Term Paper on "End-Of-Life Decision-Making and the Role of the Advanced Practice Nurse"

Term Paper 5 pages (1819 words) Sources: 10

[EXCERPT] . . . .

End-of-Life Decision Making

End of life decision-making and the role of the Advanced Practice Nurse

Description of the Ethical Issue:

End-of-life decision making has gone through some great changes in the last 50 years. These changes have to do with societal attitudes about death, dying and healthcare at the end of a person's life and how they have evolved due to new innovations in healthcare -- technological, pharmacological, and surgical innovations (Daly 2006a). With these new innovations in healthcare have come very difficult challenges for patients and their families -- as well as for the people who provide the care towards the end-of-life -- nurses and doctors (Wilkie et al. 2001). The ability to be able to prolong life in patients with grave injuries or patients who are terminally ill and in advanced stages of diseases has raised very tough and important questions about the moral acceptability of stopping or forgoing treatment (2006a). One only has to look back at the highly publicized case concerning Terry Schiavo to recognize just how controversial and rife with moral and ethical dilemmas end-of-life decisions are (not to mention the legal issues that it raises).

Some very specific challenges that Advanced Practice Nurses (APN) may face are deciding to withhold treatment that could sustain life, deciding against resuscitation, and employing tactics that are both unethical and dishonest. The principle of autonomy, patients' rights to accept or forgo medical interventions, has been widely accepted as the basis for decision making. The ethical dilemma with end-of-life decision making is that there are issues at hand such as malfeasance, dishonesty, and "playing God" in the sense that one is deciding who has the chance to live and who doesn't (Daly 2006b).

Other ethical dilemmas have to do with what happens when patients (or family members) ask nurses to aid them in dying or the dying process -- assisted dying or assisted euthanasia. Studies within the last ten years have shown that nurses are commonly asked by both patients and family members to aid in the process of death (Matzo 2006). There are many boundaries -- legal, moral and professional -- that are oftentimes unclear to the APN, which is what makes end-of-life decision making so rife with dilemma.

Analysis and Literature Review

Daly (2006b) notes that during the 1990s advanced directives appeared to offer a solution to end-of-life decision making problems. Advanced directives are basically living wills that indicate what one's wishes are regarding treatment when it comes to the end of their life, usually when they are not able to express what their wishes are. The purpose of these advanced directives was to get people talking about what they would want to do "just in case." But now in the 21st century, it has become clear that advanced directives are not working as they were once hoped to work. The fact that these advanced directives have not performed the way they were hoped means that a greater communication between healthcare workers and family members is vital (Ahrens & Kollef 2003).

There are such major discrepancies when it comes to end-of-life decision when comparing people's religion, philosophical, world views and the customary beliefs of a culture. Going back to the Schiavo case, we can see "the extent to which persistent misunderstandings of complex disease states, human physiology, treatment options, and prognostic probabilities interfere with attempts to reach consensus" (Daly 2006b).

Daly (2006b) notes how important APNs are in end-of-life decision making as they are the ones who are so intimately involved in giving the care needed to the patient at the end of his or her life; however, for the APN, helping make decisions about the end of life can be very stressful. APNs can help make the decision to not initiate life-saving treatments. Matzo (2005) found that many nurses are more comfortable with not initiating life-saving treatments if they believe that they will have to stop them once begun. Withdrawing life-saving treatments or "letting die" (2005) can be considered a sort of "passive euthanasia," which has its own moral dilemmas. Others may consider the withdrawing of life-saving treatments as an act that feels like causing death or killing (2005). Withdrawing life-saving treatments ay be morally problematic for some APNs (2005) -- especially those who believe in the sanctity of life regardless of the burdens of illness and pain. APNs do have to be aware of the legal and moral consensus that recognizes no moral distinction between withholding and withdrawing life-saving treatments (2005).

Matzo (2006) states that APNs will experience uncertainty about where the legal, moral, and professional boundaries of end-of-life care are located. There is difficulty in seeing clearly these boundaries because of terminology that is used at the end of life: for example, assistance in dying, suicide, assisted suicide, voluntary active euthanasia, and nonvoluntary euthanasia.

Matzo (2005) notes that in the last ten years it has become recognized how often nurses are asked by patients to help them die. The studies related to this question have shown that nurses are often asked by patients as well as family members for assistance in dying and there is a small percentage of nurses who actually do assist.

Application of Ethical Principles

For APNs, it must not be uncommon for very ill patients or dying patients to want to die or long for an end to the process of dying (Matzo 2005). While nurses may have varied feelings about being asked to help one die, there is the need that APNs recognize the plea as a cry for help. APNs can help by offering support and better pain management (Norton et al. 2003). Many nurses will have to rely on their clinical experience when it comes to the ethical decisions that present themselves in end-of-life cases.

In dealing with end-of-life cases and the moral and ethical questions that arise because of them, healthcare professionals -- including APNs, should try to develop a system of care that can meet the needs of both the patients and the family members. Hospice services and palliative care programs are great ways to help manage and care for dying persons (Daly 2006a). However, it still must be noted that the issue of end-of-life decision making is so difficult because of APNs own fears about death as well as ambivalence or concern (2006a).

There is a key stage in making end-of-life decisions such as limiting or withdrawing life support and this is when the transition from wanting to cure to wanting to help a person die peacefully occurs. When a patient is not able to say what they want for themselves, the family members are often the next source of answers. It helps to know what the patients' beliefs were and what their values were when it comes to making end-of-life decisions; however, this is not always possible.

Goals of care must be discussed even when the atmosphere surrounding the goals or the direction of care seems to be ambivalent (Daly 2006a). There are so many cultural problems in our society when it comes to death and dying. The want to not deal with it is oftentimes quite apparent and this can come across as ambivalence on the part of both healthcare personnel and family members. There tends to be the belief today (a "technologic imperative" (2006a)), perhaps because there has been so much innovation when it comes to prolonging life, that if there is something that can save a life, we should do it no matter what -- even if that life will only be saved for a brief period or even if that person perhaps would not want to be saved (Happ et al. 2002). There is also the strong tendency to avoid considering the goals of care until a persistent deterioration in a patient's clinical condition is obvious (2006a). These are the moral and ethical dilemmas, as well as social dilemmas, that are so difficult when it comes to dealing with end-of -- the life decision making and it is our society that doesn't do much to change the way death is dealt with. The challenges that come along with the dying process are not an obvious choice between "heroics" and "humanity" (2006a). The real scenario is a lot more confusing and blurry and is about not knowing what to decide. It is a sort of ambivalence that goes along with the cultural views related to the topic.

APNs who deal with end-of-life care report feeling stressed out, frustrated, sad and helpless when it comes to having to make life/death decisions for patients and their families (Hansen et al. 2009). While there are definite innovations being developed to sustain life, there is, perhaps because of this, more of a need to improve professional education for practicing APNs in the area of end-of-life care. Without an adequate practice environment and a paucity of education on the topic, nurses are often left to deal with end-of-life care decisions on their own. This can greatly affect their job satisfaction as well as their overall… READ MORE

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