End-of-life care dilemmas have in recent years become a major cause of concern for nurses and other physicians. With the emergence of modern technology that can help sustain life even at the point where there is little hope, life-sustaining measures such as resuscitation and feeding tubes have been applied to help prolong the lives of the patient at this stage (Meisel et al., 2000). However, the decisions on the use or application of these life-sustaining measures are solely dependent on the patient's preferences or those of their family. This is coupled with the guided decision-making process between the nurse and the patient or their surrogate. As such, the communication channels between the patient and the nurse or the nurse and the family enable the patient or their surrogate to make informed decisions regarding life-sustaining measures.
Ann’s case is one that presents the dilemmas that are common in our healthcare settings. The nurse or physician may consider a life-sustaining measure such as the feeding tube deemed useful to prolong Sara’s life, but may be limited by the personal wishes of the patient. Upon recommendations to have a feeding tube installed to assist Ann in the feeding process, Frank and Sarah remembers that Ann had always wished not to have a breathing machine at any time during treatment. The dilemma in this case, for both the nurse and the family (Ann and Frank) is to determining the distinction between the breathing machine and the feeding tube since in her wishes, Ann only mentioned about the breathing machine. Could she have used the breathing machine to indicate her preference not to have any form of life-sustaining equipment used on her at end-of-life care? Or did she just dislike the breathing machine and preferred any other life-sustaining equipment?
Ethically, the advice by the nurse will always be overridden by the wishes of the patient or the family. This is since the psychological and spiritual aspects of the patients are considered to have a crucial impact in the outcomes at the end of life (Truog et al., 2001). As such, to preserve the patient autonomy, which is a psychological issue will positively influence the outcomes and when the wishes of the patient are overridden by the nurses, they may feel or experience a psychological perception of incapacitation that limits them to influence what directly influences their own lives (Meisel et al., 2000). This then would work against the code of ethics at end-of-life care that considers the patient and the family as the highest priority decision-makers at such a point.
On the legal aspect, the justice systems in most states provide and support the decisions made in an agreement between the family and the nurse or physicians. As such, the legal implications as to whether the withholding of the feeding tube would have any impacts on the final outcomes would subsequently be made from the basis of the documentation. The clinical documentation should, show that there existed an agreement between the family and the nurse. As long as this documentation exists, the nurse or physician cannot thus be held liable for any outcomes as regarding the patient’s life or health in relation to the decision made (Meisel et al., 2000).
As a nurse, I would advise Sarah and Frank to make the decisions from a best-interest view of their own by trying to make approximations of what Ann would have preferred if she was in a position to make such a decision. In this case, the application of the substituted judgment would not apply since it would limit the decision to Ann’s previous view of the breathing machine. It would not be ethical to watch and see as Ann’s situation deteriorates especially due to lack of nutrition and the bets-interest in this case would call for the application of the feeding tube. These decisions would subsequently reduce the complications of guilt that usually arise when surrogates make such decisions that relate to the patients view and preferences (Truog et al., 2001).
Meisel, A., Snyder, L., Quill, T., & American College of Physicians-American Society of Internal Medicine End-of-Life Care Consensus Panel. (2000). Seven legal barriers to end-of-life care: myths, realities, and grains of truth. JAMA,284(19), 2495-2501.
Truog, R. D., Cist, A. F., Brackett, S. E., Burns, J. P., Curley, M. A., Danis, M., & Hurford, W. E. (2001). Recommendations for end-of-life care in the intensive care unit: The Ethics Committee of the Society of Critical Care Medicine. Critical care medicine, 29(12), 2332-2348.