Grace Cullen Oligario, NP C, ACHPN Nurse Practitioner, Oncology and Palliative Care Ethics Consultant Detroit VA Medical Center

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1 Grace Cullen Oligario, NP C, ACHPN Nurse Practitioner, Oncology and Palliative Care Ethics Consultant Detroit VA Medical Center Introduction to Ethics Introduction to the process of Ethics Consultations Application of Ethics in Patient Care at the End of Life Arises when there is a conflict over beliefs, values or what is considered to be the norm for a group or for society Ethics is the generic term for various ways of understanding and examining the moral life, Beauchamp and Childress, Ethical consultations aim to provide guidance and recommendations to assist in the resolution of ethical dilemmas using the ethical principles

2 Non malfeasance doing no harm Autonomy patient s right to self determination Beneficence doing what is good Justice fairness Consult requests are typically not limited to physicians They can be requested by other staff members, patients, families, and other individuals who are faced with an ethical dilemma involving the medical center EXPLORE allow involved parties to express concerns and views Opportunity to gather information Allow for venting of frustrations Clarify misinformation, supply missing information Allow for input from the members of the Consult Team

3 PATIENT CENTERED What does the patient want? The beneficiary of any act ought to be the direct recipient of the act, C. Hayes, With an ultimate goal of not only improving patient care for an individual but the delivery of health care for the rest of the population served ETHICAL DILEMMAS TEND TO BE MORE COMMON AS THE INVOLVED INDIVIDUALS ARE FACING DEATH Patient his own death Provider death of his/her patient Family/caregiver death of a loved one

4 PRINCIPLE OF DOUBLE EFFECT has 4 conditions The act in itself is good or at least morally indifferent The good effect of the act is directly intended and the bad effect may be foreseen, but unintended The good effect is not achieved by the bad effect a state of death is not pursued to achieve a pain free state The good effect is proportionate to the bad effect the amount of pain medication used is proportionate to the need/level of pain Hayes, 2004 AMERICAN NURSES ASSOCIATION (ANA) POSITION STATEMENT ON EUTHANASIA: Nurses must be vigilant advocates for the provision of humane and dignified care. Nurses can demonstrate their respect, support and lasting commitment to patients and families without participating in active euthanasia. ANA POSITION STATEMENT ON ASSISTED SUICIDE: Nurses need to remain in the forefront as leaders and advocates for the delivery of dignified and humane end of life care. Nurses are obligated to provide relief of suffering, comfort and when possible a death that is congruent with the values and desires of the dying person. Yet, nurses must uphold the ethical mandates of the profession and not participate in assisted suicide. MEDICAL FUTILITY The providers may refuse to provide treatment in an effort to observe the principle of non malfeasance (to do no harm) The providers may advocate for the provision of treatment whose benefits may outweigh the risk such as prolonging life

5 WITHHOLDING OR WITHDRAWING MEDICAL INTERVENTIONS Withdrawing medical interventions tend to cause more of a dilemma because it is seen as an active act as opposed to the passive act of withholding treatments It is usually easily justifiable not to provide (withhold) treatments that may do more harm than good Mr. D is a 55 y/o male with PVS from an intra cerebral bleed. He is non verbal, not capable of interacting or recognizing people. He is bed bound, with a tracheostomy, feeding tube, and contracted extremities. He has outlived his 6 month prognosis while under Hospice care and appears to be clinically stable and no longer meets guidelines for continued Hospice care. ETHICAL QUESTION: In discussing goals of care w/ his family, should the issue of continuing w/ his artificial nutrition be explored? Could the patient, if he was able, potentially desire to have this medical intervention be withdrawn for futility? Could continuing to live in a vegetative state be considered futile? How do we apply the ethical principles of non malfeasance, beneficence, autonomy and justice to this case?

6 Mr. S is a 54 y/o male w/ schizophrenia and a court appointed guardian. He was found to have a nearly obstructing, malignant sigmoid colon mass. The recommendation was made for a surgery that will potentially extend his life as opposed to having it shortened without one. The pt. refused to undergo surgery for fear of ending up with a colostomy. His guardian consents to have the pt. undergo surgery. ETHICAL QUESTION: Should the surgery be performed after obtaining consent from the legal decision maker even though the recipient of the act and its consequences is the patient? How do we apply the ethical principles in this case? The pt. proceeded to undergo a subtotal colectomy and ended up with an ileostomy. Complete surgical excision of the tumor was not possible due to its location and local spread. The recommendation was for the pt. to undergo palliative chemotherapy and radiation after his surgical wound heals and he regains his strength. The pt. continued to deteriorate and went under Hospice care. He died 5 months later.

7 Handbook for health care ethics committees, Farber Post, L., Blustein, J., and Neveloff Dubler, N. Baltimore: Johns Hopkins University Press, The Oxford handbook of bioethics, Steinbock, B. Oxford; New York : Oxford University Press, Improving end of life care : why has it been so difficult?, Jennings, B., Kaebnick, G., and Murray, T. Garrison, New York : The Hastings Center, Managing death in the ICU : the transition from cure to comfort, Randall Curtis, J. & Dubenfeld, G. D. New York : Oxford University Press, Ethics in clinical practice, Ahronheim, J. C., Moreno, J., & Zuckerman, C. Boston : Little Brown, American Nurses Association. Position Statement on Active Euthanasia. Washington, DC: Author; American Nurses Association. Position Statement on Assisted Suicide. Washington, DC: Author; Beauchamp T, Childress J. Principles of Biomedical Ethics. 4 th ed. New York: Oxford University Press; Dahlin C. Journal of Hospice and Palliative Nursing, Vol. 6, No. 1; Dalinis P. Journal of Hospice and Palliative Nursing, Vol. 6, No. 2; 2004.

8 Hayes C. Journal of Hospice and Palliative Nursing, Vol. 6, No. 1;

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