Nursing Ethics for End-of-Life Planning
Nurses bear special responsibility as they care for patients who could become terminally ill. They hold a unique position as not only a medical professional but as a resource and advisor for families and individuals facing imminent death. Nurses have the opportunity to influence and help people in some of their greatest times of need. Because of this, the ethical and legal issues that come into play can be complex and should be navigated with care.
Guidelines Produced by the American Nurses Association
The American Nurses Association’s Center for Ethics and Human Rights published a position statement effective in 2016 (updating a position last published in 2010) that articulates their guidelines for nurses in the case of end-of-life care. This document states that “Nurses are obliged to provide comprehensive and compassionate end-of-life care.” Here are a few of the services a nurse should be prepared to provide for his or her patient should they be reaching a terminal point:
- Recognition: The nurse should be able to recognize signs indicating that his or her patient could be nearing death.
- Family contact: The nurse should engage in communication with the patient’s family. It is imperative that the family is notified with enough time to be able to see the patient, spend time with them, help make treatment decisions and begin to make arrangements for their death.
- Coordination with other medical professionals: The nurse must be able to communicate with not only other physicians working with the patient but with any other professionals or resources that could be utilized in a patient’s case, including ethics professionals or committees, lawyers or attorneys or decision-making experts.
- Understanding of ethics principles that could affect decision-making: Making decisions surrounding the imminent death of a patient can often produce difficult, nuanced or ethical conundrums. Nurses should be equipped to help families and individuals understand the situation at hand and be able to guide them through decisions.
Ethical End-of-Life Situations Nursing Professionals May Encounter
Nurses who work closely with those approaching the end of their life because of age, terminal illness, or other causes will confront difficult ethical situations and must be prepared to choose the course of action that will best serve their patients, his or her family, and the nurse’s employing entity. Nurses can broaden their perspective and be better prepared for these often convoluted situations by studying health care related legal cases and reviewing ethical research and case studies published by reputable sources.
As an example, an ethical case exploration was published by the International Journal of Nursing Sciences in December of 2015. The case involved a 57-year-old patient diagnosed with aggressive prostate cancer and told he may have only 4-6 weeks to live. The patient disclosed to one of his caretaker nurses in private that he planned to commit suicide and requested that the nurse not tell anyone of his plan. The nurse had to decide how to proceed – should she respect his wishes for her silence or opt to reveal his plan to other involved caretakers to prevent the suicide plan?
The situation described above is far from an isolated scenario. Jessica Zitter, M.D, addresses ethical end-of-life questions in her book Extreme Measures: Finding a Better Path to the End of Life. She hypothesizes that, contrary to what many medical professionals may be taught in medical school, attempting to keep every patient alive as long as possible by whatever mechanical or device-laden means necessary may not be the most ethical mindset with which to approach end-of-life care. When should comfort and dying in a more whole or lucid state, though more quickly, be endeavored in favor of keeping a patient technically alive but unresponsive or unaware?
Several foundational ethical principles come into play when nurses make medical care decisions and should form the basis of every nurse’s decision-making process. The Online Journal of Issues in Nursing compiled a shortlist of these principles. “Autonomy” refers to a nurse’s agreement to respect another person’s right to independent decision-making. “Beneficence” refers to a nurse’s responsibility to act according to the patient’s benefit and to provide compassionate care. “Nonmaleficence” requires that a nurse not cause harm or hurt to their patients. “Fidelity” refers to acting with loyalty, fairness, honesty, and dedication and requires keeping promises made. These, along with other core ethics principles, must inform a nurse’s decision-making when faced with complex end-of-life questions of care.
Recommendations for End-of-Life Care
For a nurse to be proficient in end-of-life care, they should be able to:
Recognize the multi-faceted nature of comfort. Providing quality care does not just involve physical actions but requires attention to emotional, spiritual and psychological needs. Nurses must demonstrate aptitude in not just treating a patient’s physical pain or illnesses but should demonstrate a care for their wishes, desires, emotions and beliefs. A nurse does not have to share religious views or need personal experience with the illness or condition at hand to be able to offer a listening ear and a compassionate touch. Often these actions will more significantly benefit a dying patient than administering pain medication or providing physical care.
Understand palliative care. Nurses should have a strong understanding of what types of care can help a dying patient manage their pain symptoms to provide comfort. Palliative care refers to treatment that isn’t meant to cure the underlying condition but rather to relieve pain or provide comfort to ensure as painless an end as possible for the patient. This mindset must be understood for effective clinical decision-making.
Stay up to date on end-of-life care. Nurses who work with terminally ill patients should take the time to research strategies and best practices in advance care planning. They should devote time to professional development in this area so that they can provide up-to-date care for every patient.
The Effects of Decisions on Terminal Patient Care
Decisions made by nurses pertaining to their terminally ill patients can significantly affect not only those patients but their families, other caretakers and any other involved medical professionals. Nurses must be able to recognize the point at which curative treatment may no longer be viable and a transition to palliative care to simply keep the patient as comfortable as possible may be necessary. Nurses should also keep themselves up to date on state and federal laws that pertain to terminal patient care. One example of this type of legislation is the Death with Dignity Law. According to DeathWithDignity.org, 35 states have either already passed or are considering enacting legislature that would allow physician-assisted death. Nurses that practice in these states should be aware of the implications of such legislation.
Nurses who serve terminally ill patients should make an effort to stay as apprised as possible regarding the latest in terminal illness ethics, state and federal statutes and resources available to the terminally ill and to their families. Nurses have a responsibility to those with terminal illness to do all they can to provide comfort and good counsel during their last days. Because of this, lawyers who work with nurses in end-of-life cases or provide counsel to either patients or nurses must make sure they understand the legislative precedents in each state in which they practice that might pertain to such situations.
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Critical Care Nurse
Death With Dignity
Nurses Service Organization
American Nurses Association – Code of Ethics for Nurses
American Nurses Association – Short Definitions of Ethical Principles
American Nurses Association – Nurses’ Roles and Responsibilities