Introduction
In the course of their duties, nurses usually experience ethical dilemmas, which are very complex to resolve because the decision-making process involves patients, relatives, and healthcare providers. Although nurses may have probable solution regarding a given ethical dilemma, patients, relatives, and other healthcare providers offer alternative solutions. In this view, nurses experience dilemmas, which often hinder them from executing their functions. Despite the complexity of ethical and legal dilemmas that nurses face, they have a duty as change agents. Since nurses have extensive knowledge about ethical and legal dilemmas, application of their knowledge is imperative in effecting change in the nursing practice. According to Ulrich et al. (2011), “critical care nurses often face suffering head-on and might question the balance between the value of attempts to preserve a patient’s life and aggressive physiological measures that appear to prolong anguish and yield no fruitful outcome” (p.2511). Owing to dilemmas, nurses have to maintain a delicate balance of the benefits and losses of their decisions. Therefore, this course work examines the dilemma of withdrawing versus withholding life support devices as a nursing issue, and then defines the role of nurses as change agents.
Summary of the Nursing Issue
The nursing issue in question touches on the ethical and legal dilemma that I experienced in the course of my nursing profession. In 2008, I was nursing a patient under the intensive care unit. The patient was a thirty-year-old man who had been in the intensive care unit for over a year because his family was not ready to lose him. The patient had consumed a great deal of resources and there was no hope of him recovering. Before his condition worsened, the patient had issued an advance directive by instructing the healthcare providers to terminate his life in case there was no possibility of recovering. When I saw that the patient had no possibility of surviving, I agreed to respect his advance directive. According to my perception, it was ethical and legal to terminate his life, given that there was no chance of him surviving and he had given the advance directive to terminate his life.
However, the family objected any attempts to respect his advance directive and preserve the quality of his life for he was writhing in pain. The family protested and threatened to sue the management of the hospital if it agreed to keep the advance directive of the patient. This scenario created another side of the dilemma because the healthcare providers could not effect the advance directive, and thus they agreed with the family members, who are the surrogate decision makers. As family members objected the application of the advance directive, the patient lived in anguish for about one year in intensive care unit after which he died. Hence, the outcomes of the decision show that the healthcare providers should have adhered to the advance directive, which would have saved the patient from experiencing the untold anguish that he went through.
Ethical and Legal Influence
The heart of the nursing issue in this context lies in ethics and legal aspects of withdrawing and withholding life support devices of patients under in intensive care units. Ethical and legal dilemmas emerge when patients, surrogate decision makers, and healthcare providers do not agree on the manner in which they administer healthcare services to patients. Since autonomy of patients is paramount in nursing, advance directives enhance autonomy of the patients. “Advance directives were designed to protect patient autonomy under the belief that patients who lose decision-making capacity are more likely to receive the care they want if they choose a surrogate decision maker, document their wishes, or both” (Silveira, Kim, Langa, 2010, p. 2012). Hence, the use of advance directives in providing patient care is important because it enhances delivery of quality healthcare according to the patients’ needs.
Family members form part of the significant other of the patients; thus, they are surrogate decision makers who act for the benefit of patients. Family members have a noble role in the decision-making process because they are the major stakeholders who have the responsibility of taking care of their patients (Burkhardt & Nathaniel, 2008). Keeping patients in intensive care units requires a great deal of resources, which family members are liable to pay. Moreover, supporting the lives of patients using machines and devices causes a great deal of suffering, which plunges both patients and families into anguish and misery. Therefore, family members are surrogate decision makers who are responsible for the healthcare of their patients.
Comparatively, nurses have ethical and legal duty to provide appropriate healthcare because they are advocates of patients. In this case, nurses play a central role in advising patients and family members on the nature of healthcare services that patients require, providing prognosis, and estimating costs required to maintain patients in intensive care units. Withdrawing or withholding life support devices is a complex ethical and legal issue that requires an input of the nurses, who are the prime advocates for patients. Kierzek (2010) asserts that advance directives are only important if patients have a full understanding of the benefits and burdens associated with a given intervention that sustains life. Hence, informed decision-making on the part of patients influences nursing practice.
Although the advance directives benefit patients, they restrict nurses from making professional judgments regarding the conditions of their patients. “Early evidence suggested that living will have little effect on decisions to withhold or withdraw care and do little to increase consistency between care received and patient wishes” (Silveira, Kim, and Langa, 2010, p. 2012). Evidently, patients with advance directives do not receive life-sustaining care when compared to those who do not have the directives. Moreover, family members do not have full control of the decisions that patients make because surrogate decisions are only effective if they comply with the patients’ advance directives. Since healthcare providers are important stakeholders in the decision-making process, they have overriding influence on decisions of patients and family members for they act in beneficence. Thus, patients and family members have limited powers in making decisions for they have minimal understanding of healthcare interventions.
Role of Nurse as a Change Agent
Nurses have a noble role of effecting changes in the healthcare system because they constantly interact with patients, hence understanding their conditions more than other healthcare providers do. Since they are patients’ advocates, they always act in beneficence to enhance outcomes of the interventions that physicians have prescribed. In this case, nurses have to comply with the principle of veracity. The principle of veracity requires nurses to provide adequate information to the patients so that they can make informed decisions regarding their healthcare (Burkhardt & Nathaniel, 2008). Hence, nurses have a crucial role of providing essential information to patients as well as family members so that they can make informed decisions and enhance delivery of quality healthcare.
Nurses also have sufficient knowledge and skills in decision-making. They are aware of various theories and decision-making models, which are critical in making evidence-based decisions. Thus, nurses are change agents since their decisions have far-reaching impacts on resolution of ethical and legal dilemmas that healthcare providers constantly face in the course of their duties. The nursing profession has developed varied theories and decision-making models, which guide nurses on how to resolve complex ethical and legal dilemmas that deter nurses from delivering quality healthcare to patients. In the aforementioned nursing issue, the dilemma of whether to follow the patient’s advance directive or adopt surrogate decisions of the family prevented the nurses from withdrawing life support device that sustained the life of the patient. According to Tai and Li (2011), healthcare providers and nurses influence decisions with regard to decisions of withdrawing or withholding life support devices. Thus, as a change agent and leader, nurses have a role in ensuring proper resolution of ethical and legal dilemmas in nursing.
My Reaction
In the case study, since I complied with the surrogate decision makers, the research about issues surrounding this case shows that advance directives are more important when compared to surrogate decisions. I have learned that surrogate decision makers should comply with the advance directive of adult patients who can make informed decisions about their lives. In the United States, “it is ethically and legally permissible for patients to refuse or to request the withdrawal of life-sustaining treatments” (Muller et al., 2010, p. 791). Similarly, nurses also have ethical and legal permission to comply with advance directives. Thus, I should have obeyed the advance directive of the patient despite the fact that family members threatened to sue the hospital.
Education of Nurses
For nurses to understand how to resolve ethical and legal dilemmas on whether to withdraw or withhold life support devices, they need sufficient education. The education should comprise ethical and legal aspects of advance directives and surrogate decisions; moreover, it should outline the role of patients, family members, and nurses in the decision-making process about the dilemma. Burkhardt and Nathaniel (2008) assert that understanding of ethical and legal issues of health is critical for nurses to improve resolution of dilemmas that hinder them from delivering quality healthcare. Therefore, education of nurses in the aspect of ethical and legal issues surrounding withdrawal or sustenance of life supporting devices in essential.
Conclusion
The nursing profession is full of ethical and legal dilemmas that nurses constantly encounter whilst executing their duties. Resolution of ethical and legal dilemmas is a complex process because it involves patients, family members, and healthcare providers. For proper resolution of ethical and legal dilemmas, nurses should have sufficient knowledge and skills in ethics and nursing laws, so that they can apply nursing theories and decision-making models in decision-making processes. The dilemma of withdrawing or withholding life support devices is a sensitive issue in nursing because it involves ending one’s life. In this view, nurses have a noble role of ensuring that patients receive the deserved quality healthcare. As advocates of patients and agents of change, nurses have the responsibility to enhancing resolution of ethical and legal dilemmas in the healthcare system.
References
Burkhardt, M. A., & Nathaniel, A. K. (2008). Ethics & issues in contemporary nursing (3rd ed.). Albany, NY: Thomson Delmar Learning.
Kierzek, G. (2010). Advance directives and surrogate decision making before death. New England Journal of Medicine, 363(3), 295-296.
Muller, P., Swetz, K., Freeman, M., Carter, K., Crowley, M., Severson, C., Park, S., & Sulmasy, D. (2010). Ethical analysis of withdrawing ventricular assist device support. Mayo Clinic Proceedings, 85(9), 791-797.
Silveira, M., Kim, S., & Langa, K. (2010). Advance directives and outcomes of surrogate decision making before death. New England Journal of Medicine, 362(13), 1211-1218.
Tai, C., & Li, D., (2011). Factors influencing decisions to withdraw or continue life support and attitude towards treatment of the critically III: A survey of registered nurses in intensive care units. Proceedings of Singapore Healthcare, 20(3), 181-189.
Ulrich, C., Taylor, C., Soeken, K., O’Donnell, P., Farrar, A., Danis, M., & Grady, C. (2011). Everyday ethics: Ethical issues and stress in nursing practice. Journal of Advanced Nursing, 66(11), 2510-2519.