Analysis Regarding Advance Care Directives in the Nursing Practice - Assignment Example

Introduction This paper explores aspects and issues regarding advanced care directives (ACD) in the nursing practice. Patient autonomy is entrenched in palliative health care. However, implementing end-life decisions and interventions presents nurses with dilemma- ethical and legal. The dilemmas revolve around end-life interventions and questions of euthanasia. The role of nursing advocacy is also met with dilemmas with reference to accountability ethics enshrined in the International Council of Nurses code of ethics. This paper explores these dilemmas using a case study that involves a critical patient- Mrs Jordan, her family, a nurse- Janet and a doctor Johnsone. Question 1: legality and ethicality of Janet’s actions in original version The original version presents Janet as playing the role of an advocate for the patient and the family and taking the concerns of the family at heart. She is torn in between her advocacy roles and being answerable to the doctor with respect to palliative health care for Mrs Jordan. There are legal and ethical issues in her conduct. Ethically, nurses are bound to the role of advocacy. Advocacy has to do with representing others’ wishes or interests amidst their inability to do them (Sim 1996). Patient autonomy is now an inherent aspect in health care provision and there are increasing societal expectation that an individual’s wishes on advanced care provision are honoured. By playing an advocate for Mrs Jordan’s case to Dr. Johnson Janet is adhering to ethics. It is also in line with the NSW guidelines providing for the right of patient to life and care. In situations where optimal life sustenance therapy has been applied and death is imminent, the focus should focus on providing dignity and comfort to the dying patient. However, her intervention in ending Mrs Jordan’s life presents her with repercussions described in the doctrine of double effect. As described in Chiarella (2006), the doctrine points to actions having two effects: good and bad. By nursing ethics, Janet is bound to be an advocate of the patient. However, Janet’s withdrawal of the non-adrenaline bag and replacement with another substance may be construed as being illegal. Legally, although the nurse is not justified in withdrawing the non-adrenaline without the doctor’s approval, her withdrawal may not be construed as illegal since it was not intended to cause death. In law, the question of intent for undertaking any activity is fundamental. According to the NSW guidelines it is a fundamental principle that a patient be provided dignity. Additionally, if withdrawal of life sustenance is meant for comfort and dignity, then it is permissible. Question 2: Legality and ethicality of Janet’s actions in alternative version The alternative version of the case presents several legal aspects. Firstly, the interventions undertaken by the health care providers are as a result of a consultation with all parties: nurse, doctor and family. There is consensus that Mrs. Jordan is terminally ill and that her will over palliative care needs to be honoured. By law, any killing is prohibited even in terminal illness and cases where death is imminent in spite of the extent of the situation and patient’s wish for death (McIlwraith & Madden 2006). In withdrawing of life-sustaining treatment, the law views the cause of death as being the underlying illness and not the withdrawal (NSW Department of Health 2005). In addition, there is the principle of life sanctity providing for the sanctity of life and absoluteness of its value. However, the principle is not absolute especially with regard to patient’s autonomy. In this view, it is necessary that the consensus is based on informed consent from the patient or a representative. As such the Not-For-Treatment (NFT) or NFR directives are justified by law. The action differs from that in the original version by virtue of the consensus arrived at in deciding Mrs Jordan’s life. In the original version, the nurse’s accountability and responsibility are not well pursued due to lack of cooperation. According to Fry & Johnstone (2002) cooperation entails making end-life decisions based on active participation with all relevant individuals. This principle focuses on mutualism of goals and priorities and is implemented in addressing Mrs Jordan’s advanced care directive (ACD). By advocating for the patients’ and family’s concerns, the nurse complies with Australian Nursing and Midwifery Council (ANMC) value statements especially with the valuing of nursing care quality. They are bound to minimize risks and striving to offer the best available care. In addition, by the NSW code, both the nurse and the doctor, the senior treatment officer, owed Mrs Jordan accountability. Question 3: Euthanasia All Australian states and territories consider euthanasia as illegal. However, with regard to the concept of ACD and patients’ autonomy in accepting or refusing treatment has implied that health care givers often do it. Whether passive or active, euthanasia is faced with conflicting views on its legality and morality (Huxtable 2007). In practice, a reference to euthanasia implies assisting a patient to die. Whereas this may imply compromising on the sanctity of life principle, ACD also ethically binds palliative health care providers to demonstrate adherence to INC code of ethics especially for accountability, responsibility and care. Currently, the practices used to end lives of suffering terminal illnesses include the use of Do not resuscitate (DNR), and NFT directives. In case euthanasia was legalized, it is in my view that there would be not much difference. Essentially, interventions such as NFT amount to euthanasia practice, although it is passive and may thus not be considered homicidal. This would find strength in the laws acceptance of ACD thus requiring doctors and nurses to comply with the wishes of the patient or the representatives. In addition, there is an increasing prevalence of terminal illnesses and ageing (Preston 2007). A reference to the Northern Territory Rights of the Terminally Ill Act indicates legalization of assistive actions by palliative care givers (Fry & Johnstone 2002). In the legalization, the threshold of the intervention is to the extent that the actions do not amount to the intention of killing-homicide. This would amount to professionals using passive methods such as NFT and DNR (Chiarella 2006). In considering the legality and morality of any intervention, there are key aspects of consideration: ACD, the situation of the patient as assessed by the professionals and mutual consent based on the principle of cooperation (Abrams 1990). Question 4: advocacy and ethics of accountability Advocacy in the nursing practice refers to the role of the nurse speaking or defending the course of a patient incapacitated to do so by illness (Sim 1996). Fry & Johnstone (2002) indicates advocacy as being central to the nurse-patient relationship and having various interpretations: right protection, value-based decision model and the respect for persons. The rights protection interpretation views the nurse as defending rights of patients whereas in value-based interpretation the nurse assists in discussing the ACD choice and implications (Abrams 1990). This is consistent with ACD planning (NSW Department of Health 2004). Thirdly, the respect-for-persons view implies that the nurse will focus on the welfare, dignity and privacy of patient. Advocacy is related to accountability. The ANMC conduct statement 2 charges a nurse with a responsibility to be accountable. The ANMC indicates that “nurses are personally accountable for the provision of safe and competent nursing care” (ANMC 2008). Accountability implies being answerable and responsible. Answerability implies both legal and moral accountability which the nurse owes the patient in palliative care. A patient in intensive care or terminal illness accompanied with suffering and imminence of death is not in a position to represent their interests. As such, it the moral duty of the nurse to ensure that health is promoted and restored, there is prevention of further illness and that the patient’s suffering is alleviated. These responsibilities imply the need for critical decisions. Whatever model or method of decision making it is the role of the nurse to ensure that the value of intervention is based on patients’ needs (Chiarella 2006). Thus, advocacy is as central to ethics as accountability. With respect to Janet’s actions, this paper is of the opinion that she was acting ethically by advocating that Mrs Jordan be accorded her ACD wishes. The patient could not speak for herself but had ACD wishes which could not be implemented without Dr. Johnson’s consent. Janet was thus bound to push to have NFT intervention to relieve the patient the pain and preserve her dignity. However, her action of changing the IV Fluid in the original version does not amount to accountability for lack of cooperation in decision making. Question5. Do-Not-Resuscitate orders by nurses Yarling & McElmurry, (1986) indicate that authority to write ACD implementation orders is often an area of conflict physicians and nurses. This has prompted hospitals and health organizations establish policies determining how and who should make the decision as well as implement. Citing that there is no logical reason for confining the duty to doctors, they suggest that DNR order writing should be a decision that overlaps both nursing and nursing. In supporting this suggestion, it is vital that the decision be based on helping the patient but not professional territoriality. The nurse is bound to be accountable as an advocate and participates in ACD planning and implementation. As such, the nurse is found in a difficult position, similar to Janet’s since he/she cannot make decisions commensurate to the challenge of the patient’s suffering. In addition, it is nurse who implements both the DNR and NFT decisions. As such, it is only rational that nurses are authorised to make such orders. Given such implications, such permissions to nurses would have alleviated the ethical and legal complications that faced Janet in the original version. The concept of accountability requires that nurses have full autonomy. If a nurse is to be legally and morally answerable and responsible then having authority to write orders would be appropriate. Nurses owe full duty of care to patients. In palliative health care, the duty has more implications given the imminence of death and extent of suffering. As such, care is vital in the relationship. Conclusion The original version presents the nurse as having compromised ethics and legal accountability with regard to end-life decisions. It presents the dilemmas inherent in making and implementing decisions. The alternative version has demonstrated end-life decisions being made and implemented in legal and ethical manner especially as concerns cooperative decisions. The nurses’ advocacy is important if one is going to be accountable to the patient. With reference to euthanasia, there are legal prohibitions. However, interventions such as NFT are essentially euthanasia only that it is passive, thus not amounting to homicide. Finally, in order to get rid of legal and moral dilemmas and conflicts, it is vital that nurses are allowed to give orders. This is in line with their expected accountability. Reference list Abrams, N. 1990, A contrary view of the nurse as patient advocate. In Pence, T. & Cantrall, J., Ethics in nursing: an anthology (pp. 102-105). New York: National League for Nursing. ANMC, 2008, Code of Professional Ethics for Nurses in Australia, Canberra: ANMC. Chiarella, M. 2006, Policy in end-of-life care: education, ethics, practice, and research. London: Quay Books. Fry, S., & Johnstone, M. 2002, Ethics in nursing practice, Oxford: Blackwell. Huxtable, R. 2007, Euthanasia, Ethics and the law: from conflict to compromise, Oxon: Routledge. McIlwraith, J., & Madden, B. 2006, Health care and the law (4th Ed), Prymont : Thomson . NSW Department of Health, 2004, Using Advance Care Directives, Sydney: NSW Department of Health. NSW Department of Health, 2005, End-of-Life and Decision Making Guidelines, Sydney: NSW Department of Health. Preston, N. 2007, Understanding ethics, Annandale: Federation press. R, Y., & McElmurry, B. 1986, Re-thinking the nurse's role in "Do Not Resuscitate" orders: a clinical policy proposal in nursing ethics. In Chinn, P, Ethical Issues in nursing (pp. 123-134), Maryland: Aspen Systems Corp. Sim, J. 1996, Ethical decision-making in therapy practice, London: Bailliere Tindall. Read More