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End of Life Dilemma: Key Ethical Values Essay


Introduction: Ethics in Nursing

Autonomy as One of the Key Ethical Values

Though autonomy is not listed in some of the ethics philosophies (Faden, Kass & Goodman, 2012), it is mentioned quite often in the virtue ethics domain as one of the basic values that a democratic society must incorporate into its framework as a basis for interpersonal relationships. Particularly, autonomy is interpreted as the promotion of the patient with an ability to choose their own. In virtue ethics, the concept of autonomy is identified as “an important moral constraining principle” (Gillon, 2014, p. 3), though some scholars claim that it is “given excessive weight” (Gillon, 2014, p. 3) in the contemporary ethics-related studies.

Significance of Autonomy in Healthcare

Among the key ethical values that a nurse must uphold in critical cases, autonomy takes a rather significant spot. According to the official definition provided by the American Nurses Association (ANA), patient’s autonomy is typically identified as “agreement to respect another’s right to self-determine a course of action; support of independent decision making” (American Nurses Association, 2010, p. 1)

It would be wrong to claim that autonomy is the focal point of nursing ethics. Instead, the phenomenon shares an equal amount of significance with other essential issues: “A medical ethicist, for example, needs to be not merely benevolent, kind, and a respecter of autonomy, but also knowledgeable about medicine or, at the very least, in excellent communication with those who are” (Swanton, 2013, p. 665).

A Response from an APRN

Justifying the Choice of an APRN

The principle of autonomy can be used to justify the behavior of an APRN in case of facing an issue such as the end of life dilemma. Growing increasingly important with the introduction of new healthcare tools for assisting elderly people and the reconsideration of the process of healthcare provision to the latter, the end of life dilemma poses a rather tricky choice in front of an APRN; particularly, a nurse has to decide whether an elderly person, who is practically incapable of taking care of themselves, should be taken to a hospice or a nursing home to be provided with the corresponding services.

The specified issue has become all the more significant with the adoption and the further promotion of the Medicare reform. According to the latter, patients are not going to receive financial support from the state government unless specific illnesses are addressed in the course of a treatment (Stevenson et al., 2013). The so-called Prospective Payment Systems (PPS), therefore, cannot guarantee that the choice made by the APRN will be based on the needs of the patient and not the financial benefit of the institution.

Additionally, the option of remaining at home deserves to be mentioned as one of the choices that the patient is free to make. The specified option can be viewed as the issue of the ultimate controversy, as the patient refuses from the services provided by the corresponding healthcare services and chooses to die. As a result, a nurse faces the dilemma of either respecting the patient’s choice and, therefore, doom the patient to death, or going against the patient’s will, yet preserving their life. Therefore, the principle of autonomy as the basis for ethics in nursing may justify the APRN’s decision to consider either the hospice palliative care or the decision to allow the patient to stay at home as compliance with the patient’s desire to either receive the treatment of the finest quality or to retain their relationships with their family, communication with their neighbors, etc.

A Practical Example: Hospice as the Optimum Solution

The case written by Bekkema et al. (2014) can be viewed as a prime example of addressing the dilemma of the end of life from the perspective of autonomy. It is quite remarkable that the situation in the specified case study was aggravated to an even more complicated stage, as the patients in the study had intellectual disabilities. Therefore, taking their choice into account was all the more ethically questioning, as the patients could hardly define what was best for them in terms of psychological and physiological needs.

The study shows that the specified dilemma can and should be addressed from the perspective of virtue ethics, as the given angle helps view the situation from the position of the greater good for the patient and at the same time pay enough attention to the patient’s autonomy as one of the focal points of virtue ethics. More importantly, the example under analysis demonstrates that the uncertainty about the subject matter coupled with the unwillingness to upset the patients often serves as the key factor behind the nurse’s decision to choose the home treatment as opposed to hospice and the related solutions: “Important decisions at the end of life, such as whether or not to start life-prolonging treatment or whether to move to another home, were often taken in multidisciplinary meetings together with relatives” (Bekkema et al., 2014). The study, however, shows quite clearly that it is the choice of the hospice treatment that seems to be the most beneficial one for patients in terms of the quality of care and the services provided. The patient’s gravitation towards the idea of spending the end of their days in the bosom of their families, however, can be enhanced by the specifics of their culture and the closeness between the members of their community. For instance, in a range of African communities, elderly patients prefer to remain among their family members when they are at the death’s door: “Similarly, a study of African Americans facing end-of-life decisions reported that African Americans prefer to have family and friends by their side towards the end of their life” (Hiruy & Mwarni, 2013, p. 192).

Values and Outcomes

Value Leading to a Different Outcome

As it has been stressed above, the choice of the ethical theory, from the perspectives of which the subject matter is viewed, defines the course of the nurse’s actions to a considerable degree. For instance, the value of the patient’s autonomy, which dictates that the nurse’s choices should align with the needs of the patient and that an APRN must respect the patient’s wishes, may lead to the patient being allowed to stay at home with their family, as well as to the conclusion that the hospice treatment is the ultimate solution to the case in point. The value of nonmaleficence, in its turn, will prevent the nurse form suggesting sending the patient to their home, as the specified action is likely to lead to a deterioration of the patient’s physical health with no proper support from the corresponding healthcare services (Baumrucker et al., 2010). Even though the specified approach invites more opportunities for the discussion of the subject matter with the family and the patient (Morrison et al., 2013), the outcomes of the communication are most likely to address the needs of all stakeholders involved; as a result, the needs of not only the patient but also the family members, who may suffer because of the inability to provide proper services to the latter, will be taken into consideration. Moreover, the value in question will also make the APRN reconsider the idea of sending the patient to the nursing home as a cheaper alternative to the hospice, as the given decision will ultimately result in the patient suffering from a much lower quality of the services provided (Maher, 2012).

Similar Examples from Literature

The subject matter has been viewed from a variety of angles after the recent change in the end-of-life services provision. Particularly, the problem concerning the choice between a hospice and a nursing home has been raised (Thorsteinsdottir, Swetz, & Tilburt, 2013). Because of the emphasis on the financial aspect of the issue that emerged with the Medicare reform promotion, a range of healthcare organizations go against their ethical principles and choose not the best, but the cheapest approach, i.e., the nursing home (Miller et al., 2011). Additionally, the freedom of choice versus the wishes of the patient as a major issue has also been discussed quite a few times (Riedl, Mantovan & Them, 2013). Therefore, the authors of most sources seem to agree that the patient’s autonomy plays an essential role in determining the location of the end-of-life care, yet the needs of the people, whom the specified decision will affect, also must be taken into consideration. Consequently, the subject matter can also be viewed from the perspective of the consequentialism theory as the means of addressing the demands of all stakeholders involved.

Ethical Theory: Consequentialism

The ethical dilemma in question can also be viewed from the perspective of consequentialism (Ledger et al., 2012). According to the ethical framework in question, the approach towards the patient and the treatment of the latter must be based on the Medicare reform. As it has been stressed above, the emphasis on the financial aspect of the healthcare services provider has made the process of selecting the appropriate measure for addressing the needs of the patients rather complicated. Moreover, by choosing the hospice environment, an APRN may aggravate the patient’s state due to the restriction in the latter’s contact with the family members (Larcher, 2013). The adoption of the consequentialism approach, therefore, may make the APRN gravitate towards allowing the patients to spend the rest of their days with their family members or in the environment of their home.

Conclusion: Locating the Right Ethical Approach

Making the right choice when defining the appropriate strategy towards the end of life dilemma is complicated due to the numerous stakeholders involved. Because of the financial pressure that APRNs experience after the adoption of Medicare, as well as the need to cater to the emotional needs of the patient, the family environment is often chosen, although the hospice care should be preferred based on the needs of all stakeholders. Based on the principles of consequentialism as one of the key healthcare ethical frameworks, an APRN must consider hospice treatment first as the one that allows for providing the patient will all the resources needed, as well as relieving the family members of the stress from caretaking.

Reference List

American Nurses Association. (2010). Short definitions of ethical principles and theories. Familiar words, what do they mean? Web.

Baumrucker, S. J., Sheldon, J. E., Stolick, M., Oertli, K. A., Harrington, D., VandeKieft, G., & Morris, G. M. (2010). End-of-Life care: When the state is the guardian. American Journal of Hospice & Palliative Medicine, 27(4) 289–294.

Bekkema, N., Veer, A. J. E. de, Hertogh, C. M. P. M. & Francke, A. L. (2014). Respecting autonomy in the end-of-life care of people with intellectual disabilities: a qualitative multiple-case study. Journal of Intellectual Disability Research, 58(4), 358–380.

Faden, R. R., Kass, N. E. & Goodman, S. N. (2012). An ethics framework for a learning health care system: A departure from traditional research ethics and clinical ethics. Web.

Gillon, R. (2014). Defending the four principles approach as a good basis for good medical practice and therefore for good medical ethics. Journal of Medical Ethics, 41(1), 111–116.

Hiruy, K. & Mwarni, L. (2013). End-of-life experiences and expectations of Africans in Australia: Cultural implications for palliative and hospice care. Nursing Ethics, 21(2) 187–197.

Larcher, V. (2013). Ethical considerations in neonatal end-of-life care. Seminars in Fetal & Neonatal Medicine, 18(2), 105–110.

Ledger, U. S., Begley, A., Reid, J., Prior, L., McAuley, D. & Blackwood, B. (2012). Moral distress in end-of-life care in the intensive care unit. Journal of Advanced Nursing, 69(8), 1869–1880.

Maher, J. (2012). Nursing voice needed in end-of-life choice bill debate. Kai Tiaki: Nursing New Zealand, 18(9), 30.

Miller, S. C., Gozalo, P., Lima, J. & Mor, V. (2011). The effect of Medicaid nursing home reimbursement policy on Medicare hospice use in nursing homes. Medical Care, 49(9), 797–802.

Morrison, L. J., Calvin, A. O., Hope, N., & Storey, C. P. (2013). Managing Cardiac Devices Near the End of Life: A Survey of Hospice and Palliative Care Providers. American Journal of Hospice & Palliative Medicine, 27(8), 545–551.

Riedl, M., Mantovan, F. & Them, C. (2013). Being a Nursing Home Resident: A Challenge to One’s Identity. Nursing Research and Practice, 20(3), 1–9.

Stevenson, D. G., Ayanian, J. Z., Zaslavsky, A. M., Newhouse, J. P., &. Landon, B. E. (2013). Service use at the end-of-life in Medicare advantage versus traditional Medicare. Medical Care, 51(10), 931–937.

Swanton, C. (2013). A virtue ethical account of right action. In R. Shafer-Landau, Ethical theory: An Anthology (pp. 644–675). New York, NY: Wiley-Blackwell.

Thorsteinsdottir, B., Swetz, K. M. & Tilburt, J. C. (2013). Dialysis in the frail elderly – a current ethical problem, an impending ethical crisis. Journal of General Internal Medicine, 28(11), 1511–1516.

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