The purpose of this paper is to identify a situation of ethical and legal concern that has been experienced in practice, and to subject the situation to ethical and legal analysis. The focus will be upon the implications for the patient and the role of the nurse.
The use of the term ethics, as stated by Beauchamp and Childress (2001), suggests the application, comprehension and study of moral life. Understood literally ethics is the science of morals and the area of study concerned with the principles of human duty (OED 1989).
The patient identified within this paper will be referred to as Mrs Patel. In accordance with the Nursing and Midwifery Council (NMC) Code of Conduct (2004), Clause 5, the names of all people and clinical areas, used within this paper, will be changed to maintain confidentiality.
Mrs Patel, a 65 year old lady, had been admitted to the ward with advanced deterioration in her condition. It had been noted by the medical and nursing staff there were no benefits to be gained by the patient in continuing any further medical intervention (Trnobranski 1996, BMA 2000, DoH 2005). The recommendation and rationale to withdraw treatment was put to her next of kin, as the patient was incapable of making a decision, to which they agreed (Tilden et al 2001). The decision was then made to ensure the patient remained comfortable and pain free.
According to the rulings of the case NHS Trust A v. M and NHS Trust B v. H (2001) regarding the withdrawal of life sustaining treatment from a patient it was shown that it was the right of the patient to receive such treatment according to Article 2 of the Human Rights Act (2000). But if the treatment was shown to be futile the court found that the hospital was not obliged to continue treatment (DoH 2005). In the case of Mrs Patel the team members involved in her care had shown that to continue with any further treatment was found to be futile and only served to prolong any discomfort that she was feeling.
Although the scenario given so far is in itself an area open for discussion with regards the ethics behind the decisions made and the roles played by the staff and family, this paper will focus upon the area of maintaining the patients comfort. The situation will specifically concentrate on regular turning, the use of analgesics and the conflicts that arose between duty of care to the patient and the wishes of the family. During the morning handover the instructions with regards Mrs Patel’s care were to maintain the patients comfort and to administer prescribed analgesia when required by the patient. The instructions included regular turning, which was to be documented in the turning chart found in her notes.
Evidence has shown that the ideal for turning the immobile patient is once every two to four hours in order to prevent the formation of pressure ulcers (Quinton 2003, Bale 2000). With regards to Mrs Patel the decision was made to turn her every four hours. This decision was based upon the discomfort Mrs Patel appeared to express when she was turned. The doctor was informed and it was considered in the best interests of the patient to administer analgesia, prior to turning, in order to ease the pain the patient appeared to be feeling.
Mrs Patel’s family, aware of her condition, had taken upon themselves to maintain a bedside vigil. In order to provide the patient and family with privacy and dignity the nursing staff decided to move Mrs Patel’s bed from the main six bedded bay into a side room. The family members were encouraged to ask questions or talk with staff if they were concerned or had queries with regards to Mrs Patel. On one such occasion Mrs Patel’s son enquired as to why the staff were administering analgesia to her as he did not feel comfortable with this. He suggested that the analgesia was making his mother drowsy and he wished for her to be more alert.
The staff explained that it appeared that Mrs Patel appeared to be in pain whilst they carried out her regular turns and they wished to decrease this pain and ensure the patients comfort. Mr Patel suggested that the staff cease turning his mother thereby reducing the need for analgesia. Acknowledgement was given that this would appear to be the better solution but it was shown that the discomfort that Mrs Patel experienced from remaining in the one position would still involve the use of analgesia in order to lessen the pain plus the increased risk of breakdown of tissue within the pressure risk areas adding further discomfort to Mrs Patel’s condition. He appeared to understand and consented to allow the nursing staff to continue with their care.
The belief that Mrs Patel was experiencing pain was based upon the verbal (groaning) and non-verbal cues (facial expressions, and tension of body resisting movement) given by Mrs Patel plus the regular observations (blood pressure, pulse and respiration) carried out (Panke 2002). Although not entirely reliable ways of assessing pain these appeared to be the only ways of assessing the patient’s pain due to her inability to communicate effectively (Duke 2000). These assessments plus the recommendation from the Palliative Care team who were involved with Mrs Patel’s care prompted the decision to prescribe analgesia.
There was a conflict in the duty of care and the obligation towards caring for the family involved. The priority for the nursing staff was to provide care for the patient that could be justified and a rationale given and shown to be within the patient’s best interests. But there was also the consideration towards acknowledging the stress that the family were in and facilitating their needs (Tilden et al 2001).
From the perspective of the author the duty of the nurse is to maintain at all times that of beneficence and non-maleficence towards the patient. The conflict arose when the needs of the patient’s family appeared to override the responsibilities of the nurse to the patient. Whilst the nurse involved appeared to consider the request of the patient’s son she provided a rationale to show that the procedures being carried out were necessary and were for the benefit of the patient. It was felt by the author that the nurse may have helped the family further by searching to see if there was an underlying need behind the concerns expressed that the patient’s son had not vocalised, such as; not wishing his mother to be given the pain killers due to the sedating effects upon her thereby possibly denying him the opportunity to communicate with her before she died.
If one was to look at this situation from a deontological point of view one can see that the nurse was acting in a morally correct manner where the obligation was to ease the patient’s pain and to maintain her comfort. The consequences of the administration of the analgesia were that the patient remained sedated thereby denying the family the ability to communicate effectively with their mother and vice versa. The consequences according to the theories espoused by Kant are irrelevant as long as one acts in a morally correct way (Beauchamp and Walters 2003).
But the assumption is being made that the staff were acting in the patients best interests. Acting as advocate for the patient the staff involved made the decision to prescribe and administer analgesia for her on a regular basis based upon the assessment results which showed that the patient was in pain. The patient was assessed to be incapable to make the decision for herself so consent was given by the next of kin.
The question is raised; if the analgesic was withdrawn, would the patient have the ability to make an informed choice as to whether she would chose to stay alert, albeit in pain, and communicate with her family or to remain sedated and pain free? Therein lies the quandary; by withdrawing the analgesia from the patient there is the possibility of allowing the patient to become more alert and possibly giving her the ability to make a choice but the danger here is the conflict with the nurses duty to provide care which is based upon the ethical principle non maleficence. Non maleficence tells us that we may not inflict harm upon others which, according to Beauchamp and Childress (2001) includes the rule “Do not cause pain or suffering”.
Moving on to the third ethical principle of autonomy the author will attempt to further discuss the role of the nursing staff involved in this scenario. Autonomy literally means self governance, where the individual is seen to control their own actions and thoughts (Drife and Magowan 2004). O’Neill (2001) writes the right to autonomy involves the individual determining the course of their own life and the right to express and carry out their own wishes and desires. Closely connected to the right to autonomy is competence to make decisions and give consent which, as briefly highlighted earlier, the patient, due to her deteriorating condition, was assessed to be incapable of giving consent or making decisions regarding her treatment.
Part of the role of the nurse, according to the Code of Professional Conduct (2004), is to respect the patient’s right to autonomy and their right to accept or refuse any health care intervention. If it has been shown that the patient is incapable of making an informed choice about their care it is the role of the nurse to find out if the patient has made any advanced statements or indicated any preferences with regards to their treatment. If these preferences were not made known then it is the duty of the nurse to provide care that is seen to be in the best interests of the patient (NMC 2004).
It has been shown that the best interests of the patient were taken into account when deciding the care that Mrs Patel received. Regarding the needs of the family, these were not discussed during the handover of the plan of care for Mrs Patel. Although it was shown that the staff had made attempts to help the family by facilitating their needs to communicate, it was felt that the family’s needs were not deemed a priority. According to the National Institute for Clinical Excellence (2004) guidelines the importance of the role played by families and carers is often gone unnoticed by health professionals but this is often a case of the family unwilling to express their own needs and putting the needs of the patient first.
With regards to Mr Patel it was shown that he had expressed discomfort with the analgesia given to his mother as it appeared to keep her sedated. It was felt that the underlying rationale behind this concern would have been best explored by the nurse thereby possibly giving Mr Patel some comfort. If necessary the inclusion of another member of the health care team to help support the family during this time could have been considered. The Code of Professional Conduct (2004) highlights the importance of working within a team, of which the family are viewed to be included.
Reflecting upon the literature reviewed for this paper it has been shown repeatedly that every decision taken or action made by the nurse has ethical implications. From getting the patient out of their bed every morning at the same time as everyone else to administering medications and providing bedside care, all of these give rise to ethical questions and possible dilemmas. The subject matter of ethics, the use of analgesics within end of life care and the inclusion of the family/carers within the care of the patient are areas that have inspired this author to explore and study further beyond this paper.
During the literature review it became obvious that the topic of end of life decision making was studied and written about to a great extent, which if chosen for the scenario for this paper would have made the task easier, whereas the literature available regarding the use of analgesia and the inclusion of families within end of life care was not as extensive. The inclusion of the family and carers is an area that has been included by the government and the NMC in many of the policies and papers yet seems strangely amiss in the articles searched for. The online search criteria used for this paper included OVID and Blackwell Synergy.