22
Unit 1
Contemporary concepts in nursing
substances used to treat symptoms) and withholding a diagno-
sis to the patient. Both involve the issue of trust, which is an
essential element in a person-centred relationship. Placebos
may be used in experimental research in which the patient
is involved in the decision-making process and is aware that
placebos are being used in the treatment regimen. However,
the use of a placebo as a substitute for an active drug to show
that the patient does not have real symptoms is deceptive.
Informing patients of their diagnoses when the family
and doctor have chosen to withhold information are ethical
situations commonly encountered. Nurses often use evasive
responses to the patient’s questions as a means of maintaining
that request. This area challenges the nurse’s integrity as trust
is an essential part of the therapeutic relationship. Strategies
the nurse could consider in this situation include the following:
•
Being truthful to the patient.
•
Providing all information related to nursing procedures
and diagnoses.
•
Communicating the patient’s requests for information to
the family and doctor.
Finally, although providing the information may be the
morally appropriate choice, the manner in which the patient
is told is important. Disclosure of information merely for the
sake of patient autonomy does not convey respect for others.
End-of-life issues
Dilemmas that centre on death and dying are prevalent in
medical-surgical nursing practice and frequently initiate moral
discussion. The dilemmas are compounded by the fact that
the idea of curing is paramount in healthcare. With advanced
technology, it may be difficult to accept the fact that nothing
more can be done, or that technology may prolong life but at
the expense of comfort and quality of life. Focusing on the
caring as well as the curing role may assist nurses in dealing
with these difficult moral situations. End-of-life issues are dis-
cussed in detail in Chapter 12.
Pain control
The use of opioids to alleviate a patient’s pain may present
a dilemma for nurses. Patients with intractable pain may
require large doses of analgesics. Fear of respiratory depression
or unwarranted fear of addiction should not prevent nurses
from attempting to alleviate pain for the dying patient or for a
patient experiencing an acute pain episode. In the case of the
terminally ill patient, for example, the actions may be justified
by the principle of double effect (Chart 2-2). The intent or
goal of nursing interventions is to alleviate pain and suffering
while promoting comfort. The risk of respiratory depression
is not the intent of the actions and should not be used as
an excuse for withholding analgesia. However, the patient’s
respiratory status should be carefully monitored and any signs
of respiratory depression reported to the doctor.
Do-not-resuscitate orders
Although it is acknowledged that there are various levels of
a ‘do not resuscitate’ (DNR) order (also known as ‘not for
resuscitation’ (NFR)) that can range from total DNR to ‘CPR
but no intubation’, all these orders present controversial issues
for nurses. When a patient is competent to make decisions, his
or her choice for a DNR order should be honoured, according
to the principles of autonomy or respect for the individ-
ual (Johnstone, 2009). However, a DNR order is at times
interpreted to mean that the patient requires less nursing care,
when actually these patients may have significant medical and
nursing needs, all of which demand attention. Ethically, all
patients deserve and should receive appropriate nursing inter-
ventions, regardless of their resuscitation status.
Life support
In contrast to the previous situations are those in which a DNR
decision has not been made by or for a dying patient. The
nurse may be put in the uncomfortable position of initiating
life-support measures when, because of the patient’s physical
condition, they appear futile. This situation frequently occurs
when the patient is not competent to make the decision and
the family (or surrogate decision maker) refuses to consider a
DNR order as an option. The nurse may be told to perform a
‘slow code’ (i.e. not to rush to resuscitate the patient) or may
be given a verbal order not to resuscitate the patient; both
are unacceptable medical orders. The best recourse for nurses
in these situations is to be aware of hospital policy related to
advance directives and reversal of treatment. The nurse should
communicate with the doctor. Discussing the matter with the
doctor may lead to further communication with the family and
to a reconsideration of their decision, especially if they are afraid
to let a loved one die with no further efforts to resuscitate.
Food and fluid
In addition to requesting that no heroic measures be taken to
prolong life, a dying patient may request that no more food or
fluid be administered. Many individuals think that food and
hydration are basic human needs, not ‘invasive measures,’
and therefore should always be maintained. However, some
consider food and hydration as means of prolonging suffering.
In evaluating this issue, nurses must take into consideration
the potential harm as well as the benefit to the patient of
either administering or withdrawing sustenance. Research has
not supported the belief that withholding fluids results in a
painful death due to thirst (Hunter, 2012).
Evaluation of harm requires a careful review of the reasons
the person has requested the withdrawal of food and hydra-
tion. Although the principle of autonomy is supported by the
NMBA (2008; Chart 2-3), there may be situations when the
request for withdrawal of food and hydration cannot be upheld.
For patients with decreased decision-making capacity, the
issues are more complex.
Preventive ethics and advance directives
In order to prevent a dilemma, strategies to help nurses antici
pate or avoid certain kinds of ethical dilemmas should be
part of care planning. A patient may be able to make their
wishes known but the legal situation is unclear. When uncer-
tainty exists, this may be resolved through a legal petition. In
Australia the possibility of a person refusing food and fluid
varies between States. Most Australian States and Territories
have legislation regarding end-of-life decisions. It is important
to be aware of the legislation relevant to the State in which
the nurse is practising.
Frequently, dilemmas occur when the healthcare practi-
tioners are unsure of the patient’s wishes before the person
becomes unconscious or too cognitively impaired to com-
municate directly. Advance directives are documents that
specify a patient’s wishes before hospitalisation and provide
valuable information that may assist healthcare providers in
