Introduction
As advocates of patients, nurses experience ethical dilemmas, which require them to make ethical decisions according to their professional guidelines and code of conduct. Ethical dilemmas are usually complex and require the application of ethical frameworks in their resolution. According to Canadian Association of Nurses (2008), ethical frameworks are essential in ethical decision-making since they guide and direct nurses on how to make ethical decisions and arrive at favorable solutions, which comply with the code of ethics and nursing standards of practice. Effective resolution of ethical dilemmas is dependent on the ability of nurses to apply ethical frameworks in line with the code of ethics and standards of practice (Bach, Ploeg, & Black, 2009; Ellen, & Kulig, 2012). Essentially, nurses must make ethical decisions in a professional manner to avert unethical acts of commission and omission. Therefore, this essay examines ethical dilemmas associated with end-of-life care and applies the ethical decision making framework (EDMF) in conducting effective, informed, ethical, and professional nursing response.
The Ethical Decision Making Framework
Assessing and Describing the Situation
The case study (appendix A) presents an ethical dilemma of end-of-life care. MacLeod, Wilson, and Malpas (2012) argue that the end-of-life care presents complex ethical dilemmas, which require systemic resolution. The dilemma requires the intervention of nurses because the interests of family members differ in the aspects of the treatment that the father requires. Oncologists and nurses had assessed the condition of Smith and found that the use of life-supporting machine was fruitless because lung cancer had reached a stage where it was a terminal illness. While his wife supports the application of the advance directive, children have consented that it is futile to use life-supporting machine to sustain the life of their father. The children told the nurses not to inform their parents about the terminal condition because it would traumatize them. Hence, the ethical values involved here are truthfulness, client choice, respect for life, client well-being, and privacy and confidentiality. According to College of Nurses Ontario (2009), patients have right to obtain the right information about their condition, but the extent of disclosure varies according to the potential harm of the information. In this case, nurses have to determine whether to inform the parents about the terminal condition and futility of life-support machine.
The ethical dilemmas in the case study have numerous other ethical values. In handling ethical dilemmas, nurses should ensure that they consider client choice, respect for life by preserving human dignity, promote well-being of patients, and treat any information with appropriate privacy and confidentiality (Canadian Association of Nurses, 2008). In this view, nurses should consider the advance directive as an expression of client choice, well-being of the patient by providing the best care, and respect for human life and dignity by promoting quality of life. Additionally, nurses should treat divergent views as private and confidential information to avert conflicts in the family. Fundamentally, nurses have to assess if the advance directive is rational and effective in improving well-being and quality of life (Halpern, Loewenstein, Volpp, & Cooney, 2013). Two possible ways of resolving the dilemmas are to inform his wife about the terminal condition and futility of life-support system with a view of not adhering to the advance directive or adhere to the advance directive by not informing the wife about the terminal illness and futility of life-support machine to avoid traumatizing her.
Making Plans/Deciding Upon an Approach
In the resolution of the dilemma, the appropriate approach is to inform the wife about the terminal condition of his husband and explain how life-supporting machine would not help sustain his life. Truthfulness and honesty enable patients and surrogates to make informed decisions of the treatment interventions (Fowler & Hammer, 2013). Hence, as a surrogate, the wife requires the right information regarding the condition of his husband and treatment interventions necessary. College of Nurses Ontario (2009) holds the nursing practice of standards and ethical values of well-being and respect for life require the use of reasonable efforts in preserving human dignity. Since the use of life-supporting machine is futile, it does not constitute a reasonable effort. Therefore, the approach requires counseling of the wife to mitigate the impact of bad news and consultation among children, nurses, wife, and oncologists regarding the enforceability of the advance directive.
Implementation
After extensive consultation on the approach of resolving the dilemma, the implementation process is necessary. The first activity entails provision of the right information to the family members, particularly the wife. Thorns (2010) asserts that disclosure of the right information enables patients to make informed decisions about their treatment options. The process of disclosing shocking information is very delicate, and thus, the wife requires appropriate counseling to mitigate the impact of bad news on her life. Moreover, oncologists, nurses, children, and the wife would consult each other and agree on how to overrule the advance directive basing on the facts of the terminal illness and futility of life-support machine. Eventually, oncologists, nurses, and family members have to accept the fact that Smith has a terminal condition and their decisions would lead to a natural death. Since the fact could cause trauma, the parties involved require social support and counseling. Burkhardt, Nathaniel, and Walton (2014) argue that support systems are essential because the resolution of ethical dilemmas affects parties involved. The provision of social support and counseling would be appropriate after the implementation of the plan as it enables healthcare providers and family members to cope with the trauma associated with the action taken.
Evaluation of Outcomes
The decision to inform the family members about the terminal condition of Smith and the futility of using life-support machine complies with the ethical values, nursing standards of practice, and code of ethics for registered nurses in Canada. According to Toren and Wagner (2010), resolution of ethical dilemmas should comply with the ethical values such as truthfulness, preservation of human dignity, promotion of well-being, and provision of ethical care. The decision made complies with these ethical values, and thus, it is an effective approach. From the case study, it is evident that the family members lacked the right information regarding the terminal condition of Smith and the ineffectiveness of life-supporting machine. Kirklin (2007) argues that truthfulness is important because it grants autonomy to patients for them to make informed decisions regarding their treatment options. Therefore, healthcare centers should formulate policies and guidelines that direct them in the resolution of ethical dilemmas.
Conclusion
Ethical dilemmas often complicate nursing practices for the available ethical frameworks and guidelines do not provide clear resolution mechanisms. The case study depicts an ethical dilemma of end-of-life care and issues related to the terminal illnesses and the use of life-support machine. The existence of the advance directive and lack of the right information compelled the family to make uninformed decisions. Hence, the resolution of the dilemma required the disclosure of the right information and engagement of family members and healthcare providers in the decision making process. Being a sensitive issue, the resolution of the ethical dilemma needs a social support system and counseling of involved parties. Analysis of the expected outcomes shows that they comply with the ethical values, codes of ethics, and nursing practices in Canada.
References
Bach, V., Ploeg, J., & Black, N. (2009). Nursing roles in decision making in critical care settings, Western Nursing Research, 31(4), 496-512.
Burkhardt, M.A., Nathaniel, A.K., & Walton, N.A. (2014). Ethics and Issues in Contemporary Nursing (2nd ed.) Toronto, ON: Nelson Education.
Ellen, M., & Kulig, J. (2012). Palliative and end-of-life services in rural and remote geographies. Journal of Rural and Community Development, 7(4), 1-3.
Canadian Association of Nurses. (2008). Code of Ethics for Registered Nurses. Web.
College of Nurses Ontario. (2009). Practice guidelines: Ethics. Web.
Fowler, R., & Hammer, M. (2013). End-of-life care in Canada. Clinical & Investigative Medicine, 36(3), 127-132.
Halpern, S., Loewenstein, G., Volpp, K., & Cooney, E. (2013). Default options in advance directives influence how patients set goals for end-of-life care. Health Affairs, 32(2), 1-10.
Kirklin, D. (2007). Truth telling, autonomy, and the role of metaphor. Journal of Medical Ethics, 33(1), 11-14.
MacLeod, R., Wilson, D., & Malpas, P. (2012). Assisted or hastened death: The healthcare practioner’s dilemma. Global Journal of Health Science, 4(6), 87-98.
Thorns, A. (2010). Ethical and legal issues in end-of-life care. Clinical Medicine, 10(3), 282-285.
Toren, O., & Wagner, N. (2010). Applying an ethical decision-making tool to a nurse management dilemma. Nursing Ethics, 17(3), 393-402.
Appendix A
Created Ethical Dilemma
Smith is a 65-year-old man, who suffers from lung cancer and depends on life-support machine. Smith has been suffering from lung cancer for a period of 10 years and has been relying on chemotherapy from Ontario Healthcare Center. Oncologists have assessed his condition and have noted that he has limited chance of survival as his condition has progressively worsened with time. Smith had issued an advance directive, which required the use life-support machine since he hoped it would improve the prognosis of his condition. His wife, Sarah, who has 60 years, is also optimistic that the life-support machine would enable her husband to recover, and thus, she enforces the advance directive. As oncologists have indicated that Smith has minimal chance of survival, his children decided not to inform their parents about the prognosis of the condition because it would traumatize them and cause other complications.
In the case study, the dilemma emanates from the use of life-support machine in prolonging the life of Smith. As Christians, Smith and his wife believe that the use of life-support machine is an effective intervention that would improve prognosis of the condition. On the other hand, healthcare providers, nurses, and oncologists have lost hope, as they perceive all interventions as fruitless, including the use of life-support machine. Moreover, his children have weighed the options of life-support and concurred that their father has a negligible chance of survival. In this view, nurses experience ethical dilemmas on whether to support Smith and his wife in the use of life-support machine or inform them about the prognosis and the futility of using the life-support machine.