Ethical problem
Stacy (2012) reviewed a case study of an irreversible case of pneumococcal pneumonia who had become mechanical ventilator support dependent. The male patient had decided to be removed from the ventilator and allowed to die with full knowledge of his irreversible condition and the eventual death that will come upon him after all life-maintaining support were removed. Although the family did not agree on the removal of the life-support treatment, they acceded to the wish of their father and approved the gradual removal of the ventilator referred to as terminal weaning. This case, unlike most controversial cases that leads to the controversial issue of the right of the treatment team to withhold or discontinue the life-support treatment when it considers the patient’s prognosis as “futile” despite the explicit desire of the patient or his family to keep the life-support on, constitute an easy case to decide and handle by nurses and other healthcare professionals involved in the interdisciplinary team handle the patient’s.
However, what will the nurse do had the situation was the opposite of the case studied? Is it ethical for the treatment team, including the nurses, to do so? Is that action tantamount to killing? Even if the patient, or his family if the patient is no longer competent to make the decision, requests the removal of the life-support treatment, is it ethical for nurses to withdraw the life-support treatment and let the patient die?
Hypothesis, perspective, and position
Section D (“Preserving Dignity”), number 9 of the Code of Ethics for Registered Nurses vowed nursing support to terminally ill or dying patients by providing them comfort, alleviating their suffering, advocating for relief of their discomfort and pain, and supporting their dignified and peaceful death (CNA, 2008). Moreover, the American Nurses Association (2013) reiterated that nursing care should prevent and relive the dying patient of the symptoms and suffering and nurses should “not act with the sole intent of ending a patient’s life” (p. 2) on grounds, such as compassion, respect for patient autonomy, and quality of life issues.
My position supports the professional stand of the CNA and the ANA in upholding a nursing care that provides palliative care to dying patients and does not support the withdrawal or withholding of the life-support treatment even at the medical opinion of “futile” treatment unless the patient, or his family if the patient becomes incompetent to make the decision, decides to let this be removed. Subsequently, I believe that medical opinion on treatment futility is not ethically adequate to give it the authority over the life of the dying patient without his or his family’s consent.
Other salient perspectives and positions
The American Nurses Association (2013) insisted that it is unethical for ICU physicians not try to rescue patients with irreversible conditions even against the will of referring physicians or relatives. This is so even if critics may label this action as tantamount to providing disproportionate care in the ICU (thus, a waste of organizational resources, which can be provided to patients with better prognosis) and an act of injustice, unfair, inequitable, and inappropriate distribution of scare ICU resources in society. These arguments, however, assumes that the pronouncement of “poor expectations” rightly and justifiably losses the patient’s claim for his right to be provided medical care until death if the patient chooses to.
Such attitude unwittingly disrespects the dignity of the dying person, brushing him off with lesser right for nursing and medical care simply because he was pronounced of poor expectations (ANA, 2013; CNA, 2008). The idea of “waste” of organizational resources holds only when these resources are given to those who ‘do not deserve’, cutting the value of the dying person far less than those who are not dying (Lachman, 2015).
Furthermore, even if prolonging the life of the terminally ill patient increases hospital operating costs, compromises the patient’s quality of life, causes moral distress and avoidance behavior in ICU nurses (e.g. restricts their ability to exercise autonomy in initiating decision making to remove life-support measures), and violates the will of the patients many of which refuse to postpone their death, nurses should not shirk from their obligation to provide life-supporting service. The contention of increasing hospital operating costs is invalid because hospitals are essentially business institutions that provides services to patients, including dying patients, with profitable prices in mind. Thus, while providing ICU services to dying patients, the hospital nevertheless recovers those costs and make profits over it. Conversely, the compromised quality of life of the dying patient is not for the director of the ICU to decide but of the patient and his family. If the patient or his family prefers to prolong the life of the patient, then such ‘concern’ is misplaced and dishonest. In addition, the issue on the moral and emotional distress of ICU nurses is blown out of proportion because nurses who are committed to their chosen profession will not discriminate their services between dying and non-dying patients. The moral distress can only reasonably occur if the nurses insist on expecting more recovering from the patient than is possible and refuse to accept the facts of the patient’s terminal situation. The professional centeredness of nurses serves them better in providing nursing care than the purported emotionality assumed by Kompanje, Piers, and Benoit.
Moreover, ANA (2012) further recommends that ICU physicians should not decline admission of patients again with poor expectations wherein care adds no value to the patient unless the patient preferred that option as in Stacy’s case study. Declining admission of patients with “poor expectation” is tantamount to refusing the dying patient his right for medical and nursing care, an unjust act for not treating all like cases alike. In fact, doing so will hold the physician and the hospital criminally liable for that action. That constitute an unethical refusal of the hospital to provide medical care to the patient. Conversely, the contention of “no value” of ICU services to the patient is not for the ICU physician to make because the concept of value is different from that of the physician and that of the patient and his family. For the patient and his family, the knowledge that the dying patient receive life-support treatment can be considered adequate value more than the prospect of full recovery or even survival. Staying longer with a love one can mean to certain families more than the money they pay for ICU services. For the ICU physician or nurse to make that decision for the patient or the parents will be overreaching their capacity to make life-death decision for dying patients.
Impacts
Prolonging the life of a terminally ill patient may be the principal cause of moral distress of ICU nurses who will be charged in delivering of the “futile care” and in communicating unrealistic prospects to patients and their families. It will also lead to compassion fatigue and burnout as a consequence of providing care to patients without prospect for survival. However, this view underestimates the nurses’ professional capacity to provide nursing care to their dying patients with objectivity over the patients’ terminal condition and likelihood to coming death. A nurse who gets burned out in the prospect of death of her dying patient make an erroneous choice of profession. Instead, caring for a dying patient gives the ICU nurse provides a unique professional opportunity to live up to her vow to care for the patient until his death. Such nursing service is the epitome of the nursing profession, providing care from life until death. Razban et al (2016) insisted that the attitude of nurses can influence the discourse over withholding and withdrawing of life-support treatments to dying patients. And they are required to make a choice in favor of the patients they serve.
The insistence of healthcare providers to make a decision whether to provide or not medical care to dying patients takes away from these patients their right for medical care, their right to be respected towards their death the same respect accorded to non-dying patients, and their sole right to make the ultimate decision to be removed from the life-support treatment in order to die. Thus, while the patient or his family believes that medical care is necessary, the hospital has the ethical obligation to provide the dying patient medical and nursing care until his death as long as the patient or his family are willing to pay the price of medical and nursing care. Acting otherwise will be unjust and results to criminal liability under the law (Lachman, 2015)
The ethical issue over consenting to the insistence of certain healthcare providers to decide whether or not to provide or refuse medical and nursing care to dying patients challenges the nursing profession to look into its values as a care providing profession. It challenges the nursing profession to reevaluate its stance on the end-of-life nursing care issue and find the most ethical stand that reflects its historical compassion and commitment to the patient’s care.
Conclusion
The withdrawal of life-sustaining treatment bears a fundamental question on the right of the healthcare provider to do so without the express consent of the patient or his family if the patient is rendered incompetent by his condition to do. The insistence of certain healthcare providers for this authority to decide implies a deep-seated value that disrespects the right of the dying to a life-sustaining medical care, which is protected by law and, thus, comes with a criminal liability to those who insists of violating it. My position to uphold the lofty ideals of the nursing profession is consistent with the respect of human dignity and the privilege for providing patient care even to the dying.
References
ANA (American Nurses Association). (2013, April 23). ANA Position Statement: Euthanasia,
Assisted Suicide and Aid in Dying. Silver Spring, MD: ANA Center for Ethics and Human Rights.
CNA (Canadian Nurses Association). (2008, June). Code of ethics for registered nurses. 2008
centennial ed. Ottawa, ON: Canadian Nurses Association.
Lachman, V.D. (2015, January-February). Voluntary stopping of eating and drinking: An ethical
alternative to physician-assisted suicide. Medical Surgical Nursing, 24(1): 56-59.
Razban, F., Iranmanesh, S., Aliabadi, H.E., & Forouzi, M.A. (2016). Critical care nurses’
attitude towards life-sustaining treatments in South East Iran. World Journal of Emergency Medicine, 7(1): 59-64.
Stacy, K.M. (2012, June). Withdrawal of life-sustaining treatment: A case study. Critical Care
Nurse, 32(3): 14-24.
