Ethical Dilemma in Nursing Homes Regarding Terminally Ill Patients
Abstract
There are ethical issues that arise regarding decision making on the end-of-life of a patient particularly considering the hardship of making the family come into consensus. The nurses end up in a dilemma due to the conflict of their morals and values to those of the patients thus causing distress in making the final decision (Karnik & Kanekar, 2016). Patients, caregivers, and relatives may become emotional, grieve, and feel the loss (Coelho & Barbosa, 2017). Therefore, novice nurses need to be better prepared by ensuring that they understand about ethical issues that arise during end-of-life decisions to handle it as ethically required by observing all the patients’ rights (Butt & Rich, 2019). Additionally, nurses have to respect the patient’s choices and offer care that is in accordance with the patient’s desires and act as advocates to patients concerning the identification of care preferences. In such cases, caregivers are the patient’s advocates and ensure that the right resources required during the time are available to assist in such times. At times, their beliefs and values go against the patient’s wishes as the caregivers may feel it is possible to extend life through the advanced technologies (Karnik & Kanekar, 2016. Palliative care nurses establish a close relationship with the patient and establish an environment where a natural conversation is held to ensure that both the patient understands all ethical issues necessary to end-of-life (Kirkpatrick, Cantrell & Smeltzer, 2017). This paper explores the ethical dilemma in nursing homes regarding terminally ill patients.
Keywords: End-of-life, ethical dilemma, caregivers, families, palliative care, nurses
Ethical Dilemma in Nursing Homes Regarding Terminally Ill Patients
Death is an inevitable occurrence for human beings. Its occurrence is devastating especially to terminally ill patients who live each day facing the reality of death (Bertman, 2016). Fortunately, with the advancement in technology, it has become possible to reshape the occurrence of natural death and prolong life (Karnik & Kanekar, 2016). However, despite the medical advancements, there is no assured promise of recovery but rather sustenance of life with or without a significant presence or with secondary sustenance such as ventilators, feeding conduits among others. Additionally, this has allowed the patients with the help of the family to select their preferred treatment in cases of a terminal illness. Health care providers have to be knowledgeable about the ethical issues concerning terminally ill patients. Effective advanced care planning is imperative in ensuring patient independence at the end of life even in cases where the patient has lost the capability to make pronouncements (Roberts & Siegler, 2017). Medical futility in nursing homes is difficult to identify thereby hindering the achievements of the intended goals of therapy (Schneiderman, Jecker & Jonsen, 2017). Medical interventions such as simulated nutrition and hydration can be suspended or withdrawn if the measure is in line with the wish of the patient (Alves, 2019). In some situations, caregivers in nursing homes are faced with the request for physician-assisted suicide (Preshaw et al., 2016). Therefore, in such situations, the physician is in a dilemma to fulfill the request or work with the healthcare team to offer care and comfort to the patient. Additionally, caregivers have to make difficult decisions while still upholding the moral duty of assuring good care to dying patients. This paper addresses the ethical dilemmas faced by caregivers in nursing homes regarding terminally ill patients.
Historical Foundation
Nurses experience ethical concerns in three dimensions of biomedical ethics containing the comprehensive, predominant, health-related complications that influence procedure or society as a whole; dilemmas affecting institutions and those that touch on patient population or particular patients (Johnstone & Facn, 2019). All healthcare personnel involved in caring for terminally ill patients in nursing homes, nurse scholars, legislators, instructors, advisors, administrators, ethicists, advanced practice nurses, and clinical nurses, experience biomedically associated concerns daily (Olson & Stokes, 2016). To assist in maneuvering the concerns, some ethical codes guide in ensuring optimum care is given. The desire to have ethical codes guiding all healthcare providers was realized in the 1800s (Epstein & Turner, 2015). Additionally, in 1896, after the establishment of the American Nurses Association, there was the objective to formulate a code of ethics that would guide nurses’. Finally, the earliest official code was utilized in 1950. Therefore, physicians and nurses operated for many years without a governing code of ethics and only used Greeter’s Nightingale Pledge and medicine’s Hypocritical Oath.
The first outline regarding the ethical comportment of nurses was suggested by the ANA in 1926 (Epstein & Turner, 2015). Additionally, the provisions were designed in standings of several associations between the nurse and the patient, medicine, and their profession. For example, the relationship between the nurse and the patient incorporated conveying all the information, skill, and dedication to the work. Furthermore, in 1940, there was the establishment of a Tentative Code that considered nursing to be a profession and delineated many requirements comparable to those of 1926 and included the insetting of the requirements in terms of relationship with the patient. Finally, a formal code of ethics for professional nurses was adopted in 1950 and revised in 1960. The code of ethics outlined various provisions such as the central responsibility to safeguard life, ease grief, and promote health. The code of ethics aimed at extending responsibility for practice and conduct contribution in study and accomplishment on matters of regulation touching on nurses.
Code of Ethics
In 1968, the code of ethics was revised to incorporate several significant changes (Beth, 2015). The new code had an elaborate interpretation that aimed at assisting nurses understand the applicability of the provision. Additionally, the provisions were reduced from 17 to 10 which were considered to be more manageable. Therefore, the nursing obligations became more duty-bound where the responsibilities were to respect man’s dignity, unhampered by deliberations of race, belief, color, or social standing as well as safeguarding an individual’s right to privacy. The codes of ethics have been revised throughout time concerning changes in technology, social changes, research, education, health policy among others (ANA, 2015). Consequently, all the code of ethics aimed at advancing the occupation and building and maintaining a conducive work environment.
The present-day code of ethics formulates a principal establishment for the profession to direct nurses in their pronouncements and behavior (Epstein & Turner, 2015). Additionally, they institute an ethical order that is not traversable in any role and setting. Finally, the nurses inscribe the code of ethics by accepting the professional commitment to society as well as practicing the professional values, duties, and obligations. The provisions and interpretive statements are a representation of professional ideals that emphasize the broad expectations without articulating exact activities or behavior (Fowler, 2015). The code of ethics concerns the personal, shared nursing purposes, engagements as well as necessitates each nurse to validate ethical proficiency in the professional undertaking.
The Essence of Understanding Ethical issues in Nursing Homes with Terminally Ill Patients
End-of-life requires paramount decision making because it can terminate or prolong human life which can leave the caregiver in dilemma thus calling for a code of ethics considerations (Karnik & Kanekar, 2016). Additionally, in end-of-life care, many ethical dilemmas arise due to situations such as a breakdown in communication, compromise of patient autonomy, non-beneficial care, shared decision making, and ineffective symptom management. Therefore, it is imperative for nurses in care homes to understand ethical dilemmas for them to allow patients, family members, and caregivers the opportunity to experience end-of-life with dignity.
Difficult Decisions in End-of-Life Care
Caring for end-of-life patients allows nurses and caregivers to witness the complications and difficulty in making decisions that must be made by the patients and family concerning various delicate matters (Taylor, 2019). Despite nurses having their principles, ideals, and beliefs, they occasionally do not relate to the patient’s beliefs and requests and internal misunderstanding can arise (Olson & Stokes, 2016). However, the nurse has to remain focused on facilitating the patient to evaluate the paybacks and problems of the involvement rather than just the intervention itself. Some of the complex issues include:
Stopping/Suspending Medical Interventions
In care homes, the decision to stop medication is always a difficult one to make the medication may be non-life supporting other multifaceted interventions such as mechanical ventilation (Taylor, 2019). Additionally, the rationale to stop the medication is based on the outcome. If the side effects are outweighing the benefits, it is only rational to withdraw the medication (Fischer, 2015). Therefore, in some situations the interventions to prolong life increase suffering thus decreasing the patient’s quality of life. Additionally, the patient or surrogate decision-makers may decide to stop the medication which is always a difficult choice to make for the family and the caregiver. This calls for advance directives that enable the patients to make medical decisions know to the family and caregivers in the event they are unable to make the decisions themselves (Olson & Stokes, 2016). When a family member or caregiver is mindful of the nature of care that the patient need, then the burden to make choice is reduced (Crooks et al., 2017). Additionally, it assists in the prevention of some life-sustaining management beforehand as no judgment will need to be made to remove the involvement, as well as the overall cost of futile treatment, is reduced.
Do Not Attempt Resuscitation (DNAR)
A patient may have made the decision not to attempt resuscitation. This implies that in the result of cardiac arrest cardiopulmonary resuscitation (CRP) should not be attempted on the patient (Fischer, 2015). Additionally, the CRP may embrace the use of chest compressions, cardiac medications, or the assignment of an inhalation tube. Consequently, caregivers experience difficulties in deciding as they have to watch the patient die. Patients near death often make these decisions that the family and caregivers are obliged to comply with (Olson & Stokes, 2016). At times the term natural death is used by healthcare institutions in place of DNR orders (Hardy, 2018). Therefore, DNR stipulates that CRP should not be attempted on the patient and allow natural death implies that only comfort procedures should be taken to contain symptoms allied to comfort. Additionally, caregivers may find it against their values to safeguard life to avoid interfering with natural dying but make it comfortable when they are in a position to extend life.
The Principle of Double Effect (Hastening Death)
The double effect principle is used about some of the decisions made by caregivers and they result in desirable and undesirable effects (Fischer, 2015). For example, a caregiver may administer pain medication to assist in alleviating a patient’s pain and grief but the same medication contributes towards the hastening of the patient’s death. Therefore, despite the medication having the ability to reduce the patient’s pain, it also reduces the respiratory rate to life’s inconsistent level thus hastening death (Duckett, 2018). The caregiver in this case is in a dilemma to initiate the intervention or let the patient experience the pain (Fischer, 2015). Additionally, the offer is considered palliative treatment which gives the patient reassurance and comfort which in turn anticipates consequence of the intervention by lessening the pain or the respirations.
Respect to Autonomy
Bioethics and end-of-life ethics considers respect for autonomy as a key concept in particular. The nursing ethical principles require that the patient has informed consent to respect the autonomy and enable him/her to make decisions resulting from actual and accurate information (Butt & Rich, 2019). Therefore, the principle of respect for autonomy is viewed as rational thus attracting more attention in medical ethics in specific the end of life care ethics (Gomez, Maeseneer & Gastmans, 2019). The autonomy principle is considered to be an arrangement to esteem the patient’s right to self-determine the progress of action and to acknowledge the independence to make decisions (Fischer, 2015). Nurses in care homes have to advocate or their patient’s rights to make decisions (Olson & Stokes, 2016). For instance, some of the decisions that are made by patients are not personally favorable to the nurse. However, despite the dilemma of the patient’s choice, the caregiver has to support it in satisfaction of the code of ethics. Some decisions may include a patient suspending the management care which is at times painful to the nurse as they may not want the patient to die thus considered as unfortunates since the principle of respect to autonomy must apply (Gomez, Maeseneer & Gastmans, 2019). Therefore, communication becomes vital about dying death and choices about end-of-life care and is never easy. Patients and caregivers speak and listen to each other and offer communication about different decisions that they will make during end-of-life care (Olson & Stokes, 2016).
Principle of Beneficence
Beneficence is the standard of doing what is upright and includes prevention, removal, and non-infliction of harm (Butt & Rich, 2019). In care homes handling terminally ill patients it as at times challenging to distinguish between doing decent actions and no damage which is non-maleficence because it is regularly easier to decide what is immoral or destructive more than what might be decent or an advantage (Fischer, 2015). Caregivers have a superior responsibility for ensuring that they cause no injury than doing something that might be of assistance to the patient (Butt & Rich, 2019). Additionally, caregivers need to understand that they have patients with difficult decisions that require them to respect the decisions as well as ensure that they are beneficial and promote patients’ wellbeing.
Principle of Non-maleficence
The principle of non-maleficence requires that caregivers make sure that no injury or harm to the patient’s by either an act of omission or commission (Varkey, 2020). Additionally, caregivers should provide standard care to ensure minimal risks to avoid being held accountable by the law due to violation of the code of ethics. As a caregiver, some intervention to patients causes harm and pain thus requiring the application of the principle of non-maleficence (Fischer, 2015). Additionally, if a patient’s death is forthcoming and requires pain management to maintain comfort then the nurse needs to administer the medication despite the fear that it might hasten death. According to the Code of Ethics for Nurses (ANA, 2015), the caregiver must provide intervention of relieving pain to the dying patient despite the underlying consequences which are death to comply with the code of ethics.
Principle of Justice
The justice principle of fairness governs social fairness as well as seeking to determine whether someone should receive or is entitled to receive a resource (Butt & Rich, 2019). The American Nurses Association’s (2015) code of ethics notes that nurse caregivers have to be committed to their patients irrespective of their social status. Additionally, caregivers should strike a balance between burdens to establish who is eligible to receive some type of care. Patients with terminal illnesses in care homes receive palliative care as some medical interventions are considered futile (Kirkpatrick, Cantrell & Smeltzer, 2017). The decision to manage symptoms is considered just as it is based on the best interest of the patient and not age, ethnicity, or socio-economic status (Fischer, 2015). Additionally, the caregivers in nursing homes have to ensure the patients are aware of all the options available to them to ensure that they receive the best care. Furthermore, in some cases, patients may opt to receive treatment or just manage symptoms. When the caregiver gives the correct information such as if a patient needs surgery and its outcome and side effects, the patient will evaluate what is good or them and choose it (Butt & Rich, 2019). Additionally, there are cases where a patient cannot make informed decisions, therefore, the caregiver has to ensure that patient is well informed since they may not support the decision but has to respect it since it is the patient’s right. For instance, in cases where a patient’s cognitive ability has been impaired by Alzheimer’s disease, they are not in a position to make informed choices. Therefore, the caregiver has to involve surrogate decision-makers such as family to ensure the best for the patient.
Advance Directives
The use of adverse directive helps the caregiver overcome any dilemma on the termination of the life of an ill patient. These are documents designed to enable competent patients to make a decision plan in advance about future terminal illness (Peicius, Blazeviciene & Kaminskas, 2017).To start with, adverse directives are classified into two, proxy and instructional indicating a patient’s wishes in future about end-of-life decisions which aid both the caregiver and family by easily complying with the wish. Additionally, it gives the patient an individually autonomous choice on the best-preferred method to end-of-life. It is the responsibility of the caregiver to provide end-of-life care information to patients to allow competent individuals to document their preferences autonomously which can be documented by the authority for future use(Karnik & Kanekar, 2016). The family or the primary caregiver plays the central role in making decisions in case of an incapacitated patient. The virtue of the family member relationship enables the role of proxy which might not be the patient preference but it is respected in the case where no clear explicit declaration is provided by the patient (Peicius, Blazeviciene & Kaminskas, 2017). Therefore, the proxy decision is not likely the best preference at taking end-of-life but is majorly considered to judge the medical situation depending on how the caregiver evaluates the patient’s condition.
The family members playing the proxy or surrogate decision of any incapacitated patients are likely to have emotional attachment hence fulfilling their moral interest which is against the principle of beneficence therefore caregivers must diversify on whether to accept or decline the treatment(Butt & Rich, 2019). Additionally, in some eventful situations, any unstable preferences on the patient may not be considered reliable thus requiring the renewal evaluation as well as proper decision making from the primary caregiver. To avoid any instance of ethical and legal issues it is the responsibility of the caregivers to provide proper education the society at large about the legal rights and requirement that are necessary for patients on accepting or refusing any adverse directives and recommended treatment that can terminate illness (Peicius, Blazeviciene & Kaminskas, 2017). Finally, ensure the proper acquisition of information on the use of adverse directives and the implications that arise from planning by either the primary caregiver or the patients as well as the legal issues,
Ethical Theories Involved in End-of-Life Care
Caregivers have to apply various theories in the process of overcoming the dilemma in end-of-life by trying to consider the patient’s preferences and perspective. To start with is the egoistic theory that caregivers overcome by ensuring that they are working for the benefit of the patient (Karnik & Kanekar, 2016). Additionally, family members should also put aside their self-interest and make judgments according to the decision that best suits the patient on either the appropriate treatment or end-of-life care. Therefore, caregivers need to provide the appropriate treatment prognosis making the patients have an autonomous choice and make the best that suits them with the help of the family member or individually which is an act of beneficence to the patient (Butt & Rich, 2019). Furthermore, the virtue theory of ethics applies when the act of caregiver is toward achieving the greatest benefit of the patient either individually or through the family. This is achieved by the caregiver providing information about the treatment to avoid any undue harm to the patient for instance if the case is of futile treatment (Karnik & Kanekar, 2016). Additionally, caregivers have to avoid inequity by ensuring that they consider the allocation of limited resources. For instance, a case where a lot of resources are utilized to purchase expensive treatment provided to the patient during the end-of-life situation which leads to leads to unequal distribution of limited technological and medical resources. Therefore, caregivers need to address the issue of unequal or unnecessary distribution of resources by both withholding and withdrawing the futile treatment.
Future Implications
Caregivers should take the initiative of making change by involving in a discussion with the patient about palliative care of the patient’s goal of end-of-life as their preferences. Patients have a different preference, for instance, some require comfort care while other targets cure thus requiring the caregivers to enquire and get the trustful information to hinder any instance of ethical crisis that may arise from the surrounding topic (Karnik & Kanekar, 2016). Additionally, there is a potential of changing the illness by seeking stability of health preference goals which is achieved through the renewal of each specific case and opting out the scenario-based option. To facilitate improved decision making to patients, the caregivers need to provide proper communication, discussion, and education on the implication related to end-of-life to patients thus fulfilling the code of ethics (Fischer, 2015). Therefore, flexibility in both advanced directives and effective planning can be appraised due to its ability to accommodate evaluation and inadvertent scenario-based on preference change which assists in considering the patient’s autonomous choice (Roberts & Siegler, 2017).
Innovations and technological advancement as well are reforming treatment and the decision preferences surrounding end-of-life care. Additionally, technological advancement hinders the natural dying process by providing the capability of prolonging the life of a patient (Karnik & Kanekar, 2016). Therefore, the shared decision-making process on the end-of-life is determined based on patient-centered care which is achieved by the use of advanced treatment to sustain life. Furthermore, an increase in the number of patients seeking long term care is reported due to advanced technology and medical treatments. Finally, adopting a healthy lifestyle provide minimal cases of injuries, disease, and disability which lowers the rate of death and increases long term care in the later life of the patient.
Attaining information and formulating plans of the end-of-life preference should be a mortal consideration to all patients patient (Karnik & Kanekar, 2016). Plans on making the cost of futile and costly treatment cheap at the end of life should be underway thus promoting equality in healthcare for all patients. Therefore, patient autonomy ethical value should be given priority against futile and expensive treatment in circumstances that increase healthcare costs. Furthermore, a patient with the help of the family can consider futile treatments for comfort care options although they can lead to undignified and humiliating situations to patients with the emotional burden (Roberts & Siegler, 2017). In the case of futile treatment, it becomes difficult for patients seeking medical care in understanding the concept which requires that caregivers should provide detailed information that is beneficial to help in decision making.
Political Movement
End –of –life care is determined by how much control is on the patients as well as how the caregivers attend to them in the last stage of terminating the illness. Therefore, end-of-life is considered as dangerous since it is divisive and an emotional issue even to the lawmakers. Affordable Care Act (ACA) encourages that the caregivers involve a nationwide war of words by engaging the patients on how end-of-life care deteriorated quickly thus making it easy to determine the most effective which is an aging idea to American (Greene, 2018). Additionally, making Medicare expenditure make sense, in general, has been the attention of the government or legislator as well as the hospital official because the older adults are expected to consume more than six times as much of the general beneficiaries. Finally, the ACA provides that hospital is reporting a higher rate of readmission thus need to penalize the hospitals which call for more focus in ensuring that no inconveniences are received as a patient is closer to the end of life which often take place in the hospital and nursing homes.
Conclusion
End-of-life requires paramount decision making because it can terminate or prolong human life which can leave the caregiver in dilemma thus calling for a code of ethics considerations. Therefore, the shared decision-making process on the end-of-life is determined based on patient-centered care which is achieved by the use of advanced treatment to sustain life. Furthermore, an increase in the number of patients seeking long term care is reported due to advanced technology and medical treatments. Caring for end-of-life patients allows nurses and caregivers to witness the complications and difficulty in making decisions that must be made by the patients and family concerning various delicate matters. Therefore, in care homes, the decision to stop medication is always a difficult one to make the medication may be non-life supporting other multifaceted interventions such as mechanical ventilation.
Despite nurses having their principles, ideals, and beliefs, they occasionally do not relate to the patient’s beliefs and requests and internal misunderstanding can arise. Patients near death often make these decisions that the family and caregivers are obliged to comply with whereby nurses in care homes have to advocate or their patient’s rights to make decisions. The nursing ethical principles require that the patient has informed consent to respect the autonomy and enable him/her to make decisions resulting from actual and accurate information. Therefore, communication becomes vital about dying death and choices about end-of-life care and is never easy. Patients and caregivers speak and listen to each other and offer communication about different decisions that they will make during end-of-life care.
In care homes handling terminally ill patients it as at times challenging to distinguish between doing decent actions and no damage which is non-maleficence because it is regularly easier to decide what is immoral or destructive more than what might be decent or an advantage. Therefore, caregivers have a superior responsibility for ensuring that they cause no injury than doing something that might be of assistance to the patient. Additionally, caregivers should provide standard care to ensure minimal risks to avoid being held accountable by the law due to violation of the code of ethics. Finally, caregivers should strike a balance between burdens to establish who is eligible to receive some type of care since patients with terminal illnesses in care homes receive palliative care as some medical interventions are considered futile.
Adverse directives are classified into two, proxy and instructional indicating a patient’s wishes in the future about end-of-life decisions which aid both the caregiver and family by easily complying with the wish. Patients have a different preference, for instance, some require comfort care while other targets cure thus requiring the caregivers to enquire and get the trustful information to hinder any instance of ethical crisis that may arise from the surrounding topic. Therefore, it gives the patient an individually autonomous choice on the best-preferred method to end-of-life. This recommends the need for future implications which include the potential of changing the illness by seeking stability of health preference goals which is achieved through the renewal of each specific case and opting out the scenario-based option.
References
Alves, R. F. P. (2019). Has end-of-life decisions or advance directives become an economic strategy to contain health care cost as much as a way to respect patient´ s informed consent and private autonomy rights?: what can we learn from the American Advance Care Model? (Doctoral Dissertation).
American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive Statements. Retrieved from http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics.aspx
Bertman, S. L. (2016). Facing death: images, insights, and interventions: a handbook for educators, healthcare professionals, and counselors. Taylor & Francis.
Beth Epstein PhD, R. N. (2015). The Nursing Code of Ethics: Its Value, Its History. Online Journal of Issues in Nursing, 20(2), 33.
Butts, J. B., & Rich, K. L. (2019). Nursing ethics. Jones & Bartlett Learning.
Coelho, A., & Barbosa, A. (2017). Family anticipatory grief: an integrative literature review. American Journal of Hospice and Palliative Medicine®, 34(8), 774-785.
Crooks, V. A., Whitmore, R., Snyder, J., & Turner, L. (2017). “Ensure that you are well aware of the risks you are taking…”: actions and activities medical tourists’ informal caregivers can undertake to protect their health and safety. BMC Public Health, 17(1), 487.
Duckett, S. (2018). Knowing, anticipating, even facilitating but still not intending: Another challenge to double effect reasoning. Journal of Bioethical Inquiry, 15(1), 33-37.
Epstein, B., & Turner, M. (2015). The nursing code of ethics: Its value, its history. OJIN: The Online Journal of Issues in Nursing, 20(2), 1-10.
Fischer, M. H. (2015). Ethical Concerns in End-of-Life Care. Nursing Care at the End of Life, 85.
Fowler, M (2015). Guide to the Code of Ethics for Nurses: Development, Interpretation, and Application (2nd ed). Silver Spring, MD: ANA.
Gómez-Vírseda, C., de Maeseneer, Y., & Gastmans, C. (2019). Relational autonomy: what does it mean and how is it used in end-of-life care? A systematic review of argument-based ethics literature. BMC Medical Ethics, 20(1), 76.
Greene, E. (2018). The Impact of the Patient Protection and Affordable Care Act on Older Individuals.
Hardy, C. (2018). Interpretation of Do Not Attempt Resuscitation Orders for Children Requiring Anesthesia and Surgery.
Johnstone, M. J., & Facn, P. B. R. (2019). Bioethics: A Nursing Perspective. Elsevier.
Karnik, S., & Kanekar, A. (2016, June). Ethical issues surrounding end-of-life care: a narrative review. In Healthcare (Vol. 4, No. 2, p. 24). Multidisciplinary Digital Publishing Institute.
Kirkpatrick, A. J., Cantrell, M. A., & Smeltzer, S. C. (2017). A concept analysis of palliative care nursing. Advances in Nursing Science, 40(4), 356-369.
Olson, L. L., & Stokes, F. (2016). The ANA code of ethics for nurses with interpretive statements: Resource for nursing regulation. Journal of Nursing Regulation, 7(2), 9-20.
Peicius, E., Blazeviciene, A., & Kaminskas, R. (2017). Are advance directives helpful for a good end of life decision making: a cross-sectional survey of health professionals. BMC medical ethics, 18(1), 40.
Preshaw, D. H., Brazil, K., McLaughlin, D., & Frolic, A. (2016). Ethical issues experienced by healthcare workers in nursing homes: a literature review. Nursing Ethics, 23(5), 490-506.
Roberts, L. W., & Siegler, M. (2017). End-of-Life Care. In Clinical Medical Ethics (pp. 307-363). Springer, Cham.
Schneiderman, L. J., Jecker, N. S., & Jonsen, A. R. (2017). The Abuse of Futility. Perspectives in Biology and Medicine, 60(3), 295-313.
Taylor, H. (2019). Legal issues in end-of-life care 3: difficult decisions. Nursing Times, 115(1), 36-39.
Varkey, B. (2020). Principles of clinical ethics and their application to practice. Medical Principles and Practice.