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Ethical Dilemma Research Paper
Vicki Thompson
School of Nursing, Liberty University
Author Note
Vicki Thompson
I have no known conflict of interest to disclose.
Correspondence concerning this article should be addressed to Vicki Thompson
Email: [email protected]
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Abstract
Living with a chronic illness is devastating, and often times, painful. When faced with the
options of dying on your own terms vs. assisted dying, I think we all wish we had that choice.
Assisted dying is warranted in certain situations where death is imminent, and in situations
where you know your patient is in excruciating pain. Assisted dying is not approved by the
religious society and has been seen as immoral by most in society. The term “suicide” falls off
tongues like vinegar. Society has the conception that every should die naturally, as God has in
his plan for us. I will explore the differences in patient’s that die naturally vs. those that die or
request to die with assisted means.
Keywords: assisted suicide, autonomy, terminal illness, euthanasia
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Ethical Dilemma Research Paper
C.H. is a 61-year-old divorced female that was diagnosed just over a year ago with
Amyloidosis. She is 6 months post stem cell transplant from the Mayo Clinic. She also goes for
dialysis 3 days a week. C.H. has 2 daughters, 1 sister and 1 bother, who has leukemia. Her
youngest daughter is her caretaker and power of attorney. She is estranged from her oldest
daughter, who lives in another state. All other family lives in close proximity to her.
C.H. currently resides in an assisted living facility, where she seems content, as she has
her own room, with her own belongings. Following the stem cell transplant, her youngest
daughter could no longer give her around the clock care that she required.
C.H. goes for dialysis 3 times weekly and is just getting tired and worn out of the dialysis
treatments and hospital stays, knowing that death is imminent, and her health will deteriorate,
which it is already starting to do. She is a Christian and does not believe in suicide but is torn
between the decision of to just stop her dialysis and die naturally or stop the dialysis and ask for
assistance in the dying process.
There is an interest in the aid in the dying process more now, as Americans fear the dying
process, the pain and undignified death where they have no control (Matzo & Sherman, 2019).
Patient Dilemma
The Problem
C.H. has a recent diagnosis of Amyloidosis and has been through a failed step cell
transplant just over 1 year ago. This patient is struggling with the dilemma of letting herself die
naturally, or to ask for assistance in the dying process, where she is able to go quickly. She does
not like pain and feels she has suffered too much already, and for too long. She is anxious to get
to heaven, as her parents had just recently gone before her.
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Patients Perception
C.H. has the perception that if she were to go quickly, with assistance in dying, she
would forgo the chronic pain that is surely to occur. This is dignified for her and she has control
over her death and demise. She has told her daughter on multiple occasions that she wished she
was not a burden on her and having live out her final days in an assisted living facility. Her
perception is that she will take a medication and fall to sleep in order to die with assisted help.
Otherwise, she will continue her pain, and die in either this facility or in the hospital at the
decision of her body.
Patients Decision
C.H. has made her decision that she wants to try all means necessary to make this
happen, if possible. Unfortunately, assistive dying is not legal in West Virginia. She spoke to
her daughter in depth about being put into a facility in a state where it was legal. The nurse, her
practitioner and her daughter all spoke to her in great length as to whether this was something
she really wanted to do. C.H. expressed that she used to not believe in it and that it was morally
wrong, until she came down ill herself. As a Christian, she stated it was like committing suicide,
and that was against her beliefs. But has since changed her view. She asked her daughter if she
would still go to heaven if she went through with it. There was definitely a spiritual struggle
within her. No further information was needed for her to make her decision. Her daughter is a
nurse and discussed the pros and cons of each. Patient was adamant that if it was an option in
her state, she would go through with it after prayer from her pastor. It is not uncommon for
patients to struggle with the decision of assisted dying because of religious opposition because of
the principle of sanctity of life (Mroz, et al., 2021).
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Alternatives
With the patient’s diagnosis, the option, if she choose to live and die naturally, would be
to continue dialysis and attempt to control the illness the best they could. However, her kidneys
and liver were shot, and the Amyloid was already affecting her heart. At this point, it would have
been just comfort measures if she chooses to discontinue dialysis immediately. With the use of
palliative care and/or terminal sedation, her pain can be relieved (Mroz, et al., 2021).
Analysis of Facilitating Factors
Competency
C.H. is in sound mind and able to make the decision of choosing whether to die naturally
or to choose assisted death. I believe it is fear that is driving her to make a quick decision. The
patient was made fully aware by her daughter, the nurse and the nurse practitioner of the
information and the information was given freely. C.H. asked all staff and her daughter of her
options, how bad the illness would get, how fast things would progress, and her fear of
uncertainty. She knew that Oregon provided assistance in dying, which told them all she had not
only done her homework, but she had also considered it. Knowing if someone has complete
capacity to make this decision is left to the professionals. There should be more than a 2-hour
evaluation of a patient to assess their capacity to make the decision on whether assist in dying is
for them or not (Strouse & Katz, 2018).
Ethical Components
There was no formal evaluation as to the patients concerns, which was a little concerning
for the family. Due to this, I am not sure that she was given the complete information needed in
order to make this decision. In high and sight, assist in dying is not an option, due to the state
laws. The patient understood this, however, with her still continuing to ask her daughter to move
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her to Oregon so this could be an option, made me believe that she needed more explanation
before making this rash decision. As a clinician myself, I had mentioned to the nurse practitioner
that she needed someone to come talk to her about this idea. However, that never happened.
There can be arguments from both sides of the subject. Medical ethics establish that the
physician has a duty to their patient on the basis of ethical principles of beneficence,
nonmaleficence, respect for the patient’s autonomy, and promotion of fairness and social justice
(Sulmasy & Mueller, 2017).
As no physician came in to speak to C.H. regarding her medical interest of assisted dying,
I spoke to her regarding her apprehension. I felt it was my ethical duty, since she was a Christian
and had mentioned before that she never believed in her death being assisted, we spoke about her
thoughts and feels of dying naturally. We spoke of hospice and palliative care, hoping to ease the
fear of dying. The speaking of hospice and palliative care can ease a patient’s apprehension
about the dying process (Sulmasy & Mueller, 2017). What I find amazing is that after patient’s
and families know what palliative care is, more than 90% of patients say they want it for
themselves or family members if they become severely ill (Sulmasy & Mueller, 2017).
With C.H. being able to make whatever decision she wants to, as she is becoming more
and more ill, and exhausted of the frequent dialysis, she, unfortunately, cannot choose the
assisted dying path. At least, she cannot choose as long as she lives in the State of West
Virginia. Her daughter caught me in the hallway and explained to me that her mother
approached her with the idea of her helping with the dying process, since it is not legal there in
the state. This is a whole different subject and paper, but that topic was also discussed after the
patient was made aware that it could not be done while she was a resident of the assisted living
facility and while she resided in the state.
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Moral Conflict
It is important to recognize and assess the family’s religious beliefs. This will guide their
plan of care. For example, in some cultures, it is the oldest son that makes the decisions for the
patient. As healthcare providers, we need to recognize the role religion plays.
In the life of C.H., she is of strong Christian faith. She is a full code and wants all means
necessary to save her life. However, she stated to the daughter that when her time comes, she
would not fight it. Time on earth here is just the beginning and true life starts in heaven. The
daughter and nurse had a conversation with C.H. one night regarding her faith and discussing
next steps in care.
A separate discussion was had with the patient, daughter, and their pastor one evening. It
was not surprising to me that for 24 hours following, the patient had actually mentioned to me
that she had accepted that dying the way the Lord had intended was the right thing to do. We
had spoken on many, many occasions regarding her belief, and there is one verse we spoke about
that was near to me, with having many conversations with patients and their families. One
night, well into my shift, as she was getting her medication, she looked troubled and very
irritated. She asked if I would pray with her. I took her hand, sat in the chair beside of her, and
asked if I could see her Bible. I turned to Genesis 2:7 and read: “The breath of life in all human
beings is a gift from God and thus inherently holy” (King James Bible, 2017).
Her moral principles is what led her to ask me to sit and pray with her. She discussed
with me the fear of dying and how much control over it she would not have. We weighed her
thoughts and feelings on this choice. I then asked her how she thought her children, her sister
and her brother would feel about the assisted suicide? Would they consider that you took your
own life? Could they live and agree with that decision for you, even though it is your decision to
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make? I spoke to her that night regarding the affect this decision would have on her and her
family. However, this was ultimately her decision. That is when we got onto the subject of her
family. I may have been out of line a bit by asking her to weigh both options by comparing them
to what she wants, and then how would dying naturally vs. dying assisted or having someone to
help her end her life, how would that affect her family?
Decisions Regarding her Ethical Choices
Decision Determined
The ethical decision made by the patient and her family was to proceed with the act of
natural death. C.H. decided, after many discussions with myself, other clinicians, a lot of prayer,
several gatherings with not only her daughter, but the rest of her family, that she was being
selfish in leaving them if there is a best option. She never asked her daughter again after that if
she would help her to end her own life, if assisted dying was not an option.
Even though she felt, if assisted dying WAS available, she would be ok to leave this
world when God called her home and if she was able to have the availability of palliative care in
order to help with her pain. After that decision was made, she seemed at peace with it, and it
didn’t seem like she was in a constant life struggle any longer. Thereafter, she would talk a lot
about her life and how much, not only her family, but her church family meant to her. C.H.
responded one shift that she was not afraid to die now. “I am afraid of heights. It’s the trip to
heaven I am scared of.” She definitely knew how to brighten the mood when things started to
get too serious.
Support
The nursing staff team and the nurse practitioner were all onboard with her decision. We
all agreed to help her the best we could with her decision to die naturally, when that time comes,
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which was getting more near than we all realized. We all took turns reading the Bible with her
and praying with her when she asked. We even offered to pray with her ourselves when she
seemed to have periods of irritability.
When it came to her family, the daughter approached us on numerous occasions to thank
us for being so supportive, giving her the education needed to try to make this decision, give her
the space and resources, and above all to pray with her. All of her family was supportive of her
decision and actually thanked C.H. for letting them be a part of her decision and to allow them
the opportunity to share the rest of her days with her. The family expressed how much it would
mean to be involved in the miracle of her leaving this life to go on to a better one. To me, it was
a beautiful thing. Death is imminent in all of us. However, what a gift it is to be with your
loved one at the end of their days and see them off to Heaven.
Implementation and Outcome
At the end of life, the family should be reassured of certain things to come. These
include: The patient will not be abandoned by the team; The patient will not suffer; and support
the family’s decision whatever they decide (Matzo & Sherman, 2019). She was declining
rapidly.
C.H. passed away on a Wednesday afternoon at 3:30 pm. Unbeknownst to the daughter,
C.H. had declined to go to her dialysis treatment that day and asked the nurse to pray with her
just an hour before she passed. A 4:15 pm, the daughter received a call at work that her mom
had passed away. The plan the family thought was in place, did not turn out the way it had been
discussed by the patient. Instead of being surrounded by family, the patient had changed her
mind, we are guessing, and just fell asleep and never woke again.
The daughter stated she had just spoken to her mother 3 hours prior, without any hint of
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anything being wrong. C.H. spoke and joked around just like usual and never did mention that
she declined to go to dialysis that day. Did she know that she was possible going to pass away?
With all the previous talk about dying in pain, not wanting to die naturally, when it came to the
moment, it looks as if God answered her prayers. She passed away on her own terms.
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References
King James Bible (2017). King James Bible Online. https://www.kingjamesbibleonline.org/
(Original work published 1769)
Matzo, M., & Sherman, D. (2019). Palliative care nursing: Quality care to the end of life. (5th
ed.). Springer Publishing Company, LLC
Mroz, S., Dierickx, S., Deliens, L., Cohen, J., & Chambaere, K. (2021). Assisted dying around
the world: a status quaestionis. Annals of palliative medicine, 10(3), 3540–3553.
https://doi.org/10.21037/apm-20-637
Strouse, T. & Katz, M. (2018). Terminal illness and the 6-month prognosis. Concepts and
Terms in Physician-Assisted Death. https://www.ncbi.nlm.nih.gov/books/NBK525943/
Sulmasy, L. & Mueller, P. (2017). Ethics and the legalization of physician-assisted
suicide. https://doi.org/10.7326/M17-0938
