The Doctrine of Double Effect: Nursing Care - Case Study Example

Introduction This study proposes to enquire into one aspect of nursing care in which the Doctrine of Double Effect can be applied. Palliative care in which patients need to be put on sedation evokes DDE involving ethical questions. Whether by applying the DDE, the sedation can be justified under nursing perspective will be the main object of this study. This doctrine of double effect originated from Roman Catholic theology which advocated its use when harmful result of an action becomes unavoidable. It gives practitioner choice to select the lesser evil. (HPNA 2003) Four ingredients should be present in the said doctrine. An action is permissible even if it has one good and one bad effect provided that 1) Action is not immoral, 2) It is resorted to achieve good effect without the intention of any bad effect though it may be anticipated, 3) Good effect is not achieved through bad effect, and 4) the action is resorted to under extreme crisis situation. (Sulmasy and Pellegrino 1999) Palliative care Palliative care is one area where nursing profession faces ethical questions. Apart from the principles of beneficence, maleificence, doctrine of double effect gives the nursing profession justification for the desired action. Palliative care warranting sedation is an alternative to euthanasia. The intent behind palliative care is to minimise distress and euthanasia is to let the patient die. Doctrine of double effect motivates the professional to resort to palliative sedation as an alternative to let the patient suffer from pain, though euthanasia will give the same result but it is against ethical principles as an extreme and easy but cruel alternative. An unintended effect of an intervention is far superior to an intended effect of an intervention. Hence, intentionally causing death by euthanasia is abhorred and non-violent means of embracing death without pain through high dose of tranquilisers and opioids is advocated A case of terminally ill 78-year old man is presented here to explain the application of the doctrine. He had advanced prostate cancer spread to his bones and bone marrow. His platelets count in blood was threatening to cause severe internal bleeding. The Diclofenac treatment for his bony pain was contraindicated as the drug would cause further worsening of platelets condition and the bleeding would increase which was a life threatening condition. Therefore Diclofenac was stopped to reduce bleeding. But due to the stoppage, his pain increased. The question was whether Diclofenac should be restarted. Applying the principle of double effect, it can be said that Diclofenac can be restarted so that the patient’s severe pain can be mitigated even though its potential to cause bleeding is foreseen. The good effect of reducing the pain outweighs the risk of death due to side effects of bleeding. Earlier, due to increase in pain at the back, he was put on catheter which later infected the site. Now unless the catheter was removed, infection would proliferate and hasten his death. The dilemma now calling for application of the double effect doctrine was whether catheter should be removed as other wise he would develop meningitis. By applying the doctrine, it was decided not to remove the catheter because if catheter was removed, he would die of pain and if not removed; he would be free from pain though in both cases death was a known possibility. Actually the patient died within 48 hours peacefully with no evidence of meningitis. On reflection, in the first situation, the patient was fully conscious and he was part of the decision making to continue on Diclofenac. In the second situation of having to remove catheter, he was not competent enough to decide and the medical staff decided in the best interests of the patient. This doctrine can be abused and it is also prone to criticism. The honest intent cannot however be proved (Kendall, C.E 2000) Timothy E et al (1997) have mentioned four methods of ending the lives of terminally ill patients as a part of palliative care. They are voluntary fasting, terminal sedation, physician-assisted euthanasia and voluntary active euthanasia. Patients can stop eating and drinking voluntarily which will result in their death due to dehydration or some other reason. Though this is acceptable, family members may not wish to see their relatives starving to death. Second one is terminal sedation which is also acceptable since they become unconscious, though they also die of dehydration and starvation. Physician assisted suicide is different from euthanasia in that in the case of former a lethal dose is given to the patient by the physician and the patient does the act where as in the latter, physician himself carries out the act. Role of nurses in palliative sedation is equally important as they spend more time with patients than their families and medical professionals. They discuss with family members the plan of action for palliative care, make documentation for the purpose obtain consent from the patient or the family for palliative care and keep the family motivated to face the inevitable. They look for the symptoms of respiratory distress and ascertain patient’s body language of persisting pain, unabated symptoms, and acute suffering. They have to keep the sedation level under check by looking at the patient’s expressions on the face, stroking over eyelids. If there is no eye lid flicker, then the patient is under profound sedation and it may need to be adjusted by proper medication. In the palliative care, the patients gradually lose their vital signs and the family should be kept informed of this. There will be risk of aspiration during the liquid intake. Family member present are educated to give comfort to the patients for oral care, eye care and skin care. They should also be advised suitably if the patient wants to breathe his last at home. Nurses are expected to give as much care to the patient’s family as they give to the patient. The ending days and the last hours of the patients must cause deep anxiety on family members and therefore the nurses must take care of them and lessen their tension by explaining them the dying process and also they must take care to inform them that dying symptoms are only to serve as general guideline since each patient will have unique characteristics of dying. The psychological support they give the patient’s family members and other caregivers will leave a lasting impression of the patient’s dying moments and therefore nurses literally take part in their grief. They should also make sure that the palliative care is consistent with their religious and cultural beliefs. If nurses whose cultural and religious beliefs are inconsistent with the palliative care so desire, they should be allowed to abstain from giving such care and engage some one else. (Knight P et al 2006) Although it is within the legal tenets, nurses have to take great care against providing such care indiscriminately since still a lot of controversy is surrounding the principles of double effect doctrine and allied ethical principles of autonomy, and beneficence. They have to understand the nuances and subtleties of palliative care and as part of the care team they must prove themselves as having facilitated a peaceful death for the patients and relief to their families. Nurses will also keep educating others who have less knowledge of the ethics involved in such situations. The discussion on palliative care as one of the actions involving double effect doctrine is strengthened by the observation of Coyle and Goldstein (2001) that nurses should view the doctrine as an essential construct to appreciate that they in effect control the complex symptoms when the end of life is approaching in a patient. They conclude that giving opioids to a hypotensive patient on death bed and in pain is a good palliative care and not euthanasia. According to Glynn (1999), doctrine of double effect is an ethical pillar of palliative care and approving its practice would promote human care for the dying. The most important part of the ethics of the medical profession “First, do no harm”, will be best complied with if only the doctrine is understood in broader terms. The Palliative care under Doctrine of Double Effect (DDE) is not however without criticisms. Quill and Dresser (1997) state the problems arise when it is argued that physicians assisted suicide is not in conformity with the DDE since ultimately a lethal agent is knowingly allowed to be administered and that in the case of terminal sedation, it is achieved by withdrawing life giving therapies. Conclusion The criticisms leveled against Doctrine of Double Effect are equally forceful to that of its advocates Hence the rule of double effect need not be invoked to justify palliative sedation since it does not fully conform to the doctrine but at the same time palliative sedation should however continue to be practiced since it appeals to the common sense. Nurses play painful roles in the palliative care of the terminally ill patients as they literally live with them until their end. Though who are able perceive the painful suffering can not afford to dismiss the practice for want of double effect. Double effect doctrine is too technical and abstract without the other side of the coin, to be applied in palliative care decisions in practical life situations. References Coyle Nessa, Ph.D., and Goldstein-Layman Mary, R.N., in Chapter on "Pain Assessment and Management in Palliative Care," Palliative Care Nursing: Quality Care to the End of Life: 2001 Glynn Kevin, M.D., January 29, 1999 "'Double Effect': Getting the Argument Right" Commonweal: accessed 24 Oct 2007 < http://www.euthanasiaprocon.org/> HPNA: Hospice and Palliative Nurses Association. “Position statement on palliative sedation at end of life”. Journal of Hospice and Palliative Nursing. 2003; 5(4):235-237 Kendall, C E. "A double dose of double effect.” Journal of Medical Ethics.  26.3 (June 2000): 204 Knight P, Espinosa L, and Bruera E. Sedation for refractory symptoms and terminal weaning. In: Ferrell B, Coyle N eds. Textbook of Palliative Nursing. New York: Oxford University Press; 2006:467-482 Quill Timothy, M.D., Dresser Rebecca, J.D., and Brock Dan, Ph.D., 1997 "The Rule of Double Effect—A Critique of its Role in End-of-Life Decision-Making," New England Journal of Medicine1997 accessed 24 October 2007 Sulmasy DP, Pellegrino ED. The role of the double effect: cleaning up the double talk. Arch Intern Med. 1999; 159:545-550 Timothy E.Quill, Lo Bernard, and Brock W Dan, "Palliative options of last resort: a comparison of voluntarily stopping eating and drinking, terminal sedation, physician-assisted suicide, and voluntary active euthanasia.” JAMA, The Journal of the American Medical Association.  278. n23 (Dec 17, 1997): 2099(6).  Read More