Ethical and Professional Implications Essay

The NMC (2015) are the providers of the Nursing Code of Conduct. The code contains the professional standards to which all nurses must uphold, allowing for accountability of patients that come into their care. As well as the code of conduct, all nursing professionals have a responsibility to develop their knowledge in relation to law within clinical practice, and furthermore, ethical frameworks that are linked to judgment and decision making when providing care (Savage & Moore, 2006). In light of this, the overall aim of this essay is to elaborate on issues surrounding law and ethics in nursing. To do so, a case study has been chosen from a previous clinical experience. The focus of the case study will be on the decision of withdrawal from life sustaining treatment. Emphasis will be largely on the law and ethics concerning the issue of withdrawal from treatment. Moreover, the ethics and law involved in the palliative/advanced end of life care planning and decision making. In order to protect the identity and uphold the confidentiality of the case study, a pseudonym will be used throughout. Hendrick (2005) portrays confidentiality as being ‘one of the most important and well established moral obligations of health-care ethics’.

The practically speaking, the case of Nancy Cruzan highlights the fact that an individual cannot rely only on telling his would be decision maker what type of care is desired should that individual become incompetent. Such evidence may not be viewed as sufficient to refuse medical treatment as happened with Nancy Cruzan. It thereby becomes important to record exactly what type of treatment should be accepted or refused if one’s decision making capacity is lost. The most common way to do this is in the form of an advance directive. Such a document would declare not only who the patient wants a surrogate decision maker, but also relates the degree of treatment desired by the patient. The presence of an advance directive makes caring for incompetent patients much easier because confusion over the patient’s wishes is avoided. Had Nancy Cruzan made an advance directive, withdrawing the artificial nutrition

.“As medical technology continues to advance and health care choices become more complicated, the preservation of end-of-life autonomy is an increasingly important issue faced by various client populations.” (Galambos, 1998).

Other barriers in implementation might include the legality of certain medical interventions, associated costs and limited resources for providing the best care possible (Mason, 2013, p.12). As nurses, a barrier in implementing advance directives might also arise when advocated end-of-life wishes are undervalued or poorly recognized by others who do not share the same comfort or high priority in the medical workplace. Finally, the patient, families, and healthcare professionals face barriers in misconceptions regarding advance directives, especially in regards to

Advance Directives by the patient designates no feeding tubes, artificial ventilation, or CPR. Concerns regarding alteration of mental status consequential to his illness provoke the physician to seek consultation from the designated Power of Attorney. Nursing responsibilities compel the nurse to consider if the proposed actions of Dr. G violate the patient’s rights of self determination and confidentiality and prompt the nurse to advocate for the patient’s desires regarding medical treatment. Health care providers have a responsibility to honor the patient’s autonomy and provide quality medical care (Badger, 2009 p122). Providing artificial nutrition and ventilation transgresses the patient’s directives and is unethical. The physician appears to be asserting a paternalistic approach in deciding what is best for this patient. Should the interventions be temporary and provide resolution of the condition, the physician can defend his actions as being healing and beneficial. However, there is a chance that the interventions may be permanent and futile; avoiding passive euthanasia and terminal dehydration, serving only to prolonging the illness. Violating the patient’s directives of care by performing invasive procedures can lead to legal incriminations of assault and battery.

The Superior Court of Los Angeles County became a pivotal case in a patient’s right to refuse treatment. In the initial case Ms. Bouvia and her legal team sought a court order to have the NGT removed and to stop all medical treatments she did not consent to. She argued that this treatment would not be a cure for her condition and would not improve her quality of life. The hospital staff argued the interest of the state prevailed over a patient’s right to refuse treatment. They noted that the state and healthcare teams viable interests include: “(1) preserving life, (2) preventing suicide, (3) protecting innocent third parties, and (4) maintaining the ethical standards of the medical profession, including supporting the right of physicians to effectively render necessary and appropriate medical services” (Liang & Lin, 2005). Additionally they sighted Ms. Bouvia’s failed previous attempt to “starve herself to death” in 1983 with the assistance of her medical team. The court denied her request citing these key interests and the fact that medical professionals felt that Ms. Bouvia could live 15-20 additional years with supplemental nutrition justified the state’s interest in preserving her life. The court also stated that any other decision would be condoning a medical team to aid and abet suicide.

This film explains the legal role of advance directives in end of life issues. An advance directive is “a written document directing how medical decisions are to be made in the future when the patient lacks decisional capacity and is unable to decide and choose” (Hanlon, End of Life Issues, Slide 28, Bullet 1). All three of the cases demonstrate the importance in filling out some form of directive. When there is nothing to go off of, it makes decisions extremely tough for families and medical providers. Having legal documentation of patient wishes helps understand what treatments they would or would not consent to. In cases like

The primary goal of the healthcare providers in the Cruzan case was to provide medical care to prevent the death of a patient. “When a patient’s prognosis for meaningful survival is poor, there is a change in focus from restrictive care to palliative care” (Lones, M., 2015). Cruzan’s condition did not allow for palliative care, but the medical staff placed her on life support to prolong her life. The conflict arose between the family and the medical staff due to there was no documentation indicating the patient’s wishes. Cruzan did not have an advanced directive or living will to assist with the end of life decisions that were left up to the hospital and her parents. Advance directive document the decisions for medical care for terminal

This can be a difficult time not only for the patient but also for the loved ones and family. Sue Ellen, due to the fact that she was in a comatose state isn’t aware that she is possibly living in her final days of her life. During this stage health care professionals try to make the patient as comfortable as possible. The healthcare workers and physicians tried to make Sue Ellen as comfortable as possible. There are several myths about the end of life care that support good health care and good medical ethical practices. During this critical time, ethics, clinical judgement, and the law can run into major conflicts. The patient, families and physician can find themselves considering clinically actions that are ethically appropriate, but could possibly raise legal issues. In this particular case, Sue Ellen family and the healthcare facility are concerned. According to Meisel, Snyder, Quill (2000), “The 7 major legal myths regarding end-of-life-care are: (1) Forgoing life-sustaining treatment for patients without decision-making capacity requires evidence that this was the patients actual wish. Sue Ellen, did not have person that was a designated surrogate. This would play a major factor in my decision as a Health Administrator to have her moved from the AICU to a hospice facility for care. (2) Withholding or withdrawing of artificial fluids and nutrition from terminally ill or permanently unconscious patients is illegal. The only time

Patients with severe illness can deteriorate, become physically or mentally impaired and be unable to make or communicate healthcare decisions. Modern healthcare can prolong life, but this may result in prolonged pain and suffering or reduced quality of life. Moreover, some patients, due to experience, religious views, cultural views or advice from family and friends, may want to deny some future treatments that they receive or request for others. In such situations, the Advance Health Directive (AHD) document can come into effect and be used by patients to express their healthcare directions.(1) An AHD is a legal document, which is a form of living will, in which a patient can

Ethical dilemma may also arise in cases where a patient may feel their right to DNR should be carried out when giving direct order. The DNR process, however, is required to be documented by a physician. Andrew Putnam (2003) presents a case where an eighty-eight year old patient’s code status was DNR; “However, the patient has never signed formal advance directive statement or assigned durable power of attorney for her health care to anyone.” (Putnam, 2003, 2025) Ethics can be simply stated as doing the right thing (Roberts, 2002, 242); but in this case ethics is questioned because the physician was faced with the decision to carry out the wishes of the patient or to make a decision based on legality. In this case, it may have been morally right to carry out the wishes of the patient who wanted DNR orders carried out, but it may have been the right choice to do the legal thing and not carried out due to lack of signed documentation.

In end-of-life scenarios, where the patient may not be able to communicate their wishes, decisions must be made either by the healthcare professional(s) or family member(s). However, who gets to decide or where the line should be drawn are not always clear. Consequently, not all decisions may be ethically permissible. To illustrate, I will discuss a scenario in which physicians and family are not in agreement. Upon proving a brief summary and explaining the ethical dilemma, I will provide moral reasons for two ethically permissible choices from which, by referencing the principle of autonomy and Utilitarianism, will determine which course of action ought to be carried out.

This past Tuesday, I attended Dr. Eric Vogelstein’s philosophical forum titled “Advance Directives: Problems and Prospects.” This talk focused upon the use of advance directives, which can be described as written legal documents that detail a patient’s wishes regarding their medical treatments in the case that he or she unable to verbalize them due being in an unforeseen medical state or circumstance, as well as the implications of their use in the medical field. Advance directives themselves usually consist of living wills, either scenario-based and value-based, and medical powers of attorney (i.e. proxy designation). Thus, the purpose Dr. Vogelstein’s discussion was to examine whether such ethical justification can be considered as valid

The limitations regarding, “the right to life” was a topical issue at the time of the Karen Quinlan case. The court ruled that the decision should be in the hands of ethics committees, another important realisation from the Quinlan case ruling. Many ethics committees were formed to make the decisions. Hospitals and all extended care facilities got an ethics committee. It was thought that they should be the decision making body in the future. However, it is now the opinion of experts that the authority of the ethics committees is limited. Any decision must belong to patients, and/ or their proxy. Out of this case there has also developed advanced health directives, which led to a society becoming aware of the need to create living wills as to what family members were to do or not to do in conditions of “extraordinary” medical care. The power of attorney also came to the forefront. Many people today would recognise the name of Terry Schiavo. Karen

Therefore, other ways are done to bring the decision to light.  An “advance decision” is where they have already made preparation anticipating such events, stating whether they choose to live or die. Not only that, a “Lasting Power of Attorney” (“LPA”) which would make the choice for the patients based on the circumstances of the patient’s welfare. There are also concerns as to whether the patients were in an autonomous state making such preparation, whether they were uninfluenced by others, their decision solely based on their reasoning.