The Role of Nurse Autonomy and Ethics in End-of-Life Care

As a patient, one can expect a certain amount of rights and responsibilities when requesting medical treatment. These rights include the right to make decisions, have questions answered accordingly prior to those decisions being made, and the right to have your decisions upheld and respected by the medical professionals from which care is obtained. However, in some circumstances, medical professionals often find themselves being asked to comply with the wishes of a patient who, due to the medical condition being treated, may not be able to make effective decisions for his or herself.

It is at this time that the medical professional relies on the patient’s Power of Attorney (POA) for Healthcare or family to assist in the decision-making process. Ethical dilemmas arise, however, when the POA is unavailable. It is at this time that the medical professional may find themselves acting more as an advocate for the patient, than the caregiver. This essay is in response a case study presented in which a patient with mental retardation, Mr. E. states he does not want a ventilator or feeding tube placed after presenting to the hospital with presumed aspiration pneumonia secondary to a lack of control of his esophagus. Per the case study, Mr. E. has advance directives stating his desire to have no life-sustaining treatment, including feeding tubes and ventilators. Yet, due the patient’s medical condition, he was placed on a ventilator and a feeding tube was inserted when the patient’s POA was unavailable and another family member arrived at the hospital and gave consent.

This is a clearly ethical violation of this patient’s rights. The State of Illinois Nurse Practice Act of 2007, lists in its Scope of Practice for a registered nurse the duty of “advocating for patients” (Nurse Practice Act, 2007). To advocate for someone is to “plead in favor of” that person, his or her wishes or desires (Merriam-Webster, n. d. ). In this case, the patient’s wishes have been clearly documented via his advance directives and it now becomes the nurses’ responsibility to advocate for those wishes to be followed.

Furthermore, the Act also lists in its Standards of Professional Conduct for Registered Professional Nurses that the RN shall “Report unsafe, unethical or illegal health care practice or conditions to appropriate authorities” (Nurse Practice Act, 2007). In this case, when the patient’s wishes are being dismissed by the physician, it falls on the nurse to follow chain-of-command per hospital protocol in an effort to bring the ethical dilemma to the attention of others in an effort to preserve the patient’s rights.

In addition to state law, all nurses in America follow a Code of Ethics put forth by the American Nurses Association (ANA), which includes “The Right to Self-Determination” In this provision, the ANA states the nurse “has an obligation to be knowledgeable about the moral and legal rights of all patients to self-determination [and] preserves, protects, and supports those interests by assessing the patient’s comprehension of both the information presented and the implications of decisions” (American Nurses Association, 2001, prov. 1. 4).

In the case study presented, Mr. E. not only verbalized his refusal of ventilator and feeding tube placement, but also had advance directive paperwork in his chart to validate his wishes. Since advance directives serve to state the patient’s wishes should he become unable to speak for himself, it becomes the basis for the nurse’s steps for advocating for the patient’s wishes. In this case, the nurse needs to bring the advance directives to the attention of all personnel involved in the case and fight for the patient’s wishes to be fulfilled.

Additionally, the physician should have deferred to the advance directives, eliminating the need for the POA or surrogate to consent to treatment, and, ultimately, eliminate the invasive placement of both the ventilator and feeding tube against the patient’s wishes (“Statement of IL Law,” 2011). Violating this patient’s advance directives by ignoring the living will and taking consent from a person unnamed on the POA paperwork is a clear violation of the patient’s rights and is completely unethical.

As difficult as it may be to abide by the wishes of a patient who will die without treatment, it is the patient that medical professionals serve before all others…including the family of the patient. Though Mr. E. ’s nephew arrived before the named POA did, he did not have the right to any information regarding the status of Mr. E. and gave consent for the treatments performed. Per the advance directives, this person was not listed as a person approved to speak for Mr.

E. , and his consent should not have been allowed to usurp the advance directives. By not reporting the violation of the patient’s advance directives, the nurse has not only gone against the ethical code of self-determination and the standards of practice for nurses, but has also opened a question of autonomy. Yes, nurses depend on orders from physicians for many facets of patient care. But, the nurse lso holds the responsibility to make her own decisions in regards to ethical treatment of patients. It is the nurse’s burden to be accountable to the patient for the actions taken (or not taken) in the course of that patient’s care. By failing to advocate for the physician to follow that patient’s advance directives, and reporting the physician’s actions through the proper chain-of-command, the nurse failed both the patient and the nursing profession.

If the nurse had chosen to follow chain-of-command as specified by her facility’s protocols, it is very possible this patient may have had his wishes upheld, gone without two very invasive procedures. And, though he may have passed away without these treatments, it would have been a decision he was allowed to make himself. He would have been allowed to pass away with the dignity he had asked for by having advance directives in place.

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