Position Paper on Autonomous Decision Making as End of Life Issue in Nursing Homes
- Data Collection and Assessment of Data
Introduction
Physicians and nurse practitioners providing care to dying patients often confront many ethical dilemmas and challenges. As a vent unit nurse, one of my primary roles entails offering good care to the elderly, and this requires that I must be knowledgeable in my role concerning any potential ethical issue and be aware of the strategies and interventions aimed at avoiding conflict in the nursing home. It is essential that as a nurse, I remain proactive concerning decision making while using advance directives so that autonomy of the patients can be preserved even if the patient under my care or in the institution as a whole has lost their capacity to make decisions. In turn, this presents one of the common ethical issues often encountered in nursing homes – autonomy and decision making in end of life care. During the end of life, ethical dilemmas often arise, but the most common ethical issue of autonomous decision making.
Situational Considerations
Situational consideration refers to the external factors that influence the decisions that a person makes based on their context. Some of the situational considerations that contribute to the ethical dilemma include the culture, religion, and economic status of an individual. Culture as a consideration affects the perspective and communication process and thus affecting the decision-making process. Schweda et al. (2017) stated that cultural factors affect patients’ responses to medical issues along with the patient-physician relationship. Various patients often have various demands attributed to their cultural beliefs, and this affects their capacity to make a sound decision regarding their life and health. At the same time, religion tends to influence the type of care that patients require, and these might be against the ethical nursing practice. According to Daisy and Josiane (2016), religion and spiritual factors influence medical decisions making, particularly in the event of a terminal illness. Economic status affects the type of services that a person can receive at the end of life care. Freeman et al. (2018) argued that the socioeconomic status of many patients, especially financial pressure, is highly likely to influence their decision to pursue or reject life-extending care and utilization of quality-of-life sustaining programs in nursing homes.
Health Team Considerations
The decision-making process in a nursing home and that involves the health and wellbeing of patients is an intricate system that consists of every member of the organization to promote quality care. The decision-making process in the determined ethical issue often involves doctors, nurse specialists, and social care workers. The doctors involved are required to have specialized training as specialized physicians and meeting the licensure necessary for the particular practice as per the requirements of the state. The nurses are required to at least have a BSN and MSN, and one must have background training on cultural competence, case management, and patient/family education. The social workers are also required to at least have a bachelor of social work. It is this category of professionals that are always involved in the decision-making process. The most affected individuals are the nurses as they are always involved in the day to day care provision with the patients. A qualitative study by Lai et al. (2018) highlighted that nurses are always engaged in educating, giving advice, and offering emotional support to the patients and their families that leads to a caring relationship that can easily affect their objectivity in the decision-making process. The autonomous decision making thus becomes an ethical issue that continues to affect many nurses involved in the end of life care.
Organizational Considerations
The nursing home has always been dedicated to creating an environment that promotes holistic care to the patients and their families while at the same time offering opportunities for the development of the nurses’ education and wellbeing. The mission of the nursing home is to provide compassionate and excellent personalized care in a home-like environment that will enable everyone to live a complete life. The organization’s values relevant to autonomous decision making include valuing reliable, knowledgeable, and trustworthy caregivers who deliver quality care to the patients and their families. The other value aligned with the ethical issue is respect. The organization is often committed to respecting the dignity and value for every person while providing care in an ethical and supportive work environment. The key policy of the organization that aligns with the determined ethical dilemma is the need for every practitioner must practice accountability, and this entails a commitment to honesty and integrity in achieving the desired outcomes for the patients and their families. The procedure involved in the autonomous decision-making process entails respecting the patients’ autonomy and privacy, while at the same time communicating with the associated with the care practitioners on any ethical issue affecting decision-making for the nurse in practice.
- Problem Identification
Ethical Considerations
The primary ethical consideration related to end of life care is respecting the autonomy of the patients. One of the fundamental ethical principles in nursing is autonomy, and this refers to the fact individuals have the right to self-determination. In other terms, nurses are called to recognize that patients are allowed to make decisions about their lives without interference from others. In turn, this means that whenever nurses are making decisions regarding the patients’ health and wellbeing, they must have the patients at the center of the decision making process as a way of respecting their autonomy, even if the patient is dying. Rodríguez-Prat et al. (2016) concerning the issue of autonomy during the end of life highlighted that nurses are required to have a good understanding of the ethical principles as well as issues like medical futility along with the withdrawing and withholding of medical interventions and the legal ramifications of such ethical issues. The other ethical consideration is the principle of beneficence. The principle of nursing of beneficence infers a balance of possible benefits and risks or harms associated with the provision of care. In the end of life care, this becomes a serious issue because, in the process of decision-making concerning the end of life care, it is always highly likely that there will be a conflict between what is good between the nurse and the patient or the patient and the healthcare institution. At the core of the nursing care practices at the nursing home, every nursing practitioner is always called to make decisions regarding what is suitable for the patient while adhering to ethical nursing, which ensures quality care and protection of the patients’ lives.
Non-Ethical Considerations
One of the non-ethical consideration and then relates to the medical and legal aspects of nursing is informed consent. The principle of informed consent asserts that nurses are always required to get permission from the patients before proceeding with medical intervention. Bester et al. (2016) indicated that the principle of informed consent seeks to protect the patients from any form of malpractice in medicine and to ensure that they receive the quality of care they believe is essential for their wellbeing. This connects to the ethical consideration in the sense that informing the patients and allowing them to decide their course of care allows selecting a practice that only creates an ethical dilemma. The other non-ethical consideration is providing factual information to the patients. According to Noome et al. (2016), nurses have the responsibility to offer factual information to the patients and their families concerning their health, wellbeing, and medication provision. However, this creates a dilemma linked to the principle of beneficial, which is an ethical consideration relating to autonomy and decision-making. One of the values upon which the nursing home operates on is always to offer a sense of hope to our patients. Nonetheless, this creates a conflicting approach to decision-making if the medical information would make the patients lose their hope for life. It then means that the care nurse will face the dilemma of balancing the possible benefits of the information and the associated risks. Such then become factors to patients easily inclined to patient-assisted suicide, which is not a commendable practice at the nursing home.
- Consideration of Possible Actions
Utilitarian Thinking
Utilitarianism is an ethical theory concerned with determining right from wrong by solely focusing on the outcomes. Wagner and Dahnke (2015) highlighted that it is a consequentialist theory that promotes nursing activities aimed at maximizing the wellbeing of the affected while rejecting any action that will cause happiness or harm. The utilitarian thinking holds to the idea that the most ethical choice is that which will produce the greatest good for the affected parties. The principle is defined in this context as happiness and pleasure and does not consider health as part of it. In other words, when applied to the nursing practice, it will focus on the pleasure and happiness of the caregivers and patients and their families instead of the wellbeing of the patient as regarded in the nursing practice. The viable actions regarding the selected ethical issue would be either to disregard a patient’s autonomy when making a medical decision or to respect their wishes even it means that it is against the ethical practice of nursing. The predicted consequences would be evident on the ends, and that is, the caregivers and the patients. One of the consequences would be increased morbidity or loss of life, and the possible consequence would be decreased patient satisfaction and violation of the legislation. The best possible actions that would produce the best consequence and the least displeasure for the persons affected would be to overlook the principle of privacy and confidentiality. The principle asserts that nurses are obligated to not share any personal information with other parties. However, if the information entails endangering the life or the wellbeing of the patients, then this principle should be overlooked and involve parties such as psychiatrists and chaplains along with the caring families to intervene in the decision making process.
Deontological Thinking
The deontological approach holds onto the idea that the morality of an action is defined by whether the action in itself is either right or wrong based on a series of factors instead of focusing on the consequences of the action. With deontological thinking, it would then mean that the nursing practitioners will have to consider the rightness or wrongness of their action without considering the potential consequence. The ethical rules and principles that conflict are autonomy and beneficence. It then means that the nurse would have to find a balance between respecting the wishes of the patient in that context, especially by considering the need to respect the patient’s right to self-determination and promoting care by preventing harm or removing harm that would threaten the health and wellbeing of the patients. The essential duties that emerge from these ethical rules and principles are the duty to respect the patient’s autonomy and the duty of nurses to promote quality care and do whatever they can within their roles to prevent harm to the patient. This then underpins the key ethical issue that was identified as the focus of this position paper. As Karnik and Kanekar (2016) pointed out, one of the key ethical issues faced by nurses in the end of life care is autonomous decision making since the persons have the right to propose their end of life treatment preferences and that can be against ethical nursing care. Therefore, as the conflict exists in this scenario, the duties derived from the moral rules and principles that would produce the greatest balance would be promoting quality care and doing whatever is possible in the nursing role to prevent harm to the patients. In other words, it would be ethical to do the right thing that bears the desired consequences of nursing care. Besides, this aligns with the principle of nonmaleficence that asserts nurses are allowed to inflict the least possible harm, which is denying the patients their sense of autonomy, to reach a beneficial outcome.
- Decision and Selection of Course of Action
Contribution of Internal/Group Factors
The decision will be focusing on the patients at the nursing home because they are the parties that are greatly impacted by the medical and treatment decisions. Kieft et al. (2014) mentioned that the key focus of the nursing practice in nursing homes entails the provision of quality care that ensures that the patients’ health strives and creating an environment that will foster a positive mentality towards care and their health. Based on the fact that most of the patients in nursing homes are always and critical care, the nursing specialists must make decisions that encourage their capacity to heal and get better towards their end of life. However, as Thorns (2010) mentioned respecting autonomy does not equate to choice. Thorns (2010) further explained that nurses at the end of life care must recognize that they need to explain every implication of their decisions and ensure that the patient has the capacity and a sense of appreciation to the important consequences. It is this that entails respect for autonomy. Therefore, nurses must recognize that their decisions will impact the patient more than the patient’s decision will determine their choice.
Contribution of External Factors
The institutional factors that will affect the decision and the selected course of actions are the policies and values of the nursing home. Marzorati and Pravettoni (2017) stated that values are the principal components that guide the decision-making process in healthcare organizations. At the same time, values help define the culture of an organization by influencing the way the staff interacts with the choices presented to them in the care facility. Policies, on the other hand, are the principal rules that dictate practices that are allowed and that are prohibited in the care facility. All these then must be taken into consideration when going about the decisions that the nurses must make in promoting care to the persons in the nursing home. The legal factors that the decision and the selected course of action are the legal rights of the patients and the responsibilities of the nurses in the provision of care. It will be essential to consider if violating the autonomy of the patients will bear more consequences than violating the rule in the course of providing quality care to the persons at the care facility. The social factors that will be at play include the cultural background of the patient and their socioeconomic status. Their culture influences their perspective towards care, whereas their socioeconomic status will affect their decisions on what services they can afford without burdening their families.
Quality of Decision and Course of Action
The decision, therefore, that is being made is pursuing care practices that will extend the life and enhance the health of the persons at the nursing home against the sense of autonomy of the patients that entails causing harm to their health and life. The course of action being taken hence requires creating a committee that will involve the chaplain, psychiatrist, nurse specialists, and the leading doctor who will intervene at the autonomous decision made by the patient that would affect their health and wellbeing. In the light of the preceding factors, the decision being made and the course of action can still be morally justified because the decision being made by the care team is the most ethical in the present moment. When considering the utility principle, the consequence is pleasure and wellbeing to the patients and their families. Therefore, the selected course of action is implementable as it is within the possibilities and responsibilities of the nursing team always to promote care that saves lives instead of causing harm to the patient and their family members. The determined decision aligns with the ANA Interpretive Statement Code for Nurses as it encourages nurses on informed decision-making regarding ethical violations of nursing practice. Though the statement hints on the need to respect the sense of autonomy and self-determination, it encourages nurses to always protect the patient’s health and safety even in questionable practice.
- Reflection Decision
Reflecting upon the selected decisions and the knowledge accrued indicates that it was the right decision that was acted upon by the nursing team, and it accomplished its intended purpose of adhering to the provision of quality care while improving the life of the patient. Nursing care is grounded on integrity, and integrity often calls for looking at the best decision possible that would bring the desired good. The desired consequence at the nursing home is to promote health and wellbeing through compassion and to enable the patients to achieve the highest levels of emotional, physical, and spiritual wellbeing. Therefore, from both utilitarian and deontological thinking, the decision was morally right, and this is because it preserved life, which is the desired outcome for both the family of the patients and the caregivers at the healthcare facility. At the same time, it saw an improvement in the patient’s wellbeing, which is the greatest good.