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International Journal of Nursing Education. July-September 2015, Vol. 7, No.3 33

Case Study: An Ethical Dilemma in End of Life Care

Rehana Ayyub MScN Student, Aga Khan University, School of Nursing and Midwifery, Pakistan

ABSTRACT

In any healthcare organization care providers often encounter ethical dilemmas while dealing with patients. A case study presented ethical dilemma faced by a nurse who was caring for an old female diagnosis with severe interstitial Lung Disease (ILD). The patient verbally expressed her will not to give any aggressive treatment and wish a comfort end of life. Her son desired to do all possible treatment and ultimately the patient died with painful experiences. The ethical dilemma demonstrated whether to respect the patient' autonomy or refuse and do aggressive treatment. This paper discusses a case study and present Volbrecht's framework of virtue ethics to analyze the ethical dilemma.

Keywords: Ethical Dilemma, Autonomy, End of Life Care, Advanced Directives (AD)

INTRODUCTION

A 75 year old female, admitted with severe Interstitial Lund Disease (ILD). She was known case of diabetes, renal failure and coronary artery disease. She was on continuous oxygen therapy and overnight application of non-invasive ventilator; Bi-level Positive Airway Pressure (BIPAP) machine for last 6 months. During her hospitalization, she expressed her verbal living will to her family and primary physician that she would not be given any aggressive treatments and wished to have comfort end of life. Due to the poor prognosis, the doctor had put her on (Do Not Resuscitate) DNR code status after discussing with the family. She was put on continuous BIPAP as developed CO2 Narcosis. Later, she went into renal shut down. Even knowing his mother wish and poor prognosis, the son expressed his desire to do all possible treatment other than resuscitation. Hemodialysis was done but unsuccessful due to severe hypotension. She developed multiple bedsores, hospital acquired infection in blood and urine. Concurrently, she became unresponsive. The son requested to give consultations to infectious disease (ID), pulmonology, cardiology, and nephrology. All physicians had recommended interventions based on patients’ medical problems. After 20 days her condition got worsen, she was in pain and suffering. Finally, her son decided to hold BIPAP; she went into cardiac arrest and expired within an hour.

Virtue ethics

In this case study I will use Volbrecht’s framework of virtue ethics to analyze this ethical dilemma. Virtue ethics believes on the patient’s autonomy and patient’s choice of decision making. Ethical analysis of virtue ethics focuses (a) identifying the problem, (b) analyzing context, (c) exploring options, (d) applying the decision process, and (e) implementing the plan and evaluating results (5).

Identifying the problem

This case study presents an ethical dilemma presented desirable outcome in some respects and undesirable in others. In this scenario, the patient’ decision to refuse for aggressive treatment had the desired outcome of allowing her to be remain in peaceful end of life care. However, her son’s choice also resulted in a suffering and painful experience and eventually her death. The ethical dilemma is patient’s autonomy versus the ethics of care.

Analysis of ethical dilemma

In this case the ethical dilemma is patient’s autonomy versus the ethics of care. The patient’s autonomy was neglected and treatments to prolong life, such as use of non-ventilator machine and dialysis were implemented. If her son had followed the recommendations of the doctors, the desirable outcome would have been possible peace full end of

DOI Number: 10.5958/0974-9357.2015.00129.4

8. Rehana Pak --33--.pmd 6/24/2015, 1:38 PM33

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34 International Journal of Nursing Education. July-September 2015, Vol. 7, No.3

life. On the other hand, the undesired effect would have had of feeling of guilt of son but that aggressive treatment would have survived his mother. The American Nurses Association (ANA) Code for Nurses (2001) also support that healthcare provider should respect patients’ wishes and decisions despite their own personal beliefs (2).

However, it is challenging for loved one to witness death based on a patient’s decision and such ethical incidents are thought-provoking. In this scenario to comprehend the decision-making process, one must reflect on the ethical principles of respect, compassion, autonomy, beneficence, non-maleficence, and justice. These ethical principles may influence individual’s preference. In his case, the healthcare team explained the poor prognosis to the son but he did all possible treatment including hemodialysis and non-invasive ventilator. Palliative or supportive care may provide to the patient in order to respect the patient’s autonomy, while respecting her expressed wishes. According to Winzelberg, Hanson and Tulsky (2005) claim that patients are most at risk of receiving care inconsistent with their preferences when they unable to participate in decision- making (4).

Applying an ethical decision process

Based on virtue ethics, the healthcare provider and family did not respect the patient’s autonomy and her wish to choose peaceful death was neglected. According to Winzelberg, Hanson and Tulsky (2005) stated that “efforts to improve end-of-life decision- making quality have emphasized the principle of individual autonomy to better ensure that patients receive care consistent with their preferences” (4). Patient was competent enough when she declared her choice before her condition got worsens. The care providers would have been followed the principle of beneficence, which focuses on promoting the comfort of patients. In this scenario the patient comfort was not receiving aggressive treatment but peaceful end of life care. The concept of advanced directives supports the principle of Autonomy, that an individual has a right to decide for oneself. Advanced directive is a legal document which provides information to the care providers about the patient’s wishes regarding advance treatment options for the future when decision making would not be possible for the incompetent patient (3). In many hospitals, there is no policy for Advanced Directives (AD); through this policy it would be easier for the health professionals to plan treatment according to the document of the

patient, with no doubts about the comprehensiveness of the treatment. “It is an autonomous choice of that individual. Thus, if one follows instructions spelled out by an individual, it amounts to respecting an individual which carries a great moral value. It also builds up trust between an individual and his treating physician”(1).

Implementing plan and evaluating results

The hospital where I was working, there was no policy of advanced directives. However, there was policy for end of life care. According to Akhter (2011) stated that “advance directives include living wills, durable power of attorney and health care proxy” (1). Further the author states that “it is not necessary to have a written document, a verbal expression also receives equal importance”(1). AD is a legal document which allows care providers to respect the patient’s wishes regarding advance treatment options for the future when decision making would not be possible for the incompetent patient. In my judgment, the appropriate way to handle this issue could be the concept of AD. If there would have been the concept of advanced directives, the ethical dilemma would have been dealt in a better manner. The patient would have not suffered and even the loved ones would not have feeling of guilt. The concept of advanced directive document appears crucial in such dilemmas. The introduction of advanced directives can be application of virtue ethics theory which focuses on respect the patient’s wishes.

CONCLUSION

In any healthcare industry, patients and families with diverse background approaches with various values and beliefs. Care providers need to recognize ethical dilemmas in their clinical and focus on ethical principles while dealing with such issues. Nurses knowledge regarding ethics, their ability to identify and resolve concerns in such dilemmas are crucial and challenging. In my opinion, for above stated scenario AD may helpful to address the dilemma. AD supports the principle of autonomy, that patient the right to decide for oneself about treatment plan of care. Through this concept, healthcare professional may respect the patient autonomy and prevent the family feeling of guilt. Healthcare professional can follow and educate the patients and families about AD and it would benefit both patients and care providers while dealing such ethical dilemmas.

8. Rehana Pak --33--.pmd 6/24/2015, 1:38 PM34

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International Journal of Nursing Education. July-September 2015, Vol. 7, No.3 35

Acknowlegment: Nil

Ethical Clearance: Not Required

Source of Funding: Self

Conflict of Interest: Nil

REFERENCES

1. Akhtar, J., (2010) Living Wills in Health care: A way of empowering individuals. Journal of Pakistan Medical Association, 60 (3), 240-242.

2. American Nurses Association. (2001). Code of Ethics for Nurses with Interpretive Statements. Washington, D.C.

3. Beauchamp,T., & Childress, J.(2001). Principles of Biomedical Ethics (5th ed.). New York: ‘ Oxford University Press.

4. Winzelberg, G.S., Hanson, L.C., Tulsky, J.A. (2005). Beyond Autonomy: Diversifying end of- life decision making approaches to serve patients and families. Journal of the America G e r i a t r i c s Society, 53(6), 1046-1050.

5. Volbrecht, R. (2002). Nursing Ethics: Communities in Dialogue. Upper Saddle, NJ: Prentice Hall.

8. Rehana Pak --33--.pmd 6/24/2015, 1:38 PM35

Copyright of International Journal of Nursing Education is the property of Institute of Medico-legal publications Pvt Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

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International Journal of Nursing Education. July-September 2015, Vol. 7, No.3 33

Case Study: An Ethical Dilemma in End of Life Care

Rehana Ayyub MScN Student, Aga Khan University, School of Nursing and Midwifery, Pakistan

ABSTRACT

In any healthcare organization care providers often encounter ethical dilemmas while dealing with patients. A case study presented ethical dilemma faced by a nurse who was caring for an old female diagnosis with severe interstitial Lung Disease (ILD). The patient verbally expressed her will not to give any aggressive treatment and wish a comfort end of life. Her son desired to do all possible treatment and ultimately the patient died with painful experiences. The ethical dilemma demonstrated whether to respect the patient' autonomy or refuse and do aggressive treatment. This paper discusses a case study and present Volbrecht's framework of virtue ethics to analyze the ethical dilemma.

Keywords: Ethical Dilemma, Autonomy, End of Life Care, Advanced Directives (AD)

INTRODUCTION

A 75 year old female, admitted with severe Interstitial Lund Disease (ILD). She was known case of diabetes, renal failure and coronary artery disease. She was on continuous oxygen therapy and overnight application of non-invasive ventilator; Bi-level Positive Airway Pressure (BIPAP) machine for last 6 months. During her hospitalization, she expressed her verbal living will to her family and primary physician that she would not be given any aggressive treatments and wished to have comfort end of life. Due to the poor prognosis, the doctor had put her on (Do Not Resuscitate) DNR code status after discussing with the family. She was put on continuous BIPAP as developed CO2 Narcosis. Later, she went into renal shut down. Even knowing his mother wish and poor prognosis, the son expressed his desire to do all possible treatment other than resuscitation. Hemodialysis was done but unsuccessful due to severe hypotension. She developed multiple bedsores, hospital acquired infection in blood and urine. Concurrently, she became unresponsive. The son requested to give consultations to infectious disease (ID), pulmonology, cardiology, and nephrology. All physicians had recommended interventions based on patients’ medical problems. After 20 days her condition got worsen, she was in pain and suffering. Finally, her son decided to hold BIPAP; she went into cardiac arrest and expired within an hour.

Virtue ethics

In this case study I will use Volbrecht’s framework of virtue ethics to analyze this ethical dilemma. Virtue ethics believes on the patient’s autonomy and patient’s choice of decision making. Ethical analysis of virtue ethics focuses (a) identifying the problem, (b) analyzing context, (c) exploring options, (d) applying the decision process, and (e) implementing the plan and evaluating results (5).

Identifying the problem

This case study presents an ethical dilemma presented desirable outcome in some respects and undesirable in others. In this scenario, the patient’ decision to refuse for aggressive treatment had the desired outcome of allowing her to be remain in peaceful end of life care. However, her son’s choice also resulted in a suffering and painful experience and eventually her death. The ethical dilemma is patient’s autonomy versus the ethics of care.

Analysis of ethical dilemma

In this case the ethical dilemma is patient’s autonomy versus the ethics of care. The patient’s autonomy was neglected and treatments to prolong life, such as use of non-ventilator machine and dialysis were implemented. If her son had followed the recommendations of the doctors, the desirable outcome would have been possible peace full end of

DOI Number: 10.5958/0974-9357.2015.00129.4

8. Rehana Pak --33--.pmd 6/24/2015, 1:38 PM33

w w

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n Jo

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co m

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34 International Journal of Nursing Education. July-September 2015, Vol. 7, No.3

life. On the other hand, the undesired effect would have had of feeling of guilt of son but that aggressive treatment would have survived his mother. The American Nurses Association (ANA) Code for Nurses (2001) also support that healthcare provider should respect patients’ wishes and decisions despite their own personal beliefs (2).

However, it is challenging for loved one to witness death based on a patient’s decision and such ethical incidents are thought-provoking. In this scenario to comprehend the decision-making process, one must reflect on the ethical principles of respect, compassion, autonomy, beneficence, non-maleficence, and justice. These ethical principles may influence individual’s preference. In his case, the healthcare team explained the poor prognosis to the son but he did all possible treatment including hemodialysis and non-invasive ventilator. Palliative or supportive care may provide to the patient in order to respect the patient’s autonomy, while respecting her expressed wishes. According to Winzelberg, Hanson and Tulsky (2005) claim that patients are most at risk of receiving care inconsistent with their preferences when they unable to participate in decision- making (4).

Applying an ethical decision process

Based on virtue ethics, the healthcare provider and family did not respect the patient’s autonomy and her wish to choose peaceful death was neglected. According to Winzelberg, Hanson and Tulsky (2005) stated that “efforts to improve end-of-life decision- making quality have emphasized the principle of individual autonomy to better ensure that patients receive care consistent with their preferences” (4). Patient was competent enough when she declared her choice before her condition got worsens. The care providers would have been followed the principle of beneficence, which focuses on promoting the comfort of patients. In this scenario the patient comfort was not receiving aggressive treatment but peaceful end of life care. The concept of advanced directives supports the principle of Autonomy, that an individual has a right to decide for oneself. Advanced directive is a legal document which provides information to the care providers about the patient’s wishes regarding advance treatment options for the future when decision making would not be possible for the incompetent patient (3). In many hospitals, there is no policy for Advanced Directives (AD); through this policy it would be easier for the health professionals to plan treatment according to the document of the

patient, with no doubts about the comprehensiveness of the treatment. “It is an autonomous choice of that individual. Thus, if one follows instructions spelled out by an individual, it amounts to respecting an individual which carries a great moral value. It also builds up trust between an individual and his treating physician”(1).

Implementing plan and evaluating results

The hospital where I was working, there was no policy of advanced directives. However, there was policy for end of life care. According to Akhter (2011) stated that “advance directives include living wills, durable power of attorney and health care proxy” (1). Further the author states that “it is not necessary to have a written document, a verbal expression also receives equal importance”(1). AD is a legal document which allows care providers to respect the patient’s wishes regarding advance treatment options for the future when decision making would not be possible for the incompetent patient. In my judgment, the appropriate way to handle this issue could be the concept of AD. If there would have been the concept of advanced directives, the ethical dilemma would have been dealt in a better manner. The patient would have not suffered and even the loved ones would not have feeling of guilt. The concept of advanced directive document appears crucial in such dilemmas. The introduction of advanced directives can be application of virtue ethics theory which focuses on respect the patient’s wishes.

CONCLUSION

In any healthcare industry, patients and families with diverse background approaches with various values and beliefs. Care providers need to recognize ethical dilemmas in their clinical and focus on ethical principles while dealing with such issues. Nurses knowledge regarding ethics, their ability to identify and resolve concerns in such dilemmas are crucial and challenging. In my opinion, for above stated scenario AD may helpful to address the dilemma. AD supports the principle of autonomy, that patient the right to decide for oneself about treatment plan of care. Through this concept, healthcare professional may respect the patient autonomy and prevent the family feeling of guilt. Healthcare professional can follow and educate the patients and families about AD and it would benefit both patients and care providers while dealing such ethical dilemmas.

8. Rehana Pak --33--.pmd 6/24/2015, 1:38 PM34

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International Journal of Nursing Education. July-September 2015, Vol. 7, No.3 35

Acknowlegment: Nil

Ethical Clearance: Not Required

Source of Funding: Self

Conflict of Interest: Nil

REFERENCES

1. Akhtar, J., (2010) Living Wills in Health care: A way of empowering individuals. Journal of Pakistan Medical Association, 60 (3), 240-242.

2. American Nurses Association. (2001). Code of Ethics for Nurses with Interpretive Statements. Washington, D.C.

3. Beauchamp,T., & Childress, J.(2001). Principles of Biomedical Ethics (5th ed.). New York: ‘ Oxford University Press.

4. Winzelberg, G.S., Hanson, L.C., Tulsky, J.A. (2005). Beyond Autonomy: Diversifying end of- life decision making approaches to serve patients and families. Journal of the America G e r i a t r i c s Society, 53(6), 1046-1050.

5. Volbrecht, R. (2002). Nursing Ethics: Communities in Dialogue. Upper Saddle, NJ: Prentice Hall.

8. Rehana Pak --33--.pmd 6/24/2015, 1:38 PM35

Copyright of International Journal of Nursing Education is the property of Institute of Medico-legal publications Pvt Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.