Ethical Decision Making in End-of-Life (EOL) Care

In their day-to-day work, nurses experience ethical challenges in which there is no apparent “correct” response. This is particularly prevalent for nurses dealing with end-of-life (EOL) care. Usually, Nurses who deal with patients who are approaching or at the end of their lives are often witnesses to the challenging and stressful choices that patients and families must make about a variety of sensitive problems. And although nurses have their own ethics, ideals, and opinions, they may not always coincide with the patients’ principles, ideologies, or aspirations, resulting in an internal struggle for the nurse. Some of the medical interventions and choices are usually straightforward, while others are more difficult. Irrespective of the treatment or therapy, the nurse’s primary goal ought to be to assist the patient in weighing the upsides and downsides of the procedure. They should therefore make judgments based on the ethical principles of autonomy, beneficence, nonmaleficence, and justice (Arkdeniz et al, 2021). In this paper, I will explore the five-step ethical decision-making model help Mrs. R., an 87-year-old patient suffering from advanced Alzheimer’s disease and aspiration pneumonia, to transition to end of life.

1. Assessment of the Problem

The case presented involves Mrs. R who had been hospitalized to a tiny rural hospital with aspiration pneumonia 10 days prior. Mrs. R has been ventilator-dependent since admittance, with no signs of progress in their condition. She also has advanced Alzheimer’s disease, which has taken its toll on her cognitive capacities to the point where she no longer recognizes her own relatives. According to her Family Members, Mrs. R would not have wished to be reliant on a ventilator. However, Mrs. R’s primary care physician has submitted a directive for advanced care for the patient to get aggressive rehabilitation and physical therapy. The advanced care directive opposes the patient’s preferences as perceived by the family.

2. Gather data

Mrs. R has Alzheimer’s disease that has progressed to the point of aspiration pneumonia. She cannot make an educated judgment on the course of therapy or care in her present state due to cognitive loss induced by Alzheimer’s disease. According to Schmidhuber et al. (2017), Advanced care directives should be written by the client in the early stages of dementia in order to maintain their autonomy later on. However, Mrs. R does not have advanced directives, but her family understands that she would not want to be on a ventilator. Furthermore, considering her current state, the prognosis for her sickness is bleak. Even if intense physiotherapy and physical rehabilitation are effective at treating pneumonia, the patient will be conformed to a long-term nursing facility for the rest of her life.

Moreover, family members act as the Mrs. R’s family members, and their contribution in decision-making might be regarded as the patient’s decision. Schmidhuber et al. (2017), however states that an advanced directive is required for family members to make decisions about end-of-life care. It’s unclear whether a single member of the family or primary caregiver has power of attorney under a living will or advanced directive. Regardless of legal constraints, Mrs. R’s family is concerned that she would refuse artificial life support. Ethical experts should therefore consider the family’s input when making ethical decision.

Finally, Mrs. R’s primary care physician is hesitant to remove any form of life support from any patient. The doctor makes these choices based on what he thinks is best for the patient and how he would treat his own elderly and feeble mother. He suggests that the patient undergoes intensive rehabilitation and therapy. However, McWilliams et al (2015) found that improved physical rehabilitation after ICU discharge does not result in substantial improvements in health for mechanically ventilated patients. In making this decision, the physician demonstrates paternalism by effectively overriding the patient’s wishes and ignoring the patient’s prognosis and quality of life after rehabilitation.

3. Explore available strategies

The first available strategy that can be explored is terminal removal of artificial ventilation as a second method. According to Scala et al (2020), terminal withdrawal is the removal of life support with the expectation of near-immediate death in minutes or hours. Although the strategy would save the patient the pain associated with strategy one, it would not produce the optimal end-of-life outcomes, according to the ethical ideal of beneficence. This technique, on the other hand, carries out the wishes of the family, which are thought to be the wishes of the patient, and therefore maintains autonomy. In terms of justice, the patient does not have the opportunity to benefit from the full range of good health treatment that is available at the end of life. Although terminal withdrawal prevents the patient from receiving end-of-life care, it would be preferable to aggressive treatment.

Another possible strategy is the physician’s proposed advanced rehabilitation and therapy. According to Taito et al., (2019), in terms of beneficence, this strategy provides little or no benefit to the patient. On the other hand, vigorous rehabilitation causes suffering, which is contrary to the principle of non-maleficence. In terms of autonomy, the doctor’s decision takes precedence over the patient’s informed permission, hence this technique violates autonomy. The first technique, as described by the doctor, is unethical since it violates medical ethical precepts.

The last possible alternative is to provide EOL palliative care to the patient as he or she approaches death. Based on the information received, the patient does not want to be on life support. Furthermore, harsh treatment is not medically recommended because it will not help the patient’s predicament. This EOL option is a palliative care technique in which the patient’s comfort is provided by a joint effort between the family and practitioners. In essence, the practitioner would implement a ventilation withdrawal timetable based on family and patient wishes, as well as symptom management in the final hours of life.

4. Implement strategy

At this point, the chosen plan for Mrs. R’s transition to end-of-life comfort care is a cooperative effort between the healthcare staff and the patient’s family. The family has the ability to choose the day and location of vent withdrawal as well as the post-vent care procedures. According to Price &Knotts, (2017) the nurse’s responsibility is to inform the family about the withdrawal process, expectations, and the patient’s comfort care. The nursing should also offer should offer the family some form of bereavement support. The nurse will next undertake the real vent withdrawal procedure with the family’s and attending physician’s permission. After the vent is removed, the nurse will provide comfort care to ensure that the patient is as comfortable as possible during the transition to the end if life.

5. Evaluate Outcomes

The Implemented strategy gives a variety of alternative outcomes for those involved in this ethical problem. First, the strategy aids Mrs. R’s transition to comfort palliative care and the outcome results in the cessation of treatment and the management of symptoms for the patient’s comfort. Second, the strategy’s results for the family are the patient’s will being carried out and the patient’s condition being accepted. The family already acknowledge their patients reduced mental capacity, and bereavement assistance will provide mental health help to the family in order to assure contentment and reduce the danger of trauma or depression. However, since this strategy effectively contradicts his recommended decision, the physician is likely to experience cognitive dissonance. Regardless, by carrying out the patients and family’s will, the medical practitioners will have respected patients’ autonomy and used it as a foundation for ethical decision-making.

Conclusion

EOL care for dying patients aims to alleviate or avoid pain as much as possible while honoring the patients’ wishes. Physicians, on the other hand, face a slew of ethical issues when it comes to EOL treatment. It is however essential that any choice taken by the physician, protect the rights, integrity, and vitality of all persons participating in the clinical ethical decision-making process, as the choices to be taken may affect patients’ relatives and community as well as the patients. The medical practitioners must be knowledgeable of the underlying ethical principles such as autonomy, beneficence, nonmaleficence, and justice and also heed to the decision-making model in order to tackle challenges in end-of-life care.

The ethical problem described in this scenario emphasizes the need of nurses adhering to an ethical decision-making model. The ethical-decision making model is a five-step process and helps medical practitioners make decisions when faced with dilemmas in their practice. In this case, the ethical decision-making process starts with describing the problem, which in this case was deciding on Mrs. R’s next step in care. Second, the nurse gathers all relevant information that will help her make a judgment on the problem. The nurse then creates implementation alternatives and compares them to determine which should be prioritized and implemented. At this point. the nurse implements the most ethical strategy in a collaborative manner and evaluates the outcomes for all stakeholders.

References

Akdeniz, M., Yardımcı, B., & Kavukcu, E. (2021). Ethical considerations at the end-of-life care. SAGE Open Medicine, 9, 20503121211000918.

McWilliams, D., Weblin, J., Atkins, G., Bion, J., Williams, J., Elliott, C., … & Snelson, C. (2015). Enhancing rehabilitation of mechanically ventilated patients in the intensive care unit: a quality improvement project. Journal of critical care, 30(1), 13-18.

Scala, R., Ciarleglio, G., Maccari, U., Granese, V., Salerno, L., & Madioni, C. (2020). Ventilator support and oxygen therapy in palliative and end-of-life care in the elderly. Turkish Thoracic Journal, 21(1), 54.

Schmidhuber, M., Haeupler, S., Marinova-Schmidt, V., Frewer, A., & Kolominsky-Rabas, P. L. (2017). Advance directives as support of autonomy for persons with dementia a pilot study among persons with dementia and their informal caregivers. Dementia and Geriatric Cognitive Disorders Extra, 7(3), 328-338.

Taito, S., Yamauchi, K., Tsujimoto, Y., Banno, M., Tsujimoto, H., & Kataoka, Y. (2019). Does enhanced physical rehabilitation following intensive care unit discharge improve outcomes in patients who received mechanical ventilation? A systematic review and meta-analysis. BMJ Open, 9(6), e026075.