario, the nurse professionals owe the duty for reducing the pattern of pain and distress of the treated patient. Nurse professionals require administering NGT intervention for adequately maintaining the nutrition and hydration status of the treated patient. The nurse professionals therefore, require taking assistance from the general physicians for administering ANH through NGT intervention. Concomitantly, nurse professionals require elevating the self-esteem, respect, comfort and dignity of Susan throughout the course of medical intervention. GMC and NMC advocate and follow the concept of deontology for legitimately imposing the obligation of care on the healthcare professionals (NMC, 2015 and GMC, 2010). Kant emphasizes the requirement of practicing morality in day-to-day life (Pieper, 2008). This deontologist argues that people remain confined within themselves and their end requires exploration within their confinements rather than considering them as a mode of attaining an end to a situation (Pieper, 2008:322). The deontologists follow the conservative attitude while considering the obligations of individuals while disregarding the respective consequences. The deontological theory warrants the requirement of the timely execution of duties and obligations by the healthcare providers. Therefore, with this concept in mind, healthcare professionals require lawfully following their responsibilities towards patients and psychosocial environment. The nurse professionals also require following the same ethical conventions while extending care and treatment to eligible patients. The deontologists consider food as an important life ingredient and therefore, nurses and physicians must administer the appropriate nutritional content to their terminally ill patients while extending care interventions to them in a professional environment (Hooper and Suzie (2011). This evidentially proves that the administration of ANH through NGT to Susan is morally justified for the rendering nurses and general physicians.
Ethical conventions stipulated by Beauchamp and Childress (2008) comprehensively guide nurse professionals and physicians in terms of configuring ethically appropriate decisions for administering care and treatment to the patient population. Nurses and healthcare practitioners must follow the critical attributes like beneficence, non-maleficence, autonomy and justice in the process of medical decision-making (Gordon et al., 2011). ANH requires the administration to the patient in accordance with its benefits on the wellness pattern of the treated patient (Gordon et al., 2011). The potential advantage to Susan from ANH intervention attributes to the maintenance of comfort and hydration during the terminal stage of her illness. The convention of non-maleficence advocates the administration of strategies for reducing the pattern of harm to the treated patient (Gordon et al., 2011). This principle restrains the nurse professionals from engaging themselves in activities that might produce the potential harm to the patient population. The non-maleficence convention is regarded as the fundamental medical norm across the healthcare community (Gordon et al., 2011). Accordingly, Susan requires ANH administration for preventing the likelihood of harm to the treated patient (i.e. Susan in the presented scenario). On the other hand, the administration of NGT might cause diarrhea, dry mouth & lips, and ulceration to Susan that could affect her wellness adversely (Alexander, 2011). Griffith (2014) advocates the contention related to the fact that the ANH administration at the end of life of the patient proves futile and elevates the pain and suffering of the patient. Therefore, ANH administration requires withdrawal at the end stage of life of the treated patient. Furthermore, ANH intervention also causes ascites, fluid overload and pulmonary/peripheral edema in terminally ill patients (Stiles and Ella, 2013). Contrarily, in various clinical scenarios advantages of NGT administration supersede the disadvantages that occur due to non-administration of NGT to the eligible patients. Resultantly, the physicians as well as the nurse professionals require administering NGT to Susan as advocated by ethical convention (Buka, 2014). Additionally, nurse professionals require administering various supportive strategies for maintaining the psychosocial and physiological states of Susan during the treatment interventions.
Autonomy indicates the capacity and decision-making ability of an individual in independently acquiring the available options with his/her self-determination (Lowden, 2002, p. 1326). The healthcare system provides autonomy to the patients for participating in their medical decision-making and sharing consent regarding their willingness or non-willingness in receiving a medical intervention (Avery, 2013). However, in the presented clinical scenario, Susan lacks mental capacity that makes her incapable of giving her consent to the recommended NGT intervention. Subsequently, healthcare professionals and nurses require taking ethical and lawful decision on behalf of Susan in accordance with her best interest and expected medical advantages (Griffith and Tengnah, 2013). Her daughter Julie lacks a lasting power of attorney in relation to her mother’s health and therefore, incapable of giving her consent for Susan (Weise et al., 2014; Mann and Cornock, 2007; and Harris and Fineberg, 2011). Evidence-based research literature advocates the contention related to the fact that physicians and nurses require taking professional decisions for the incapacitated patient in the context of elevating the wellness outcomes (Lemmens, 2012). Therefore, in the presented scenario, physicians and nurses require taking an evidence-based decision in the best interest of Susan.
The principle of justice warrants the requirement of administering fair, unbiased and equitable treatment interventions to the patient population (Holmes, 2010). This rationally indicates that each patient across the globe possesses equal right to the acquisition of care and treatment for enhancing his/her wellness outcomes. Healthcare professionals equitably offered similar healthcare intervention to Susan that was offered to other patients affected with similar clinical manifestations (Lees et al., 2014).
The nurse professionals require evaluating the individualized requirements of the treated patients while assessing the pattern of their relationships with family members and colleagues (Barnard et al., 2006). They also require monitoring the habits and personality treats of the patients while configuring healthcare strategies and assistive interventions. Nurse professionals require attaining knowledge regarding the concept of dying and associated care strategies for assisting Susan in her difficult scenario. They also need to understand the thought process, fear, apprehensions and perspectives of Susan while configuring a therapeutic relationship with her during the course of medical intervention. Nurse professionals should effectively assist and encourage both Susan and Julie for maintaining their physical, spiritual and psychosocial well-being during the assistive intervention.
The healthcare teams should efficiently track the best interest of patient and accordingly configure assistive strategies for acquiring the healthcare goals of the treated patients Fisker and Strandmark (2007). The nurse professionals should coordinate with the family members of the patient in preparing himself or herself for the process of dying. In the presented patient scenario, Susan wished to experience death inside her home; however, Julie failed to take that decision on behalf of Susan. In this complicated situation, healthcare professionals require taking informed decisions regarding the end-of-life of the patient in accordance with her best interest and comfort. The findings by Fisker and Strandmark (2007) state that the healthcare professionals require considering the emotional and spiritual requirements of the patient and family members while preparing her for the dying process. The legal system of the United Kingdom provides rights to the physicians as well as patients in making decisions regarding the end-of-life conditions Tingle and Cribb (2007). The research findings by Burnard and Chapman (2004) reveal that the end-of-life decisions not confined to the administration or withdrawal of therapeutic approaches rather these decisions also affect the administration or withdrawal of hydration and nutrition to the treated patients. Nurse professionals advocate the requirement of discussion of end-of-life decisions of patients with the concerned physicians for deriving best conclusion in accordance with the interests of the treated patients (Dimond, 2015). The diverse background of the nurse professionals often challenges the configuration of end-of-life decisions for the terminally ill patients (Tingle and Cribb, 2007). Evidence-based research literature advocates the requirement of developing consistency in the end-of-life decisions while configuring customized mechanisms that consider the overall patient scenarios rather than limited demographic features in preparing the evidence-based healthcare strategies for the affected patients (De Veer et al., 2008). The UK legislative conventions advocate the requirement of taking informed consent from the patient in relation to the administration of recommended treatment interventions, and unlawful touching or access of healthcare professionals to the treated patients prohibited as per the statues of law (Tingle and Cribb, 2007). Accessing or touching (of patients) by healthcare professionals is considered lawful only after acquiring informed consent from the concerned patient (Avery, 2013). The legislative conventions therefore, emphasize the requirement of the acquisition of informed consent of the patient in relation to the administration of any medical intervention that compromises the integrity of the treated patient (Avery, 2013).
The healthcare professionals require investigating the characteristics and palliative care requirements of individuals who refuse food and nutrition during their end stages of life. The healthcare teams require utilizing various screening tools for accessing the symptomatology of the terminally ill patients. Healthcare teams along with the family members of patients require periodic interaction with other multidisciplinary professionals like palliative care advisers, spiritual care experts, dieticians, pharmacists and pain-management service providers for effectively assisting the patients during the process of their dying. The healthcare teams should facilitate the easy accessibility of the services including home care, hospice care and palliative care pharmacies to the terminally ill patients and their family members. The perspective of the patient’s family members, protective prescription, clinical recommendation and advance care plan require documentation by healthcare professionals in the context of avoiding any potential conflict during the treatment process.
The research paper has debated on the ethical dilemma regarding food and nutrition support refusal in clinical practice. Susan case elaborated thoroughly in the context of the NMC Code of Conduct (2015) and Mental Capacity Act (2005). The 6C’s of nursing practice (i.e. care, competence, compassion, commitment, communication and courage) described in relation to their requirement in extending care and assistance to the terminally ill patients. Various ethical conventions were discussed in detail in the context of their relevance to the effective resolution of ethical discrepancies regarding administering food and nutrition to patients during their terminal stages. The majority of ethical conventions advocate the administration of ANH through NGT while providing end-of-life assistance to Susan. Julie’s perspective against the ANH administration justified in the context of the fact that she expected maximum comfort for her mother in her best interest and did not want healthcare teams to enforce nutritional management for avoiding the expected complications. The convention advocated by Griffith (2014) supported Julie’s belief against the nutritional administration to the terminally ill patient. Indeed, nurse professionals require practicing compassion and politeness while administering caring strategies to facilitate the process of dying for the terminally ill patient. The maintenance of dignity and respect of the patient highly warranted while administering nursing care interventions across a comfortable healthcare setting. The outcome of this particular case is unknown since Susan rested at home while receiving ANH intervention until the accomplishment of my placement at her location.