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The healthcare profession is a fluid industry. Advances and the expanse of knowledge are continuously changing interventions and treatments. The medical advances created by research and technological growth have increased the lifespan of individuals. These advances have also created new ways of prolonging life even when the most traumatic events occur to the body. In the healthcare industry, ethical dilemmas arise daily. When do we stop medically intervening to prolong life and let nature take its course? This challenges medical professionals morally and ethically which can interfere with their personal beliefs potentially having a negative impacting patient-centered care. When the decision to end life sustaining care is made, what is the ethical course of action that will create the least amount of negative impact for the patient and the family? The role of a nurse is not just medication administration and assessing the patient. A nurse is an advocate, caregiver, communicator, and team member. These roles are essential in ethically questioning situations while utilizing their knowledge of ethical principles and understanding the wishes of the patient and family. In this paper, I will be using a difficult personal experience to demonstrate end of life care and how it can impact nursing staff while challenging their ethics, morals, and personal beliefs.
An ethical dilemma is, a situation in which an individual is compelled to choose between two actions that will affect the welfare of a sentient being and both actions are reasonably justified as being good, neither action is readily justified as being good, or the goodness of the actions in uncertain (Butts & Rich, 2020, p. 46). In these situations, a decision must be made even though there is no obvious choice. This is where the dilemma occurs, and one must rely on their morals and understanding of other individuals thoughts and feelings to make the best decision. This is an individualized care, where no two situations are similar, thus no plan of care is the same.
During the last semester of nursing school, a Nursing Student (NS) was assigned to do their leadership in the medical intensive care unit (MICU). It was an average day. The NS arrived early and prepared themselves for another 12-hour shift and located their Preceptor. When receiving report, the nurse handing off said the patient was a DNR/DNI and the next sentence she was telling the NS and the Preceptor that the patient was intubated and what size of the intubation tube. Not understanding why this intervention occurred against the patients wishes, the NS began reading the notes and found that the patients son was his medical power of attorney (MPOA). When the patients health status was declining and the patient was deemed unable to make healthcare decisions, his MPOA decided that more extreme measures should be taken; therefor the patient was intubated. Soon after the shift started the patients MPOA came to visit and before even entering the room, pulled the Preceptor and NS aside to verify that we understood not to tell anyone (including other family members) any information. The MPOA expressed that they had different views about this situation. The MPOA elaborated that since the age of 18 (now 40s), they and the patient had discussed end of life care. The patient had made it clear that they did not want an endotracheal tube (ET) and for no extreme interventions to be taken in a situation like this. It was clear that this was difficult for the MPOA and that they were fighting a strong internal battle between their desires to keep the patient alive and the patients wishes. The Preceptor and NS listened to the MPOA and answered questions. The MPOA also made it clear that they knew what the patient would want and was planning to extubate the next day. In this situation, the patients health was declining even with the extraordinary measures. Later in the shift, primary team evaluated the patients extubation criteria to determine whether the patient would be able to maintain oxygenation and ventilation without mechanical support. The patient did not meet the criteria and the MPOA was now faced with the decision to withdraw care or to provide care the patient had expressed he did not want.
This ethically challenging situation began to take an emotional toll on the NS when they were able to spend time with the patient. They were restrained to protect the patient from pulling their ET out and injuring themself. The patient was alert and could answer yes or no questions. This patient kept trying to move their arm towards their mouth making hand gestures indicating to the NS that they wanted the ET removed. The patient would mouth the word out and tears began welling up in his eyes. The reached out for the NSs hand and grabbed it and held the NSs hand for a long time. The NS asked him if he liked football, the mountaineers were playing a home game, so they turned the TV on, and the NS stood there holding the patients hand and watched football. Later during the shift, the NS asked if they wanted to get cleaned up and told the patient that family was planning to visit. He agreed. This patient was alone for most of the shift and in a position that he never wanted to be in. Part of being a nurse is to improve the patients quality of life by being a caregiver. The NS stayed with him when he was alone, turned on the game because a family member had stated he was a huge Mountaineer fan, comforted him, and even had him smiling. The plan for this patient was not for him to get better and return to his loved ones, it was to remove all extraordinary measures and from what the test indicated he would pass away shortly after taking him off life support.
This interaction demonstrates how the ethical and moral values can be questioned. There are multiple ethical dilemmas presented in this situation. There are two ethical dilemmas that I want to discuss. The first is intubating a patient that expressed that was a DNI. A patients advance directive states the medical care that the patient wishes to be followed. Once a patient is deemed unable to make decisions, the MPOA has the power to make all decisions and change the plan of care. A living will is a legal document that outlines what medical care is to be provided in specific circumstances (Butts & Rich, 2018, p.216). Having a living will ensures that a persons wishes are honored. Having documents like this protects the patient and care providers. Family members are emotionally involved and cannot always make rational decisions. Sometimes family members are not ready to let go and make decisions based on their personal feelings and not what the patient wants or what is in the patients best interest. This is where patient advocacy is important. Making sure that patient autonomy is upheld makes the nurse accountable to the patient and strengthens rapport. The second ethical dilemma is extubating a patient that cannot sustain life without a ventilator. The MPOA acknowledged the patients right to die with passive euthanasia. This ethical dilemma challenges ones beliefs, by withdrawing care to a patient that cannot survive without it.
According to Schroeder and Lorenz, nursing represent the largest group of health-care professionals in the United States of America (Schroeder & Lorenz, 2018). Personal experience has shown that nurses interact with patients more than any other healthcare professional and this puts nurses in the forefront of patient centered and holistic care. Studies have indicated that family members of end of life care patients have a better sense of wellbeing if their loved ones needs are being met (Williams et al., 2015). Effective communication between a nurse, the patient and their families, along with interprofessional communication strengthen relationships and rapport (Andrade et al., 2019). The indication of having effective communication and a relationship improves outcomes and perception of the situation for the nurse, patient, and family when dealing with an ethical dilemma and end of life care.
The general perception is that nursing is about saving lives and making sick people better so they could go home to their families. Experiences like the story above change nurses perspectives about what is required of a nurse. Educating nurses on the amount of compassion that will be required, their personal morals and beliefs that will be tested is not something that can be learned in a classroom. The students are prepared by learning about ethics, morals, and belief systems and by analyzing their opinions with case studies and group discussions. Continuing education of a registered nurse is a requirement to maintain licensure, but also keeps nurses up to date on the latest research and evidence-based practice. As a nurse, ethical dilemmas are inevitable. Therefore, it is important to work as an interprofessional team so that others can bring their knowledge and experience to aide in the ethical decision-making process. Being in the front-line of patient care, nurses need to be able to identify potential dilemmas and take preventative steps by using personal experiences, education, and interprofessional teamwork strengthens a nurses ability to manage ethical dilemmas and positive outcomes.
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