The Ethical Dilemma of Advance Directives
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The Ethical Dilemma of Advance DirectivesAntoinette McNeil, BSN, RN, CCRNWashington Adventist UniversityEthics and the Adult Educator (Online)NUED 545Khadene Taffe, DNP Student, MSN-NE, BSN, RNApril 16, 2013The Ethical Dilemma of Advance DirectivesIntroductionPatients in years past died from infection or dehydration and they died at home with their love ones present at their bedside. Today many patients who have pneumonia, stroke, heart attack or trauma benefit from the technology of ventilators, cardiopulmonary resuscitation (CPR) and intensive care units (ICU) and the use of antibiotics and feeding tubes (DeWolf Bosek & Savage, 2007). With this increase technology many are living longer but it does not speak for their quality of life. In the 1950’s healthcare professionals and life guards started using mouth-to-mouth resuscitation. In the 1960’s, Drs. W. B. Kouwenhoven, G.G. Knickerbocker, and J. R. Jude incorporated chest compressions to mouth to mouth resuscitation to create CPR as we know it today (DeWolf Bosek & Savage, 2007). CPR’s purpose was to revive a healthy individual’s heart after a witness cardiac arrest (DeWolf Bosek & Savage, 2007). Today it does not matter if the individual is healthy or not, if they have a cardiac arrest event CPR will be performed.Patients wanting to have control over their healthcare decisions and how they die wanted autonomy. In the 1960’s, patient autonomy began to be asserted as an essential principle of medical ethics much to the dismay of the physician (Lynch, Mathes, & Sawicki, 2008). When looking at autonomy one assumes that one is free from the control of others and the individual have the capacity to make their own life choices (Morrison, 2011). Unfortunately, the idea that the patient had the right to make autonomous healthcare decisions was not recognized until 1973 when the American Hospital Association (AHA) drafted the Patient Bill of Rights (DeWolf Bosek & Savage, 2007).In 1990, Congress passed the Federal Patient Self Determination Act (PSDA) which was to promote patient participation and knowledge about health care options available for treatment (DeWolf Bosek & Savage, 2007). The act mandated that any healthcare institution receiving Medicaid or Medicare funds are to do the following: 1. Ask the patient upon admission if they have an Advance Directive (AD); 2. Provide written information regarding their rights to accept or refuse medical/surgical treatment in accordance to state law; 3.Give the patient the right to complete and AD; 4. Document the AD in the patient’s record; 5. Establish and communicate to staff, caregivers and patients a policy regarding implementing Advance Directives; and 6. Include a clear and precise explanation of any conscious objection that a provider, facility or provider’s agent may have regarding following an individual’s AD. Only conscious objections are allowed under state law to be included in the facilities policy (Watson, 2010).The Joint Commission (TJC) is a national organization that certifies hospitals for adherence to quality standards, supporting patient’s right to make decisions regarding their care. The Joint Commission requires hospitals to determine if every patient has an AD or requires hospitals to provide assistance to a patient completing an AD if they wish to do so (Meehan, 2009). With patient’s wanting autonomy regarding healthcare decisions, the enacting of legislation of the PSDA, Advance Directives were developed. Advance Directives focused on two principles: an individual’s right to die and death with dignity (Meehan, 2009). The question then is raised why the majority of the population isn’t drawing up Advance Directives and why they are not being enacted. Knowledge is power and unfortunately many in healthcare do not understand advance directives. As nurses we are bound by a code of ethics when it comes to caring for and advocating for our patients. The Code-of-Ethics for Nurses Provision 1.4 states that patients have the moral and legal right to determine what will be done with their own person; to be given accurate, complete, and understandable information that facilitates informed judgment. It also states that the nurse has the obligation to know about the moral and legal rights of all patients’ self-determination (American Nurses Association website, n.d.). Just to say that your patient has an Advance Directive is not enough it is your obligation to know what their Advance Directive states so that one can be an advocate for their wishes. Literature ReviewThe purpose of Advance Directives is to allow an individual to express how much or how little intervention should be done when the ability to make decisions no longer exists (Meehan, 2009). When asking about Advance Directives many will ask what is that due to they have a lack of knowledge. There are different types of advance directives and they are the following: living wills and durable power of attorney for health care. Living wills allow a patient to reject death-delaying procedures in the event that they are imminently dying from a terminal illness (DeWolf Bosek & Savage, 2007). It is known as the “five wishes” and it comes into effect when the patient has only 6 months to live (Watson, 2010). The living will helps give direction to the healthcare providers, family and surrogates regarding the patient’s wishes regarding the care they may or may not want when they can no longer make decisions for themselves (Watson, 2010).The Durable Power of Attorney for Health Care (DPOAHC) allow the same provisions as a living will but it also identifies a surrogate to make decisions whenever the patient lack decisional competence and is unable to direct in their own decision-making (DeWolf Bosek & Savage, 2007). The DPAHC becomes effective when the patient becomes unconscious or incapable of communicating their wishes. It is at that time that the healthcare agent is responsible for carrying out the patient wishes that are written and the healthcare agent cannot change the patient expressed wishes in the DPAHC (Watson, 2010).There is a new form of advance directive known as the Physicians Order for Life-Sustaining Treatment (POLST). This form requires a physicians order and can be used in conjunction with the patient’s existing advance directive. This form addresses four areas: CPR, antibiotic use, artificial nutrition, and medical intervention desired by the patient (Watson, 2010).The legal cases that sparked the need for individuals to make their end-of-life-care (EOLC) decisions were Karen Ann Quinlan in 1976 and Nancy Cruzan in 1990 in which both were in a vegetative state due to brain anoxia and were sustained on life support for several years. Conflict arose between family members those wanting to maintain life support verses those who wanted to withdraw care. Both women were removed from life support after the courts had to render judgment. The latest case was Terri Schiavo in 2005, which the Florida state legislature passed “Terri’s Law” that gave the governor power to intervene in which there was no written advance directive (Browning, 2010).Based on the legal cases that revealed the individuals did not have an advance directive, the push has been for people to develop an advance directive has been going on since 1990’s. There have been barriers to advance directives such as lack of communication between the physician and the patient and their family; lack of knowledge about advance directives; being skeptical that it would be followed; fear of having a discussion about death; procrastination; and the form are at a reading level greater than 11 grade instead of a 3rd or 4th grade reading level (Meehan, 2009). Often times a patient’s advance directive is not implemented for several reasons such as a physician is afraid of litigation; the patient’s wish is in contrast to the healthcare provider’s clinical judgment; the healthcare provider does not acknowledge a patient autonomy; the healthcare provider and or the medical facility is unaware that the patient has an advance directive (Watson, 2010). Some patients are waiting for their physician to bring up the subject and the physician is waiting for the patient to talk about it. As a resident, physicians were not taught how to communicate effectively with patients regarding end-of-life decisions (Deep, Green, Griffith, & Wilson, 2007). Nurses are often with a patient more than the physician, yet the conversation of end-of-life care goes undone due to not having enough time to talk with the patient, staffing shortages, and lack of communication between the health care team (Crump, Schaffer, & Schulte, 2010).Another factor that is a barrier to advance directives is the different attitudes, values, and beliefs regarding the end-of-life decision making from people from different cultures (Zager & Yancy, 2011). African Americans believe the healthcare system determines their treatment therefore few trust the system to best serve their interest (Zager & Yancy, 2011). The Asian and Hispanic cultures do not ascribe to personal autonomy regarding decision making, they rely on family members to make decisions for them (Zager & Yancy, 2011). The Navajo do not believe in putting one’s wishes in writing especially if they are considered negative (Zager & Yancy, 2011).Nurses spend a lot of time with patients therefore they can play an important role in advance care planning. When a patient conveys their view regarding end-of-life care the nurse should document the conversation in the patient’s chart. The note should describe the circumstance around the conversation, any values, beliefs or desires that are expressed by the patient (DeWolf Bosek & Savage, 2007). A study was done and it revealed that specially trained nurses assigned was to promote communication among patients and the health care team regarding the use of life-extending treatment and they documented the patient’s treatment wishes regarding future care (Lynch et al., 2008). Another study showed that when professional development related to advance directives which included facilitating better communication between nursing staff and patients resulted in patients completing advance directive (Johnson, Zhao, Newby, Granger, & Granger, 2012).Ethical Dilemma Case StudyA 73 year old male was admitted with a diagnosis of motor vehicle crash (MVC), closed head injury, rib fractures, and pulmonary contusions. The patient had a history of early dementia. The patient was admitted to the ICU. He was placed on a non-rebreather. His family came in to see him and brought his advance directive/living will. It stated that he did not want to be on life support but did want nutritional support. After two days in the ICU he was in respiratory distress and needed to be intubated. The patient was sedated with Propofol and treated for pain on a Fentanyl drip. The patient mouthed that he did not want to be intubated, he wanted the breathing tube out. The patient remained intubated for 4 days and was being weaned off the vent. Weaning parameters were done and the patient was extubated. When asked how he was feeling he stated that he felt better and was glad that the tube was out. His family came to see him everyday and his sister liked recording all conversations that staff had with the patient and with anyone who was in the room. No consent was given regarding recording conversation and the nurses began not wanting to care for the patient due to the sister who was very imposing and recording conversations.The patient confided to the Intensivist that he does not want to be intubated ever again. A nurse and physician assistant overheard the conversation that the patient had with the Intensivist. The patient was transferred to the medical-surgical floor. After two day on the floor he was in respiratory distress again and needed to be intubated again. There was not documentation in the patient’s record of the conversation he had with the Intensivist regarding no longer wanting to be intubated.The patient was reintubated and returned to the ICU. The Pallitive physician was consulted regarding end-of-life wishes. A DNR paper work was initiated but not completed. The patient was allowed to have pressors if needed but not to be intubated. The patient’s family wanted everything done regardless of what his advance directive stated. The patient was extubated after several days and did well. The patient was transferred to the medical-surgical floor. Much debate occurred over the patient’s advance directive as to why it was not acknowledge and carried out. The directive was felt to address illness and not being in a MVC. State Two Ethical Principles That Were BreechedThere are four values that is the foundation for PSDA and end-of-life decisions making and they are autonomy, informed decision making, truth telling and discussions as it relates to the dying process (Zager & Yancy, 2011). In this case study the two ethical principles that were breeched were autonomy and beneficence. Beneficence-fidelity is looked at as the principle of trust or obligation of a covenant (DeWolf Bosek & Savage, 2007). This principle is based on loyalty, advocacy and dedication. This principle involves an agreement to keep our promises, which is based on the virtue of caring (American Nurses Association website, n.d.). This patient trusted the physician in honoring his wish of not intubating him, but his wish went unheeded. The physician ignored the patient’s request and he did not document in the patient’s record the conversation he had with the patient regarding being intubated. Too often a physician has not dealt with their personal values as it relates to death, thus they ignore the topic. If a patient brings the topic up at times they will ignore the patient’s request. Many times based on a healthcare provider their personal belief will hinder them to acknowledge an individual’s advance directive. When on cares one will look out for what is best for our patients.The second principle breeched was the patient’s autonomy. The patient exercised his agency to desire others which include his healthcare provider to respect him and his wishes. It was evident that he did not want to be kept alive on a ventilator because that is not living. The patient had taken the time to have an advance directive drawn up stating what his wishes were. Often times patients have seen a friend or a love one kept alive by a machine and they decide that, that is not how they want to end up. He decided what he wanted and what he did not want and it was written in his advance directive. Neither the patient’s family nor his nurse advocated for him not wanting to be intubated again. The physician did not respect the patient’s autonomous decision. The nurse is the healthcare provider most intimately connected to the patient and he/she bears the obligation to act as advocate for their patients (DeWolf Bosek & Savage, 2007).Provide Solution to the Ethical Dilemma by using Ethical TheoryWhen looking at the theory of ethics one must realize its purpose is to make sense of the world and to give guidance one on how to act in it (DeWolf Bosek & Savage, 2007). With the change in society ethics has played a vital part in how we communicate and treat each other. One theory that could help with the problem of the patient in the case study is the feminist ethics. Feminist have pointed out that much of the work of daily living revolves around the people and relationships, due to morality is about how we view the world and how we should act in it (DeWolf Bosek & Savage, 2007).This theory looks at when one is in a relationship with another it is expected that each party will give special consideration to the needs of others (DeWolf Bosek & Savage, 2007). When in a relationship one advocates and helps one another but when one is not in a relationship then one cannot advocate for the other individual. When you have the nurse patient relationship the nurse advocates for the patient. The nurse and the family have a relationship with patient then they will want what is best for the patient and will advocate for the patient and respecting their wishes. Provision 1 of the Code of Ethics for Nurses reflect this theory in that nurses are to practice with compassion and respect the dignity and uniqueness of every individual (American Nurses Association website, n.d.).Another theory that can help with the violation of the patient’s right not to be intubated is utilitarianism. Utilitarianism looks at supporting what is best for a good number people and its value is determined by its usefulness, with an emphasis on outcomes or consequences (American Nurses Association website, n.d.). This will help with letting the patient know that he is respected and his wishes which will bring him peace and happiness. Provisions 2 of the Code of Ethics for Nurses reflect this theory in that a nurse primary commitment is to the patient (American Nurses Association website, n.d.).Provide Solution to the Ethical Dilemma by Using Ethical PrincipleNonmaleficence is the ethical principle that is the solution to the problem. Nonmaleficence states that one is to do no harm which is the core of the medical oath and nursing ethics (American Nurses Association website, n.d.). Placing the patient on life-support against his will and his wish is doing harm to him. When harm is done to a patient a trust is broken. Take the stand of doing no harm to maintain the trust in the relationship with the patient is what is needed to be done. Beneficence is the compassion part that is needed to ensure that one respect the patient’s will and that one will do what is needed to help the patient.Ethical Policy TestimonyThe Federal Patient Self-Determination Act states that medical facilities are to inquire and provide information on advance directive to all patients are to educate staff and the community about advance directives. What education exactly is being done in the community and to our patient’s? On admission patient’s are ask if they have an advance directive they say yes or no. If the answer is no then they are given a book on advance directives but if they say yes then the healthcare decision maker is asked to bring it in. We have policies in place regarding advance directives to ensure that their rights are being observed and not ignored. We do not have anything in place regarding teaching patients about the need for having an advance directive. In this country only 29% of the population has an advance directive. It is evident that there has not been any education done in the community or to staff regarding advance directives.. We need to do more and tighten our policy on advance directive by also teaching the patients about what it is. We need to go into the community and educate on advance directives. We need to have a team that can explain what advance directives are and can answer any questions a person may have upon admission. The team should be comprised of a chaplain, nurse, social worker and physician. When the time comes for the decision to be made families won’t have to struggle with the decision they will know what their love one wants and will make sure it is carried out. Their time will be spent being with their love one during those final moments instead of fighting amongst family about what needs to be done.The Role of the Adult Educator for Implication of Nurse and the Future for PracticeNurse educators need to provide experiences and guide nursing students in ethical decision making. By providing ethical situations will help assist students in learning how to recognize ethical dilemmas and to make decisions that will beneficial to the patient in mind (Stagg, 2010). To help the student with ethical situations have them journal, role play or have a discussion. By having students do this, it will help them in the future when they are in practice. When students find themselves in a situation as when they were in school, they will know what to do by remembering what they learned in ethics class and their clinical experiences.ConclusionEthics guide and dictate how we practice and how we treat others in our daily living. We desire respect and we want to trust those who care for us. As we continue to live, technology is advancing resulting in people living longer but how does it reflect quality of life. The older generation of 65 years and older are the ones who are drawing up advance directives. Many under the age of 65 are dying or find themselves in motor vehicle crashes that leave them in a debilitating state or they stroke due to uncontrolled hypertension.Families need to have discussion regarding end-of-life so that when their love one draws up a advance directive they will recall the conversations with their love one and will respect their wishes and have their advance directive carried out. Advance directives need to clearly stating what the individual may or may not want. Unfortunately advance directives are done for a debilitating illness, but many patients find they are in the hospital on life support due to trauma or a chronic illness that has advanced. Nurses are the ones who work closely with patients and their families thus usually are the ones who will know what the patient wants. Advance directives are good to have but much needs to be done to encourage patients to have one thus making the decisions to let them die a dignified death will not be traumatic for their love ones. Hospitals need to educate it staff regarding advance directive. Educating the bedside nurse, residents, and intensivits on the state regulations on advance directives will empower them and then they will not be afraid to talk with patients. If hospitals will have a team which comprises of social worker, chaplain, nurse, and physician who talks with patients and educate them about advance directives, this will help making a patient more knowledgeable about their treatment options for end-of-life. ReferencesAmerican Nurses Association website. (n.d.). , A. M. (2010, September/October). Life-Support Technology and the Dying Experience Implications for Critical-Care Nursing Practice. Dimensions of Critical Care Nursing, 29(5), 230-237.Crump, S. K., Schaffer, M. A., & Schulte, E. (2010, November/December). Critical Care Nurses’ Perception of Obstacles, Supports, and Knowledge Needed in Providing Quality End-of-Life Care. Dimensions of Critical Care Nursing, 29(6), 297-306.DeWolf Bosek, M. S., & Savage, T. A. (2007). The Ethical Component of Nursing Education Intergrating Ethics Into Clinical Experience. Philadelphia, PA: .Deep, K. S., Green, S. F., Griffith, C. H., & Wilson, J. F. (2007). Medical Residents’ Perspectives on Discussions of Advance Directives: Can Prior Experience Affect How They Approach Patients? Journal of Palliative Medicine, 10(3), 712-720.Johnson, R. W., Zhao, Y., Newby, L. K., Granger, C. B., & Granger, B. B. (2012, September). Reasons For Noncompleting of Advance Directives in a Cardiac Intensive Care Unit. American Journal of Critical Care, 21(5), 311-320.Lynch, H. F., Mathis, M., & Seasick, N. N. (2008). Compliance with Advance Directives Wrongful Living and Tort Law Incentives. The Journal of Legal Medicine, 29(), 133-178.Meehan, K. A. (2009). Advance Directives The Clinical Nurse Specialist as a Change Agent. Clinical Nurse Specialist, 23(5), 258-264.Morrison, E. E. (2011). Ethics in Health Administration A Practical Approach for Decision Makers (2nd ed.). Sudbury, MA: Jones and Bartlett.Stagg, D. (2010, April-June). Promoting Ethical Development in Nursing Education and Beyond. Journal of Christian Nursing, 27(2), 96-99.Watson, E. (2010, Winter). Advance Directives: Self-Determination, Legislation, and Litigation Issues. Journal of Legal Nurse Consulting, 21(1), 9-14.Zager, B. S., & Yancy, M. (2011, Fourth Quarter). A Call to Improve Practice Concerning Cultural Sensitivity in Advance Directives: A Review of the Literature. Worldviews on Evidence-Based Nursing, 202-211. ................
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