Ethical Reasoning and Nursing Care for End of Life

Moral vs ethical reasoning

- Moral
> thinking that is guided by personal standards or right and wrong
- Ethical
> thinking that is guided by professional standard that have been derived from the formal study of what criteria should be used to determine whether actions are justified

3 Cat of moral and ethic problems

- moral uncertainty
> which moral or ethical principles apply
- Moral dilemma
> when faced with a situation in which you have 2 or more choices but none seem sufficient
- Moral distress
> you as an individual know the right thing to do but institutional constraints make it nearly impossible to do what is right

5 ethical principals

- Autonomy
> people have the right to choose
- Nonmaleficence
> avoid harm
- Beneficence
> balance benefits against risk or harm
- Justice
> treat people fairly
- Fidelity
> keep your promises and dont make promises you cannot keep

Utilitarian Approach

the action is right or wrong based on consequences of the action

Deontological

- the action is right or wrong based on a rule that is independent of the consequences

The ANA Code of Ethics

- Practice with compassion & respect for each person's dignity, worth & unique individuality
- Keep your primary commitment to consumers
- Promote, advocate for and protect the health, safety & rights of patients
- Acknowledge that nurses have the authority, accountability and responsibility for individual nursing practice
- Respect your OWN worth & dignity
- Participate in establishing, maintaining and improving the health care environment for both patient & workers
- Advance the profession
- Collaborative with other professionals
- Work with nursing professional organizations

Application

- Assess: gather information to identify any ethical issues that may be present
> Is there a conflict present?
- Diagnose: make a list of possible problems
> What is the main ethical issue & who are the key stakeholders?
- Plan: what are your personal values & will they influence your ability to participate in the decision making
> Which choice is most likely to give the greatest balance of benefit vs possible harm?
> Develop a collaborative plan of action!
- Implement: put your plan into action
- Evaluate: monitor the outcome & identify were modification is needed

What can we do

- advocate
- professionalism
- professional boundaries

Advanced Directive

- Living will: Designates the types of medication treatment you would or would not want in a specific situation
- DNR: Do not resuscitate
- DNI: Do not intubate (CPR, medical management but no airway support)
- AND-I: allow natural death with interventions (medications, no CPR)
- AND: allow natural death
- POLST & MOLST: Physician's order for Life Sustaining Treatment & Medical Orders for Life Sustaining Treatment

Key decision makers

- The patient
- Durable power of attorney: Identifies WHO you want to make financial decisions if there you are not able to do so for yourself
- Proxy: a document that allows a person/patient to appoint another person the right to make medical decisions in the event that they are no longer able to do so
- Medical power of attorney: Identified WHO you want to make healthcare decisions in the event that they are no longer able to do so

Options for End of Life Care

- Palliative Care: specialized care for those living with serious illness focused on relieving symptoms & stress of the illness with a goal to improve the quality of life
> Patients can continue to have life sustaining procedures & treatments while receiving palliative care
- Hospice Care: end of life care that focuses on the quality of life when expectancy is less than 6 months time
> Patients do not continue to receive life sustaining treatments with a focus shifted to comfort and pain relief

Palliative Care

- What is the focus
> It focuses on the pain, symptoms and stress of serious illness most often as an adjunct to curative care modalities
- Who receives this care?
> Any individual with a serious illness, regardless of life expectancy or prognosis.
- Can my pt continue to receive curative txmt?
> Yes, individuals receiving palliative care are often
still pursuing curative treatment modalities.
- what services are provided?
> Pain and symptom management, help navigating treatment options, advance care planning and referrals to community resources.
- Where are services are provided?
> Anywhere medical care can be provided

Hospice Care

- What is the focus
> Hospice care focuses on the pain, symptoms, and stress of serious illness during the terminal phase.
- Who receives this care?
> Any individual with a serious illness measured in months not years.
- Can my pt continue to receive curative txmt?
> No, hospice should be considered at the point when the burden of any given curative treatment modalities
outweighs the benefit coupled with prognosis.
- what services are provided?
> Pain and symptom management, medical equipment, related medications, respite care, volunteer services, spiritual care, bereavement and counseling services.
- Where are services are provided?
> Most care settings