End-of-life Care

As the population ages in America, the dilemma of end-of-life care becomes an important issue for the professional nurse. As reported in Evidence-Based Geriatric Nursing Protocols for Best Practice, the Patient Self Determination Act (PSDA) of 1991 establishes advance directives and decision making for those when capacity to make their own health care decisions is impaired (Capezuti 2010). In light of this PDSA, nurses often find themselves involved in end-of-life situations that conflict with patient’s wishes for themselves and family’s wishes for the patient.

The dilemma presents itself in this area of conflict between the conflicting desires of patient and family. The nurse must completely support the patient’s wishes while assisting the family to do the same. The nurse is advocate for the patient, educator of the family, and liaison between the interdisciplinary team. The debate arises within those conflicts; the ANA Code of Ethics binds nurses to respect the autonomy of each patient and their decision to choose the healthcare options they believe are correct for them based on their religious, social, cultural and personal desires for end-of –life care (ANA Code of Ethics 2001).

Nurses are also bound to participate in advocating for the patient to alleviate unnecessary treatment for the patient who has designated they do not want treatments that doctors and/or families may be advocating for the patient against that patients wishes (ANA Code of Ethics 2001). The nurse must be familiar with the end-of-life wishes of their patients otherwise; the patient looses a valuable advocate to assist in achieving their goals for end-of-life care. Nurses must also be aware of their own personal values and beliefs surrounding end-of-life care for their patients’ choices to advocate adequately.

The dilemma during end-of-life issues arise when there are differing opinions between the doctor, the family and the patient about the care received during this time of life. Image the following scenario, the patient has congestive heart failure, blockages of the heart vessels, carotid vessels, and blood vessels in both lower extremities. This patient suffers from hypertension, diabetes, kidney failure, iron overload, anemia, and a cigarette addiction. The patient also suffers from sleep apnea and is oxygen dependent while asleep.

The patient has chosen for many years to refuse any invasive treatment of any of these aliments. The patient chose rather to manage the above diseases with medication over the invasive options. This patient has an advance directive stating the preference of no CPR, no artificial hydration or nutrition and desiring only comfort measures to allow for a pain-free and natural death. This patient went into respiratory distress, suffering from flash pulmonary edema, and rushed to the hospital. Medications are administered which resolve the pulmonary edema.

The patient is in a permanently weakened state but the family insists on multiple surgeries that the doctor has recommended improving the health status of the patient. The family is informed of the risks of surgery and that the patient is not a very good candidate for surgery. The family continues to insist that the patient have the surgeries. Only one sibling has a copy of the advance directives, is medical durable power of attorney and informs the family of the patient’s wishes per the advance directive.

The family disregards the advance directive to meet their own needs to keep the patient alive regardless of the patient’s wishes or the severe decline in quality-of-life if the patient were to undergo these surgeries. The patient’s desire is to leave the hospital to live out their days in the comfort of home. The family as a group has not discussed the patient’s advance directive or end-of-life wishes. How does the nurse meet the needs of patient and family in this difficult situation? The nurse must first review the advance directive to establish the validity of the patient’s desired wishes for their end-of-life care.

Then, discuss these wishes to clarify the nurse correctly understands the patients stated desires. According to Mauk, the nurse would further discuss options of palliative care and hospice care, and the family’s role in end-of-life decision-making if any. Another consideration is how the nurse could best facilitate a family discussion regarding the patient’s choices (Mauk 2010). With the patient’s desire the priority, the nurse must attempt to help the family understand the patient’s end-of-life decisions.

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