Introduction
Moral conundrums are a common occurrence in most healthcare settings. They often stem from conflicting values, personal interests, and institutional principles (Bremer & Holmberg, 2020). These challenges are solved by acknowledging individuals’ rights and respecting their expectations. Nevertheless, moral conflicts can become more complex when dealing with unconscious patients who cannot decide on their own and lack a medical directive. This necessitates that care workers incorporate ethical standards into their decision-making.
Description of the Dilemma
The quandary involves a patient’s spoken intentions to forego resuscitation in case her health condition exacerbates and her inability to formally convey this request through an advanced directive (AD), particularly a do-not-resuscitate (DNR) order, before becoming unconscious. The precipitating factors include the patient’s age, her advanced heart failure, her stated desire to avoid resuscitation, and her incapacity to sign a DNR due to unconsciousness. There are several barriers to resolving the problem.
Firstly, the lack of a legally binding document that discloses the patient’s explicit wishes on how the situation should be handled impedes resolution-making. Secondly, a possible conflict between the client’s desires and healthcare practitioners’ moral and legal responsibilities to provide the best possible care can obstruct the resolution of the impasse. Lastly, the uncertainty of the client’s family members’ choices on her behalf can deter a prompt solution to the issue.
Bias Impact
As a nurse practitioner (NP), I have always been biased towards respecting client autonomy; thus, I might be more inclined to advocate for the patient’s voiced request to be honored regardless of the lack of an AD. The bias for patient autonomy, coupled with the fact that the client had informed me about her wish not to be resuscitated, may only strengthen my resolve to ensure that her right to self-determination is respected. This implies that my partiality to patients’ freedom regarding their health may limit my ability to consider other perspectives, such as a healthcare provider’s duty to preserve or prolong the patient’s life at all costs. Therefore, recognizing and managing my biases can help me adopt an impartial approach when evaluating the dilemma, ensuring the patient’s interests are prioritized.
Relevant Ethical Principles
Various moral standards, including beneficence, justice, autonomy, and non-maleficence, are relevant to this scenario. Beneficence is integral to the case because it emphasizes that care providers act in the patient’s best interests. Justice is pertinent in this matter, as it directs a fair and equitable distribution of healthcare resources to meet the client’s fundamental needs. Autonomy is salient in the quandary because it emphasizes a patient’s freedom to self-determine their care (Varkey, 2020).
Non-maleficence is also applicable to this problem since it directs healthcare professionals to choose interventions that best minimize patient harm. While all these principles are critical, autonomy takes precedence over the rest. This is because, although the patient lost consciousness before making her desire official through an AD, her wish to avoid resuscitation ought to still be respected.
Honoring a patient’s autonomy entails recognizing their ability to decide on their healing process fully. In this regard, since the patient expressed her wish not to be resuscitated when she was still rational, this stance should guide the decision-making procedure as long as no compelling reasons override her preferences.
Theories
King’s conceptual system incorporates three components that can be leveraged to evaluate and propose solutions to the moral issue. One of these includes the personal system, which ensures that the patient’s values and experiences that might influence her decision-making are recognized (Goodwin et al., 2002). These may include past medical interventions and the pain being experienced that might cause her to refuse resuscitation.
Secondly, the model is based on the interpersonal system, underscoring the importance of cooperation and goal-setting to achieve the highest-quality care outcomes that meet patients’ needs. A nurse could mediate a discussion with the family to accurately convey the patient’s intent concerning end-of-life care, including resuscitation. Thirdly, the social system aspect considers the legal and ethical codes that guide medical practice and patient rights (Goodwin et al., 2002). In this case, an NP can consult hospital policies and legal requirements to determine how to proceed without a formal DNR.
The ethical issue can also be addressed through the synergy model. This framework advocates for patient satisfaction as a key outcome in the nursing process. In this context, this would require caregivers to respect the patient’s autonomy and final life choices. Clinicians are obligated to leverage competencies, comprising clinical judgment and ethical decision-making, to support patient needs and achieve the best possible outcomes.
According to Nania et al. (2021), the synergy structure is associated with positive staff satisfaction and empowerment, suggesting that NPs who operate within this framework may feel supported in making choices that align with their clients’ needs. The model has also been shown to positively influence system-related outcomes. When applied to this predicament, a nurse can work within the medical system to navigate the legal and ethical complexities of implementing the patient’s verbal wishes without a formal DNR order. This could involve interdisciplinary collaboration and consultation with the ethics committee to find a resolution that aligns with the patient’s needs.
Concepts from the Models and Their Relevance
King’s theory incorporates a goal-setting perspective that requires mutual agreement on health objectives between the practitioner and the patient. In the case presented, this would involve respecting the client’s conveyed requests not to be resuscitated as a shared goal, even in the absence of a formal DNR (Goodwin et al., 2002). Additionally, it is inherent to King’s premise that patients’ and care providers’ perceptions should be recognized.
The patient’s perception of her quality of life and need for autonomy should guide the care decisions. Lastly, the transactional process dictates that NPs must provide information and support, but people reserve the right to make informed decisions about their care (Goodwin et al., 2002). The strategy can ensure that providers comply with the Patient Self-Determination Act (PSDA). This concept demands that the medical team take actions that honor one’s verbal or written communication.
The synergy approach also has various concepts that can help address people’s end-of-life preferences. One of the areas the theory focuses on is reducing patients’ complications. In this case, unnecessary interventions such as unwanted resuscitation can be avoided to minimize harm. The NP’s refusal to resuscitate the client may prevent additional suffering and complications associated with such procedures.
The model is also based on the patient satisfaction notion, which requires NPs to honor a patient’s request. The principle of autonomy is realized when the client’s needs are met, and her right to make decisions about her own care is respected. Finally, the model has implications for nursing education, underscoring the need for nurses to develop competencies to meet patients’ needs. This means that NPs must be knowledgeable about the legal and ethical aspects of patient care, which can help fulfill a patient’s wishes when a written DNR is unavailable.
Proposed Solutions
The concepts of the personal, interpersonal, and social systems in King’s framework can be utilized to ensure that the patient’s needs are recognized, the patient’s family and the medical team are engaged to convey the patient’s wants, and legal and ethical standards that govern the clinical process and patient rights are easily navigated. Therefore, some remedies for this plight include documenting the patient’s verbal wishes, which caregivers can communicate to all relevant parties.
Similarly, family meetings should be facilitated to discuss the patient’s aspirations, and clear and compassionate information should be provided. Lastly, the hospital’s ethics committee and legal advisors can be consulted to explore ways to honor the patient’s verbal wishes if an official DNR is unavailable.
The synergy framework can also be applied to propose solutions to this dilemma. In this case, the patient’s characteristics, including her articulated desire for DNR, are a critical need that requires specific nurse competencies. As a medical practitioner, skills such as ethical judgment, patient advocacy, and end-of-life care planning can help achieve the best possible outcome. This can be realized when the NP’s actions reflect the patient’s articulated preferences.
Therefore, some ways to address this problem may include advocating for the patient’s autonomy and cooperating with the healthcare team to honor their wishes. Medical attention should be coordinated to align with the patient’s final wishes, including palliative care options. The patient’s family must be engaged in shared determinations and supported as they navigate the challenging situation
Conclusion
Ethical conundrums can hamper treatment or result in suboptimal services, thereby adversely affecting a patient’s health outcomes. Therefore, healthcare workers must solve such complexities by adhering to the principles of autonomy, non-maleficence, justice, and beneficence. In addition, a patient’s AD can help determine the appropriate steps to be taken in case they fall unconscious or are in a coma.
References
Bremer, A., & Holmberg, M. (2020). Ethical conflicts in patient relationships: Experiences of ambulance nursing students. Nursing Ethics, 27(4), 946–959.
Goodwin, Z., Kiehl, E. M., & Peterson, J. Z. (2002). King’s theory as foundation for an advance directive decision-making model. Nursing Science Quarterly, 15(3), 237–241.
Nania, T., Barello, S., Caruso, R., Graffigna, G., Stievano, A., Pittella, F., & Dellafiore, F. (2021). The state of the evidence about the synergy model for patient care. International Nursing Review, 68(1), 78–89.
Varkey, B. (2020). Principles of clinical ethics and their application to practice. Medical Principles and Practice, 30(1), 17–28.