Post by Regina
Patient Autonomy and End-of-Life Care
One of the most challenging ethical dilemmas I have ever faced in nursing practice was centered around patient autonomy, particularly regarding end-of-life care. I chose this topic since it underlines the critical balance that needs to be achieved between the rights of the patient and recommendations from the medical professional, as these often present very difficult decisions for both healthcare providers and families. This is one of the most common and touching challenges in nursing practices, where nurses try to advocate for patient-centered care amidst ethical complications during treatment(Tahmasebi, 2023).
A Conflict Over End-of-Life Care
In my practice, I once faced a case of a fully developed elderly female patient diagnosed with terminal cancer and admitted to the hospital in much pain. The medical professionals felt like there were no other cures or treatments for the disease. Therefore, the medical professionals recommended palliative care to address the patient’s symptoms and keep him as comfortable as possible. The patient, before becoming ill, had stated that she wanted no aggressive therapy and was articulate in signing the directive. However, the patient’s family remained very much against the proposal for palliative care and demanded the continuance of aggressive interventions, insisting that the patient was incompetent to make rational decisions due to his condition.
The ethical dilemmas were about the patient’s right to autonomy enshrined in an advance directive while the family was expecting aggressive treatment for the patient. In this case, I experienced a dilemma where, on the patient’s side, I had to advocate for her decision while, on the other hand, talking with the family as a caring nurse. This unique case scenario defines the type of ethical decisions nurses constantly make when patients’ decisions contradict those of the family.(Molina-Mula & Gallo-Estrada, 2020).
How the Ethical Challenge Was Addressed
This situation was addressed professionally through several measures that involved other parties, including myself, the physician, two social workers, and the ethics committee. I will first look for, review, and confirm the patient’s advanced directive. Subsequently, a family meeting was held where the medical status, prognosis, and patient preferences, as shared by the healthcare team, including myself, were discussed. I supported the patient’s right to die peacefully and in a dignified manner with minimal distress as per their directive. The ethics committee was called in to help with the issue and ensure that everyone was heard and an unbiased decision was made. They supported respecting patient autonomy based on the legal documents she had signed.
Finally, the family, who disagreed with the decision of a patient not to receive any treatment at all, changed their mind to accept the patient’s decision in the final place. After some discussions with the assistance of the healthcare team, they concurred on palliative care. The patient was transferred to the hospice, where she received the last moments of her life as per the advance directive.
Reflection on the Approach Taken
I feel that the approach taken to this ethical challenge was appropriate in that a multidisciplinary team was used to formulate a plan, an ethics committee gave its opinion on the matter, and a respectful conversation with the family resulted in a decision that respected a patient’s autonomy yet provided much-needed support for this family during a trying time.
However, if I had looked at the situation objectively, I would have initiated the involvement of the ethics committee at an earlier stage. Their implication reduced conflict by bringing and presenting the family with an impartial and moral point of view that could have eased some of the family’s suffering earlier. Moreover, family meetings can occur more often to help ease understanding and communication with the family and relieve the load of emotions on the family and the healthcare team.
This experience developed a better understanding of the moral obligations that nurses have in patient self-determination in light of emotional pressure on the part of the family. The nurse plays a big part in providing compassionate care and protecting the patients’ rights (Cheraghi et al., 2023). All these call for mindful balancing between empathy, effective communication, and commitment to ethical principles to preserve patient dignity and make ethical decisions.
Cheraghi, R., Valizadeh, L., Zamanzadeh, V., Hassankhani, H., & Jafarzadeh, A. (2023). Clarification of ethical principle of the beneficence in nursing care: An integrative review. BMC Nursing, 22(89). https://doi.org/10.1186/s12912-023-01246-4Links to an external site.
Molina-Mula, J., & Gallo-Estrada, J. (2020). Impact of nurse-patient relationship on quality of care and patient autonomy in decision-making. International Journal of Environmental Research and Public Health, 17(3), 1–24. https://doi.org/10.3390/ijerph17030835Links to an external site.
Tahmasebi, M. (2023). Ethics and palliative care: a case of patient’s autonomy. Journal of Medical Ethics and History of Medicine, 15(16). https://doi.org/10.18502/jmehm.v15i16.11574Links to an external site.
Post by Soniya
In this blog post, I will talk about an ethical challenge in nursing: addressing situations where a patient clearly requires hospice care, but the family is not in agreement with each other and the patient is unable to communicate their wishes.
The Ethical Challenge: Disagreement on Hospice Care
The ethical challenge here involves respecting patient autonomy and ensuring beneficence- acting in the best interest of the patient-while also addressing conflicting family perspectives (Akdeniz et al., 2021). This situation often arises when the patient, due to cognitive or physical decline, cannot express their desires, leaving the healthcare team to rely on family input, which can sometimes be contradictory or unrealistic in terms of the patient’s needs and medical prognosis. I selected this ethical challenge because it embodies the difficult balance between ethical nursing principles and family-centered care. As nurses, we aim to honor the patient’s dignity and provide comfort at end-of-life. However, when families are at odds or in denial about the patient’s condition, it places the nursing team in a complex position. I believe it’s essential to address these scenarios, as unresolved family disputes can delay appropriate palliative care, resulting in unnecessary patient suffering.
My Experience with This Ethical Challenge
In one case, I encountered a patient who was 100 years old and had been admitted with pneumonia. Despite receiving antibiotics, her condition worsened each day. She eventually stopped eating and drinking and was only responsive to painful stimuli. Given her advanced age and declining state, the care team recommended transitioning to hospice care to focus on her comfort. However, the family was deeply divided on this decision: one part of the family saw hospice as the compassionate choice, while others held on to the hope that aggressive treatments might lead to her recovery.
What Happened?
The disagreement within the family led to delays in making a final decision about her care. Some family members struggled to accept that recovery was unlikely, while others feared that continued interventions might only prolong her suffering. This conflict created tension not only within the family but also among the care team, who wanted to ensure that the patient received the best possible care given her current condition.
How We Addressed the Situation
To address this challenge, the care team arranged a family meeting. I, along with the physician, social worker, and family members, participated in this discussion. We provided clear and compassionate explanations of the patient’s prognosis and the limitations of curative treatments in her case. We discussed the goals of hospice, emphasizing that the focus would shift to ensuring her comfort and dignity in her final days. Despite these efforts, some family members continued to insist on more aggressive treatments, holding on to the slim hope of improvement.
In response to the family’s hesitation, the team attempted a compromise: we implemented some comfort measures while allowing time for the family to come to terms with her condition. This approach was not ideal but aimed to respect the emotional needs of the family members who were not yet ready to let go.
Reflection on the Approaches Taken
Looking back, I believe the approach taken respected the family’s emotions, though it came at the cost of delaying the patient’s full comfort care. The balance was challenging, as we aimed to respect the family’s perspectives while prioritizing the patient’s well-being. Though not perfect, the compromise allowed the family some time to accept the inevitable while slowly transitioning her care to a comfort-focused approach.
What I would Do Differently
If I were to encounter a similar situation again, I would consider involving an ethics committee sooner. This additional support might have facilitated a clearer, unbiased dialogue, helping the family members navigate their emotional barriers and come to a united decision sooner. Additionally, inviting pastoral care or another support resource could provide more holistic support for the family. My goal would be to help the family reach a agreement faster to prevent unnecessary suffering for the patient.
In summary, managing ethical challenges like these requires sensitivity, patience, and effective communication. By focusing on the patient’s needs while respecting the family’s grief and concerns, nurses play a critical role in advocating for compassionate end-of-life care.
Reference:
Akdeniz M, Yardımcı B, Kavukcu E. Ethical considerations at the end-of-life care. SAGE Open Med. 2021 Mar 12;9:20503121211000918. doi: 10.1177/20503121211000918. PMID: 33786182; PMCID: PMC7958189.
Haddad LM, Geiger RA. Nursing Ethical Considerations. [Updated 2023 Aug 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526054/Links to an external site.
Khaghanizadeh M, Koohi A, Ebadi A, Vahedian-Azimi A. (2023). The effect and comparison of training in ethical decision-making through lectures and group discussions on moral reasoning, moral distress and moral sensitivity in nurses: A clinical randomized controlled trial.Links to an external site.Links to an external site. BMC medical ethics, 24(1), Article 58. https://doi.org/10.1186/s12910-023-00938-5
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