A Presentation On A Nursing Practice Issue Nursing Essay.
Decisions to commit patients to palliative care are made by doctors, the interprofessional team (IPT), and substitute decision-makers (SDM) without adequate involvement of the patients themselves due to their loss of capacity to make those decisions. Strangely, nurses are also, in many cases, cut out of the decision-making link, creating a slew of ethical and professional problems for nurses as patients’ advocates and caregivers. The presentation illustrates a case in which a change in the care plan for a patient was made contrary to what a newly-graduated RN thought represented the true wishes of the patient.A Presentation On A Nursing Practice Issue Nursing Essay.
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Palliative Care Nursing – Its Currency
• The demand for hospice palliative care in Canada is increasing. About 160,000 Canadians need palliative care each year, and only about 5% and their families are able to get these services (Brown & Sanazaro, 2006).A Presentation On A Nursing Practice Issue Nursing Essay.
• The Canadian Hospice Palliative Care Association, (CHPCA, 2007), estimates that about 62% of annual deaths in Canada requires access to hospice palliative care services and forecasts that demand for hospice palliative care services will increase over the next 40 years.
• CHPCA (2002) There is a lack of uniformity and consistency in the delivery of palliative care and states finds that “existing programs are not comprehensive, and are unable to address all of the issues faced by patients and families” (CHPCA, 2002).A Presentation On A Nursing Practice Issue Nursing Essay.
CNA and Palliative Care Nursing
Aware of the increasing need for specialized knowledge and skill to provide nursing care for clients and families requiring palliative care services, the CNA has recognized hospice palliative care nursing as an advanced practice that require the passing of examinations and certification. The explosion in demand for palliative care services require that nurses pay extra vigilance and diligence in protecting their clients from harm.A Presentation On A Nursing Practice Issue Nursing Essay.
Case Scenario: A Representation of Palliative Nursing Practice Issue
Midway through the morning of the fourth day of providing care for Mr. X, a 57-year old male admitted with metastasized rectal cancer, Akua, a newly graduated RN, was informed by the attending physician that the provision of oxygen by nasal prong or face mask was to be discontinued and only oral suctioning using the Yankauer would be allowed.A Presentation On A Nursing Practice Issue Nursing Essay.
In addition, all forms of feeding were to be discontinued. The doctor said the client’s family had given consent to this new plan of treatment. Akua knew that the revised plan of care meant a slow death for a patient that looked so much like her father and with whom she had spent lunch breaks reading stories about hope. Her initial thoughts, when she saw the physician disconnect the feeding tube and the oxygen apparatus himself was to protest, but she was afraid to do so.A Presentation On A Nursing Practice Issue Nursing Essay.
“The end of life is a sacred time in every human culture, a final opportunity to promote and experience spiritual growth. However, spiritual work is difficult, if not impossible, when in pain, and when short of breath. Palliative care can provide an environment of comfort, healing, and affirmation near the end of life, something that is deeply appreciated by patients and their families, as well as the entire health care team.” (Clary& Lawson, 2009)A Presentation On A Nursing Practice Issue Nursing Essay.
End-of-Life Care
Palliative care aims to relieve suffering and improve the quality of living and dying. Thus, nurses must provide relief from pain and other distressing symptoms, affirm life and regard dying as a normal process, neither hasten nor postpone death, integrate psychological and spiritual aspects of client care, offer support system to help clients live as actively as possible until death, offer a support system to help families cope during the client’s illness and their own bereavement, and enhance the quality of life (Brown & Sanazaro, 2006).A Presentation On A Nursing Practice Issue Nursing Essay.
It involves symptom control, such as the common symptom of dyspnea, which can be managed by maximizing client’s oxygenation though providing oxygen, positioning patients upright, maintaining a patent airway, and reducing anxiety or fever. It also involves maintaining dignity and self-esteem, which is shown when nurses respect the person as a whole with feelings, accomplishments, and passions that are separate from the illness experience. In addition, knowing clients helps to facilitate client’s decision-makig and autonomy in choosing therapies (Brown & Sanazaro, 2006).A Presentation On A Nursing Practice Issue Nursing Essay.
Systematic Review
A systematic review of the literature on the accuracy of the prediction of dying patients’ preferences by Substitute Decision Makers (SDM)Â was done by Shalowitz, DI and Wendler, D. (2006)Â using Pubmed, the Cochrane Library and manuscript references. 16 eligible studies involving 151 hypothetical scenarios and 2595 surrogate-patient were considered. 19 526 patient-surrogate responses were thus considered.Â
The studies find that, overall, substitute decision makers predicted patients treatment preferences with 68% accuracy
Thus, in one-third of all cases, SDMs’ decisions did not represent the wishes of the dying
The Presentation Addresses the Following End-of-Life Care Issues
• End-of-life care issues
• Euthanasia in Canada
• Nurse Advocacy for Patients
• Ethical implications for the nurse
• The nurse’s role in End-of-Life care
• Disagreeing with the plan of care
• Refusing the assignment and discontinuing nursing service
• Client and nurse grieving
Key Dilemmas Faced in End-of-Life Care (Kerba, 2002)
Patients’ decision-making capacity and right to refuse treatment
Does withholding and withdrawing life sustaining treatment, including nutrition and hydration, provide the dying with comfort?
What about the ethics of pain management?
Who is best qualified to make resuscitation decisions
The issues of medical futility and assisted suicide.
The Essential Steps for the Nurse
• Clarify own ethical positions relating to end-of-life, euthanasia, culture, religion
• Research and understand current legislation relevant to treatment and end-of-life care (CNO, 2009c)
• Review institutional policy relating to palliative care
• Verify MD and Inter-Professional team order
• Review client chart to assure self of existence of advance directive, properly executed consent and DNR forms
• Determine propriety of substitute decision-making process
• Is Plan of treatment appropriate?
Knowing Client’s End-of-Life Wishes
• From client’s verbal or non-verbal direct instructions
• From client’s advance directive, e.g. Living will, power of attorney for personal care
• If client is incapable, from substitute decision-maker’s instructions
• Documented instructions from another member of the healthcare team
• In the case where the nurse is involved, this is possible if the nurse is able to form a trusting relationship with the client or the family
In the preceding case, the nurse was able to ascertain that the wishes of the client and the orders of the MD were not in sync.A Presentation On A Nursing Practice Issue Nursing Essay.
Person’s who May Give or Refuse Consent under the Health Care Consent Act, 1996 (1996, c. 2, Sched. A, s. 20 (1)).
1. The incapable person’s guardian, if the guardian has authority to give or refuse consent to the treatment.
2. The incapable person’s attorney for personal care, if the power of attorney confers authority to give or refuse consent to the treatment.
3. The incapable person’s representative appointed by the Board under section 33, if the representative has authority to give or refuse consent to the treatment.A Presentation On A Nursing Practice Issue Nursing Essay.
4. The incapable person’s spouse or partner.
5. A child or parent of the incapable person, or a children’s aid society or other person who is lawfully entitled to give or refuse consent to the treatment in the place of the parent. This paragraph does not include a parent who has only a right of access. If a children’s aid society or other person is lawfully entitled to give or refuse consent to the treatment in the place of the parent, this paragraph does not include the parent.A Presentation On A Nursing Practice Issue Nursing Essay.
6. A parent of the incapable person who has only a right of access
7. A brother or sister of the incapable person
8. Any other relative of the incapable person.
Ethical Issues Confronting Nurse (Oberle & Raffin, 2008)
• Does she have moral Agency – Is nurse able to act on her moral beliefs relating to care of the dying?
• May be in Moral Distress – Nurse definitely feels that the should be provided with minimum oxygen, feeding, and suctioning but is constrained
• May be experiencing Ethical Uncertainty – Nurse has a feeling that something is missing in the revised plan of care but is not sure what it definitely is
• Ethical Dilemma – The nurse has to choose between the two mutually exclusive ethical issues of promoting the pt’s comfort by: (1) Continuing to feed, oxygenate, and suction her, OR (2) Not continuing her pt’s suffering by depriving her of basic feeding, oxygenation and suctioning
• Nurse may use an ethical decision making framework such as that by Oberle & Raffin (2008)
The nurse has to work within the interdisciplinary team and according to nursing’s scope of practice. Regardless of what the nurse believes is the correct course of action, she cannot act on her own to carry out orders that are not nursing’s specific interventions and is required to get the necessary staff to write orders, which is then incorporated into the care plan. Because nurses do not have much power to act on their own in the interdisciplinary team, advocacy becomes very important in ensuring the care plan follows patients’ wishes.A Presentation On A Nursing Practice Issue Nursing Essay.
Ethical issues can also arise when family members are unprepared for the decision-making role, and when family members do not understand the biomedical choices and treatments presented to them. Nurses are often in the middle as they attempt to comply with medical directives and simultaneously protect and advocate for their patients (Robichaux & Clark, 2006).A Presentation On A Nursing Practice Issue Nursing Essay.
Ethical Decision Making Framework (Oberle & Raffin, 2008)
• Step 1 – Assess the Ethics of the Situation: Identify the Relationships, Goals, Beliefs and Values in the situation. What is happening here?
• Step 2 – Reflect on and Review Potential Actions: Recognize available choices and determine how these choices are valued. What could I do?
• Step 3 – Select an Ethical Action: Maximize Good. What should I do? Which action will provide the maximum good?
• Step 4 – Engaging in ethical action: What will I do?
• Step 5 – Reflecting on and reviewing the ethical action. What did I do?
Current Legislation Regarding End of Life
• Euthanasia – knowingly and intentionally participating in ending a person’s life to relieve pain and suffering
• Canadian Criminal Code distinguishes between active euthanasia and passive euthanasia
• Active Euthanasia – knowingly and intentionally participating in ending a person’s life to relive pain and suffering. Is criminal and forbidden
• Passive euthanasia – includes starvation, dehydration, or withholding life-preserving procedures (Healthcare consent Act, 1996)
• Suicide not a crime in Canada but physician-assisted suicide is (Criminal Code of Canada, Section 241b)
Euthanasia and End-of-Life Care in Canada
• The Canadian Medical Association states it is not up to doctors to decide on the issue of euthanasia but the responsibility of society
• The CMA forbids Canadian physicians from participating in euthanasia and assisted suicide (CMA, 1998).A Presentation On A Nursing Practice Issue Nursing Essay.
In determining the appropriateness of the physician’s order:
The nurse must determine if Canadian laws relating to euthanasia were broken. In the presenting case, one might argue that the change in the care plan could be passive euthanasia.A Presentation On A Nursing Practice Issue Nursing Essay. It becomes important to distinguish life preserving actions from comfort measures in palliative care. From clinical experiences, patients often are NPO as they refuse meals. Often times, patients experience decreased appetite, and sometimes there will be orders for maintenance IV fluid for hydration purposes. Discontinuing the g-feed may be an appropriate decision if it is determined to be what the patient would want, but continuing the g-feed could help prolong the patient’s life. However, endotracheal suctioning and maintenance oxygen therapy are not so life-preserving measures as they are comfort measures in this case and likely will not change the clinical outcome. Passive euthanasia if not according to the patient’s wishes is unethical and could be considered clinical negligence.A Presentation On A Nursing Practice Issue Nursing Essay.