Transcript Slide 3 Ethics: Forgoing Medical Therapy TNEEL-NE

Sarah E. Shannon, PhD, RN
Ethics: Forgoing Medical Therapy
Introduction
• Nurses are perceived as having
a crucial “in-between” role:
– The communication line between the
patient and physician.
– The communication line between
family and physician.
• We look the nurse’s role at
end-of-life as a process rather
than a single decision, a
specific moment, or a single
interaction.
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Ethics: Forgoing Medical Therapy
Traditional Role:
Nurse as Patient Advocate
• For many years, the nurse’s role was “patient
advocate” (supporting a patient’s interests).
• Patient advocacy is based principle of autonomy:
– The individual’s rights to self-determination, in
particular over what happens to one’s body.
• Autonomy vs. justice
• Autonomy vs. beneficence
• Merely supporting the patient’s right to autonomy
does not resolve the ethical dilemma.
• Patient advocacy implies that an adversary exists.
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Ethics: Forgoing Medical Therapy
Issues that Impact the
Nurse’s Role
Reactions to ambivalent
situations:
Moral distress
In-between role
May Create DEEP
Impact
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Ethics: Forgoing Medical Therapy
Reactions to Ambivalent
Situations: Moral Distress
• Moral distress:
– Presented as an unavoidable part of being involved in
ethical issues.
– Characterized by anger, powerlessness, frustration,
cynicism, burnout or combinations of these feelings.
• Nurses may encounter three types of moral distress:
– Moral sadness
– Moral uncertainty
– Moral outrage
• The cure for moral distress is moral dialogue.
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Ethics: Forgoing Medical Therapy
In-between Position
• Nurses may occupy an in-between role in healthcare
interactions, or they may feel caught between:
– MDs who are in authority in the healthcare setting.
• Example: Physicians from different specialties who disagree.
– Patients who have authority.
• Is the in-between role a liability or an asset for
nurses? One view is that it is an asset:
– Nurses are uniquely positioned within the healthcare
team by being in-between.
– Nurses can facilitate communication via the access and
information gained by virtue of “being in-the-know.”
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Ethics: Forgoing Medical Therapy
Goals of Ethical Decision Making
• Nurses may need to rethink and remake their role in
ethical decision making.
– Using in-between role as a means to begin a decisionmaking process rather than focusing on ethics as a single
decision, a specific moment, or a single interaction.
• Ethics as a process:
– Allows recognition that decision making takes time.
– Lets one to accept that the right steps were taking place.
– Helps one commit to keeping the lines of communication
open with families, patients, and colleagues as the best
preventative medicine in ethics.
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Ethics: Forgoing Medical Therapy
Ethics Resources for Nurses
• When nurse’s are overwhelmed,
external resources should be
utilized. Examples include:
– Institutional ethics committees and
ethics consultation services.
– Clinical nurse specialists or others
with expertise in a particular area.
– The ethics literature on a
particular topic (Kelso book).
KELSO
Books –
Still Work
Kelso, L. A. (1994). Alcohol-related end-stage liver disease and transplantation: The
debate continues. AACN Clinical Issues, 5(4), 501-506.
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Ethics: Forgoing Medical Therapy
Strategies to Promote Ethical
Decision Making
• Nurses can use strategies to promote ethical
decision making regarding end-of-life choices
and to encourage dialogue between people
involved in the patient's case.
• These strategies fall into three general areas:
Knowing
Facilitating
Guiding
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Ethics: Forgoing Medical Therapy
Knowing: Understanding all
People Involved
• Understand the perspectives of all the people
involved in the patient's case.
• These people fall roughly into three groups.
Imagine perspectives of the following:
Patient
Family
Other caregivers
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Ethics: Forgoing Medical Therapy
Facilitating: Communication
Between People
• Bringing together: Arrange the logistics of bringing
the involved people together to talk,
– Example: Identify a private room for family discussions.
• Informing: Translate the specialized language of
healthcare (complexities, equipment, etc.)
• Preparing: Prepare others for discussions by
affirming the need for communication
– Ask rhetorical questions: “What are we really doing here?”
• Supporting: Affirm the value of each person’s input,
share other person’s sorrow when hard decisions
must be made, and be present when physicians talk.
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Ethics: Forgoing Medical Therapy
Guiding: Acting as a
Reference Group
• Orienting: Help the family and others function in
their normal social or professional roles within the
high-tech environment of healthcare.
• Directing: Guide others about the scope of their
social or professional roles given the clinical
reality.
• Sharing: Offer your presence to others in difficult
and unfamiliar experiences.
– In particular, being present when death occurs if
possible.
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Ethics: Forgoing Medical Therapy
Characteristics of the
Organizational Environment
Accepting the
Personhood of the
Professional
Tolerating Ambiguity
Transcending Roles
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Ethics: Forgoing Medical Therapy
Accepting the Personhood
of the Professional
• The organizational culture accepts the
personhood of the professional by recognizing:
– Connections between patients, families and
professionals extend beyond walls. Supporting
healthcare professionals to maintain contact with
patients and their families as they transfer between
services or settings within an organizational structure.
– Professionals also grieve and need support. Creating
opportunities such as memorial services for long-term
patients offers an opportunity for the participation of
professionals as persons.
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Ethics: Forgoing Medical Therapy
Tolerating Ambiguity
• The organizational culture tolerates ambiguity by:
– Accepting that clinicians need to be able
to be unsure about ethical issues
– Offering novice and experienced
clinicians encountering new situations
support as they become familiar with
difficult clinical situations and treatment choices.
– Encouraging dialogue while tolerating disagreements
and conflicts.
– Refusing to accept a dead end in communication
about an ethical issue.
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Ethics: Forgoing Medical Therapy
Transcending Roles
• The organizational culture can help healthcare
professionals transcend roles by:
– Moving beyond negative stereotypes of other professionals
or family members such as the uncaring physician or the
problem family.
– Creating opportunities for open discussion of treatment
choices among the healthcare team (particularly where
there is disagreement about the plan of care).
– Ensuring that disagreement
is not personalized to
a single individual or to
a professional group
such as surgeons.
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