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Ethics. Khaled Abdallah Khader King Hussein Cancer Center . What is Ethics?. Common responses: “Ethics has to do with what my feelings tell me is right or wrong.” “Ethics has to do with my religious beliefs.” “Being ethical is doing what the law requires.”

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Ethics

Ethics

Khaled Abdallah Khader

King Hussein Cancer Center


What is ethics

What is Ethics?

Common responses:

“Ethics has to do with what my feelings tell me is right or wrong.”

“Ethics has to do with my religious beliefs.”

“Being ethical is doing what the law requires.”

“Ethics consists of the standards of behavior our society accepts.”

“I don’t know what the word means.”

“Raymond Baumhart, Sociologist”


Ethics and values

Ethics and Values

Principles that define behavior as right, good, and proper.

Ethics is about putting principles into action.

Values are inner judgments that concern how a moral person actually behaves.


Values morals ethics

Values, Morals, & Ethics

  • Values are freely chosen, enduring beliefs or attitudes about the worth of a person, object, idea, or action (e.g. freedom, family, honesty, hard work)

  • Values frequently derive from a person’s cultural, ethnic, and religious background; from societal traditions; and from the values held by peer group and family

  • Values form a basic for “purposive behaviour”; The purposive behaviour is based on a person’s decisions/choices, and these decisions/choices are based on the person’s underlying values.


Ethics

Values are learned and are greatly influenced by a person’s sociocultural environment (e.g. folk healer, observation and experience)

People need societal values to feel accepted, and they need personal values to produce a sense of individuality.

Professional values often reflect and expand on personal values

Once a person becomes aware of his/her values, they become an internal control for behaviour, thus, a person’s real values are manifested in consistent pattern of behaviour


Ethics

Nurses acquire these values during socialization into nursing – from codes of ethics, nursing experiences, teachers, and peers.

Watson (1981) outlined 4 important values of nursing:

Strong commitment to service

Belief in the dignity and worth of each person

Commitment to education

Autonomy

Nurses often need to behave in a value-neutral way (i.e. being nonjudgmental)


Ethics

Nurses need to understand their own values related to moral matters and to use ethical reasoning to determine and explain their moral positions.

Moral principles are also important, otherwise they may give emotional responses which often are not helpful.

Although nurses can not and should not ignore or deny their own and the profession’s values, they need to be able to accept a client’s values and beliefs rather than assume their own are the “right ones”

This acceptance and nonjudgmental approach requires nurses to be aware of their own values and how they influence behaviour


Ethics

What values you hold about life, health, illness, and death?

How do your values influence the nursing care you provide?

We should explore our own values and beliefs regarding such situations as the following:

An individual’s right to make decisions for self when conflicting with medical advice

Abortion

End-of-life issues

Cloning


Ethics

The process of becoming more conscious of and naming what one values or considers worthy is known as “value clarification”

In value clarification:

we examine what we believe is good, bad, beautiful, worthy, meaningful, …..and explore the process of determining our personal values.

Why?


Ethics

The purposes of value clarification

To increase our self-awareness or understanding of ourselves and assist us in making choices.

To facilitate decision-making, because we have a better grasp of our own value system.

Consequently, this will be helpful when you are faced with an ethical dilemma

Ethical dilemmas occur when individuals must choose between two unfavorable alternatives “e.g. assisted suicide”


Ethical dilemma

Ethical dilemma

  • A dilemma exists when a difficult problem seems to have no satisfactory solution

  • Or when all solutions to a problem appear to be equally favorable.

  • e.g. conflict between principles of non-malificience and autonomy

  • Situations present themselves in which moral claims compete with non-moral claims.


Moral distress

Moral distress

  • When a nurse is unable to follow their moral beliefs because of institutional or other restriction.

  • The distress occurs when the nurse violates a personal moral value and fails to fulfill a perceived responsibility.

  • Moral distress represents a practical, rather than ethical, dilemma.


Moral outrage

Moral outrage

- Occurs when someone else in the health care setting performs an act the nurse believes to be immoral.

- Nurses do not participate in the act.

- Nurses not responsible for what they hold to be wrong but perceive that they are powerless to prevent it.


Ethics

Ethical dilemmas usually have no perfect solution and those making decisions may find themselves in the position of having to defend their decisions

Value conflict occurs when we must choose between two things, both of which are important to us.

It’s the nurses’ role to help clients identify values and clarify them……

But how??????


Morals and ethics

Morals and Ethics

  • Morals: similar to ethics and many people use the two words interchangeably (closely associated with the concept of ethics)

  • Derived from the Latin “mores”, means custom or habit.

  • Morality: usually refers to an individual’s personal standards of what is right and wrong in conduct, character, and attitude.

  • Morals: are based on religious beliefs and social influence and group norms


Morals and ethics continue

Morals and Ethics (continue)

  • Ethics is a branch of philosophy (the study of beliefs and assumptions) referred to as moral philosophy.

  • Derived from the Greek word “ethos” which means customs, habitual usage, conduct and character.

  • Ethics: usually refers to the practices, beliefs, and standards of behavior of a particular group such as nurses. It also refers to the method of inquiry that assists people to understood the morality of human behaviour (study of morality)


Morals and ethics continue1

Morals and Ethics (continue)

  • In both, we describe the behaviourwe observe as good, right, desirable, honorable, fitting or proper or we might describe the behavior as bad, wrong, improper, irresponsible, or evil.

    [Such perceptions are based on values]

  • There are times when a differences in values and decisions can be accepted

  • Differences in values and decisions put people into direct conflict.

    What to do in such situations?


Morals and ethics resolving conflicts

Morals and Ethics (resolving conflicts)

  • Be constructive (rather than destructive) in the methods you choose to work toward resolving the differences

    • Listen carefully without interruptions

    • Seek clarification using gentle questioning

    • Respect cultural differences

    • Be attentive to body language

    • Explain the context of your point of view and try to picture the other person’s interpretation of what you are saying


Comparison of morals and ethics

Morals

Principles and rules of right conduct

Private, and personal

Commitment to principles and values is usually defended in daily life

Pertain to an individual‘s character

Ethics

Formal responding process used to determine right conduct

Professionally and publicly stated

Inquiry or study of principles and values

Process of questioning, and perhaps changing, one’s morals

Speaks to relationships between human beings

Comparison of morals and ethics


Ethical theories

Ethical theories

  • Teleology

  • Deontology

  • Principlism

  • Ethic of caring


Ethical theories continue

Ethical theories….(continue)

Teleology: looks to the consequences of an action in judging whether that action is right or wrong

Deontology: proposes that the morality of a decision is not determined by its consequences. It emphasizes duty, rationality, and obedience to rules

  • The greatest strength of this theory is its emphasis on the dignity of human beings.

  • Consider any termination of life as a violation of the rule “do not kill” and therefore, would not abort the foetus, regardless of the consequences to the mother.

    The difference between Teleology and Deontology can be seen when each approach is applied to the issue of abortion.


Ethical theories continue1

Ethical theories…..(continue)

Example:

Teleology approach/abortion: saving the mother’s life (the end, or consequence) justifies the abortion (the mean, or act).

This theory frequently is referred to as

utilitarianism.


Principlism

Principlism

  • it does assist nurses and health care providers who are struggling with difficult ethical issues.

  • incorporates existing ethical principles and attempts to resolve conflicts by applying one or more of those ethical principles (Beauchamp & Childress, 2001).

  • Principles are moral norms that nurses demand and strive to implement daily in clinical settings. In the case of principlism, four principles form the basis for decision making: respect for autonomy, nonmaleficence, beneficence, and justice.

  • Each of the principles can be used individually, although it is much more common to encounter two or more ethical principles used in concert or to see two or more principles coming into conflict in a specific patient situation.


Ethical theories continue2

Ethical theories…..(continue)

Ethic of caring: it is based on relationships.

  • Caring is a force for protecting and enhancing client dignity

  • Caring is of central importance in the client-nurse relationship (e.g. nurses use trust-telling to affirm clients as a persons rather than objects and to assist them to make choices and find meaning in their illness experiences)


Nursing codes of ethics

Nursing Codes of Ethics

  • A code of ethics is a formal statement of a group’s ideals and values.

  • It is a set of ethical principles that is shared by members of the group, reflects their moral judgments over time and serves as a standard for their professional actions.

  • Codes of Ethics are usually higher than legal standards

  • International, national, state nursing associations have established codes of ethics


Nursing codes of ethics purposes

Nursing Codes of Ethics (purposes)

  • To inform the public about the minimum standards of the profession and to help them understand professional nursing conducts

  • To provide a sign of the profession’s commitment to the public it serves

  • To outline the major ethical considerations of the profession

  • To provide general guidelines for professional behaviour

  • To guide the profession in self-regulation

  • To remind nurses of the special responsibility they assume when caring for clients.


Nursing codes of ethics elements

Nursing Codes of Ethics (elements)

  • Nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health, and alleviate suffering.

    • Nurses and people

    • Nurses and practice

    • Nurses and the profession

    • Nurses and co-workers


Some areas raising ethical considerations

Some areas raising ethical considerations

Professional duties

Confidentiality

Consent

Reproductive issues

End of life issues

Mental health

Disaster management

Children

Screening

Rationing (resource allocation)

Professional relationships

Genetics

Research


Why care about ethics

Why care about ethics?

  • Self-interest:

    • Some unethical actions are also illegal

    • Some can affect our careers and reputation

  • For the interest of the others

    • Some unethical decisions can hurt other individuals, the organization we work for, or society


Principles of ethics

Principles of Ethics


Autonomy

Autonomy

The right of self-determination, independence, and freedom. It comes from the Latin auto meaning “self ” and nomy, which means “control.”

Some refer to autonomy as respect for the individual and include the expectations that each individual will be treated as unique and as an equal to every other individual (Davis et al, 1997).


Autonomy1

Autonomy

Rooted in Kant’s deontological philosophy.

The ability of human beings to choose for themselves and determine their own course of life.

Writers may refer to it as the Principle of Individual Freedom (Thiroux, 1998).

Other words often associated with autonomy include dignity, inherent worth, self-reliance, and individualism.


Autonomy2

Autonomy

  • The autonomous person must be able to determine personal goals. The goals may be explicit or may be less well defined

  • The autonomous person has the capacity to decide on a plan of action.


Autonomy3

Autonomy

Four factors for violations of patient autonomy

• Nurses may assume that patients have the

same values and goals as themselves

• Failure to recognize that individuals’ thought

processes are different

• Assumptions about patients’ knowledge

base

• Focus on work rather than caring


Respect for autonomy

Respect for Autonomy

EXAMPLES

  • A patient who can no longer competently care for himself is refusing to leave his home setting, even though he may receive better care in a nursing home. Does anyone have the right to make him move? How do you continue to care for the patient in his home?

  • A patient in a nursing home who has a "Do Not Resuscitate Order" and living will experiences a medical crisis. The nursing home calls the Emergency Medical System (EMS) and the patient is taken to the hospital emergency room and treated. Should the nursing home have called EMS? Why or why not?


Beneficence

Beneficence

Requires that we provide benefits to others, and act with concern for what is in their best interest.

The obligation to do good

Rests in the ethical theory of utilitarianism

It also maintains that we ought to prevent evil or harm (Burkhardt & Nathaniel, 1998).


Nonmaleficence

Nonmaleficence

To do no harm (minimizing the harmful effect of interventions).

(the prohibition of intentional harm).

As far back as Hippocrates, physicians were entreated to do no harm.


Beneficence and nonmaleficence

Beneficence and Nonmaleficence:

  • Giving morphine to a patient for pain, yet morphine may cause side effects. Should the morphine be given?

  • A patient has advanced AIDS with related pain syndromes and is also actively abusing drugs. Do we supply that patient with pain medication?


Justice

Justice

The obligation to be fair to all people.

Does fairness mean that people should be treated the same? In terms of access to health care, is it “just” for one person to receive more resources than another receives?


Justice1

Justice

  • A patient lives in a high crime area of the city. Does the hospice provide this patient/family as many visits as a patient in another neighborhood, especially after dark? Does equitable access and allocation of resources override the safety of staff?


Fidelity

Fidelity

The obligation to be faithful to the agreements, commitments, and responsibilities that one has made to oneself and others.

Interestingly, it is one of the ethical concepts not addressed specifically in some textbooks of nursing ethics. Fidelity is the foundation of the concept of accountability that we hear about so often today.


Fidelity1

Fidelity

What are the responsibilities of health care personnel to individuals, employers, the government, society, and self?

When these responsibilities conflict, which should take priority? In reality, which do take priority? Are we obligated to provide care to all patients? Under what circumstances, if any, might this be challenged?


Veracity

Veracity

Telling the truth or not intentionally deceiving or misleading patients.

As we become adults, we see more and more instances where the choices are less clear. For example, do you tell the truth (veracity) when you know the truth will cause harm to an individual (maleficence vs. nonmaleficence)?


Ethics

Take a moment to reflect:

  • Do you tell a lie when it would make someone less anxious and afraid?

  • You might see this as beneficence (doing good), but then you have abandoned the principle of veracity.


Veracity1

Veracity

  • A husband has been told by his doctor that he will probably die of a sudden "bleed out" from esophageal cancer and is prepared by the doctor for that event.

  • The husband refuses to tell his wife, thinking it will scare her. The wife asks you what she can expect to happen when her husband dies. You know from your experience with families at the time of a "bleed out" that the wife would cope better if she knew what to expect.

  • What is your responsibility to the patient and/or his wife?


Confidentiality

Confidentiality

  • A patient tells the nurse that she plans to commit suicide and asks the nurse to keep it confidential. Does that nurse have a responsibility to tell anyone else? What about confidentiality? How could the nurse respond?


Questions

Questions???????


Ethical decision making

Ethical decision making


What is ethical decision making

What is ethical decision making?

  • When faced with an ethical dilemma the objective is to make a judgment based on well-reasoned, defensible ethical principles.

  • The risk is poor judgment i.e. a low-quality decision

  • A low-quality decision can have a wide range of negative consequences


Two types of ethical choice

Two types of ethical choice

  • Right vs wrong: choosing right from wrong is the easiest

  • Right vs right

    • Situation contains shades of grey i.e. all alternatives have desirable and undesirable results

    • Choosing “the lesser of two evils”

    • Objective: make a defensible decision


Making defensible decisions

Making defensible decisions

  • First step in ethical decision making is to recognize that an ethical dilemma exists

  • Why a “defensible decision”?

    • Two well-meaning individuals can examine the same situation and arrive at different courses of action

  • High-quality ethical decision: based on reason and can be defended according to ethical concepts

  • Ethical decision making is not a science. It is however a skill – a survival skill


Law and ethics

Law and ethics

An act can be:

  • Ethical and legal

  • Ethical but not legal

  • Not ethical but legal

  • Not ethical and not legal

  • If case in 1 or 4, decision is obvious

  • If case in 2 or 3, or if law is not clear then further analysis is needed.

  • If law provides answer, no further investigation is needed


  • Ethics

    • There are several models based on a process of steps (vary from 5 to 20 steps).

    • the easiest ethical decision making model to use in clinical settings is the MORAL model (Thiroux, 1977). It was developed by Thiroux (1977) and then subsequently, applied to nursing situations.


    Ethical decision making models

    Ethical decision-making models

    MORAL model (Thiroux, 1977).


    A framework for ethical decision making edm

    A framework for Ethical Decision Making (EDM)

    • Recognize an ethical issue

    • Get the facts

    • Develop options

    • CHOOSE (make a decision)

    • Monitor and modify (Act and assess)


    Step 1 recognize an ethical issue

    Step 1: Recognize an ethical issue

    • Is there something wrong personally, interpersonally, or socially?

    • Could the conflict, the situation, or the decision be damaging to people or to the community?

    • Does the issue go beyond clinical, legal or institutional concerns?


    Step 2 get the facts

    Step 2: Get the facts

    • What are the relevant facts of the case?

    • Be sure you have adequate information to support an intelligent choice. You can’t make good decisions if you don’t know the facts.

    • To determine the facts, first resolve what you know and, then, what you need to know.


    Step 3 develop options

    Step 3: Develop options

    • What are the options for acting? Have all the relevant persons and groups been consulted?

    • What does the best available literature say about the issues?

    • Evaluate alternative actions From various ethical perspectives.

    • Which option will produce the most good and do the least harm?

    • Utilitarian approach: The ethical action is the one that will produce the greatest balance of benefits over harms. But it is only one of the ethical perspectives.

    • Even if not everyone gets all they want, will everyone's rights and dignity still be respected?


    Step 4 choose

    Step 4: Choose

    • Talk to people whose judgment you respect. Seek out friends and mentors, but remember, once you’ve gathered opinions and advice, the ultimate responsibility is still yours.

    • What would the most ethical person you know do? Think of the person you know or know of (in real life or fiction) who has the strongest character and best ethical judgment. Then ask yourself: what would that person do in your situation? Think of that person as your decision-making role model and try to behave the way he or she would.


    Step 5 monitor and modify

    Step 5: Monitor and modify

    • Since most hard decisions use imperfect information and "best effort" predictions, some of them will inevitably be wrong. Ethical decision-makers monitor the effects of their choices.

    • If they are not producing the intended results or are causing additional unintended and undesirable results, they re-assess the situation and make new decisions


    Factors that influence ethical decision making

    Factors that influence ethical decision making

    • Codes for Nurses

    • The patient’s rights

    • Social and cultural attitudes

    • Science and technology

    • Legislation

    • Judicial decisions

    • Funding

    • Personal religious and philosophic viewpoints


    Ethics committees

    EthicsCommittees

    With the increasing complexity of ethical issues in health care, ethics committees have been created to assist in making ethical decisions in clinical settings. Ethical committees can:

    1. Provide structure and guidelines for potential problems.

    2. Serve as an open forum for discussion and debate.

    3. Function in a patient advocate role by placing the patient at the core of the committee’s deliberations.


    End of life issues

    End of Life Issues


    Decision making capacity dmc

    Decision-making capacity (DMC)

    A patient’s ability to make specific decisions regarding his or her own current or future medical care.

    DMC requires only that the patient be able to make the single decision in question


    In order for someone to have decision making capacity

    In order for someone to have decision-making capacity

    Understand and interpret the clinical information being presented

    Understand each of the options for treatment or non-treatment and the consequences of each choice

    Make and communicate a choice

    Use a rational thought processes in considering personal values and experiences as they relate to the options being presented


    Patient self determination act

    Patient Self-Determination Act

    Patients are informed of their right to accept or refuse care and make advance directives

    The Act is intended to protect the views and choices of patients when they become decisionally incapacitated.

    Includes Living Wills & Durable Power of Attorney for Health Care


    Living wills

    Living Wills

    Prepared while patient has decisional capacity

    Describes patient preferences in the event they become incapable of making decisions or communicating decisions.

    Usually describes what type of life prolonging procedures the patient would or would not want and circumstances under which they would want these procedures carried out, withheld, or withdrawn.


    Responsibilities and rights of the surrogate proxy

    Responsibilities and rights of the surrogate/proxy

    Reviewing the patient's medical records

    Consulting with the health care providers

    Giving consent

    Applying for medical benefits on the patient’s behalf

    Making life prolongation/terminating decisions if the surrogate form meets the requirements of the living will statute.


    Withholding withdrawing treatment cont

    Withholding/Withdrawing treatment (Cont.)

    Healthcare professionals may find it difficult to stop life-sustaining treatment because they have been trained to do everything possible to support life.

    Withdrawal or withholding treatment is a decision/action that allows the disease to progress on its natural course. It is not decision/action intended to cause death.

    Examples (medically provided hydration/nutrition, ventilation, dialysis)


    Do not attempt resuscitation no code

    Do Not Attempt Resuscitation/No Code

    Confirms no effort will be made to reestablish the heartbeat or breathing of a patient suffering cardiac or respiratory arrest.

    A DNR must be written by a physician: (1) at the request of a competent patient,

    (2) or according to the patient's Advance Directives,

    (3) or at the direction—or with the consent—of the patient's surrogate decision maker.


    Strategies for discussions about dnr orders and advance directives

    Strategies for discussions about DNR orders and Advance Directives

    Complete an advance directive

    Address patient misconceptions in the discussion

    Facilitate these discussions early in the course of a life threatening illness

    Explain that the discussion is important because you wish to understand and honor the patient’s wishes

    Revisit the discussion when the patient’s clinical situation changes


    Assisted suicide

    Assisted Suicide

    Assisted suicide occurs when another provides a means with knowledge of the patient’s intent to use it to commit suicide.

    Requests may signify crisis, unrelieved suffering or a plea for help

    Invites physical, emotional, spiritual, psychosocial assessment and interventions


    Euthanasia

    Euthanasia

    Greek words meaning “easy death”.

    Euthanasia is an act by which the causative agent of death is administered by another with the intent to end life.

    Killing an innocent person, even at his or her request is not ethical.

    “Code for Nurses (1985) and the ANA position statement (1994) states that the nurse should not participate in euthanasia but be vigilant advocates for the delivery of dignified and human care.


    Euthanasia cont

    Euthanasia (Cont)

    Mr. Smith is so overwhelmed at his beloved father's suffering that he decides to do whatever he has to do to end it. He administers a massive overdose of his father's pain medication, with the intention of causing his father's death, and thereby releasing him from his suffering.


    Medical futility

    Medical Futility

    Interventions that will lead to no useful result

    Conflicts: benefit/burden of treatment

    Treatment is ethically futile if it will not serve the underlying interests of the patient.

    Institutions have developed futility polices to assist in determining when a treatment is futile.


    Medical futility1

    Medical Futility

    Mrs. Anderson is terminally ill, and death is imminent for both. Mrs. Anderson’s family has been gathered around her bedside for several days, and she has said her goodbyes. She has also received the Sacrament of the Sick. When he breathing begins to be labored, one of her sons asks if she should put on a ventilator. After discussion with her physicians Mrs/ Anderson decides that would only prolong he death, which she says would serve no purpose. She asks only for sufficient pain medication to control her pain, and accepts death.


    A strategy for discussing g oals of care

    A strategy for discussing goals of care

    Begin by asking the patient/family to explain their understanding of the current situation.

    Identify the goals of care for the patient

    Begin by suggesting what interventions would be helpful in achieving the patient’s goals of care

    Suggest what interventions may not be helpful in achieving the patient’s goals of care


    Informed and shared d ecisions

    Informed and shared decisions

    “ An informed decision is one where a reasonable choice is made by a reasonable individual using relevant information about the advantages and disadvantages of all the possible courses of action, in accord with the individual's beliefs”.


    Informed consent

    Informed Consent

    The voluntary consent of the human subject is absolutely essential. Nuremberg Code

    For all biomedical research involving human subjects, the investigator must obtain the informed consent of the prospective subject…or authorized representative. CIOMS guidelines


    Informed consent1

    Informed Consent

    Disclosure of information

    Understanding

    Voluntary decision making

    Consent


    Ethics

    Case Studies


    Case 1

    Case # 1

    • Mrs. C., an 85-year-old woman with severe emphysema, is found unresponsive by her husband. He calls for an ambulance. Emergency medical personnel perform endotracheal intubation and resuscitate her successfully. She then is taken to the local hospital for treatment of pneumonia and respiratory failure. After treatment for her medical conditions, she cannot be weaned from the respirator.


    Ethics

    • The patient is able to communicate her wishes by using head signals and writing notes. After several weeks of treatment, she asks that the respirator be discontinued and she be allowed to die. Mrs. C. asserts emphatically that she would not have wanted to be resuscitated in the first place, although she never executed an advanced directive or discussed these specific wishes with anyone.


    Discussion questions

    Discussion questions

    • Is the patient’s decision a rational one?

    • What is the difference between withholding and withdrawing life-sustaining treatment?

    • In view of the fact that a potent sedative such as morphine may produce respiratory depression, should this be given prior to discontinuing the respirator? Would this constitute active euthanasia?

    • Would the situation be different if Mrs. C. had a living will?

    • What role could the nurse play in addressing the ethical issues in this case?


    Case 2

    Case # 2

    • Ms. J. F. is a 48-year-old woman. Two months earlier she consulted her doctor. She reported progressive abdominal swelling and weight gain.

    • Associated symptoms included fatigue, loss of appetite, gastric fullness, nausea, diarrhea, and intermittent leg swelling.

    • She is unable to perform her usual activities as a legal secretary and mother of a 19-year-old son. She is divorced .


    Ethics

    • On physical examination, she is a febrile, alert but pale, and in obvious discomfort. There is dullness and decreased breath sounds at the left lung base. She has marked abdominal distention with a fluid wave. There is moderate non-localized abdominal tenderness to palpation. Rectal and pelvic examination demonstrate a non-tender mass in the cul-de-sac. She is admitted to the hospital for further evaluation and management.


    Ethics

    • Laboratory and diagnostic results include the following: CBC, electrolytes, serum calcium and liver function tests are normal. Serum albumin is decreased.

    • The chest X-ray demonstrates a small left pleural effusion.

    • Pelvic ultrasound shows ascitesand a normal sized uterus; the ovaries are not visualized.

    • Abdominal CT scan reveals no organomegaly but adenopathy is present.

    • Bone scan and esophagogastroscopy with biopsy are normal. Colonoscopy confirms an extrinsic, compressing mass at 5 cm. There is diverticulosis but no intrinsic mass.

    • Paracentesis cytology is positive for undifferentiated adenocarcinoma.


    Ethics

    • During the first week of admission Ms. J. F. becomes weaker with increasing diffuse abdominal pain and a sensation of pressure on the perineum.

    • She also develops moderate dyspnea and persistent nausea and vomiting. It is thought that she does not have a bowel obstruction, rather that her symptoms are explained by ascites and involvement of the parietal peritoneum. The ascitesreaccumulates requiring repeated paracentesis. It is decided to give her an albumin transfusion replacement, morphine, and intravenous metaclopromide.


    Ethics

    • An interdisciplinary group meets to discuss her care and determine what, if any, limits should be placed regarding further investigations relative to her condition and likely prognosis, i.e. the benefit of identifying the primary site of the adenocarcinoma vs. the projected poor outcome and excess burden to the patient.


    Discussion questions1

    Discussion Questions

    • As a member of this team, how would you proceed, and what would you consider in the decision-making process?

    • What factors will assist you in determining the limits in this case?

    • How does the issue of futility influence your opinion?


    Ethics

    • As recommended by the interdisciplinary team, the attending physician proposes to Ms. J. F. the option of an empiric chemotherapy trial. The physician explains to her that the malignancy is widely disseminated, that chemotherapy might slow down the ongoing process, and that she might experience some side-effects from the therapy.

    • He is vague regarding the prognosis and potential value of the treatment. The physician does not want to needlessly alarm the patient or her companion who is anxious and confused by the rapid progression of her condition. The physician wants to maintain their morale, saying "they have enough to deal with at this moment." Consent is obtained from the patient for chemotherapy.


    Discussion questions2

    Discussion Questions

    • Why is consent a necessary component to therapy?

    • What variables can influence consent?

    • What are the requirements for consent?

    • How do you evaluate the competency of the patient?

    • Do you think that the consent was valid and without influence?


    Ethics

    • Ms. J. F. does not respond to chemotherapy. Her pain increases to the point that she can assume no comfortable position and is in constant pain in spite of all analgesic therapy, including increasing doses of morphine. She becomes more nauseated despite receiving different anti-emetics.

    • Her ascites continues to accumulate rapidly and requires repeat paracenteses to help alleviate increasing pain and dyspnea. Her serum albumin continues to drop despite replacement. She develops a thrombophlebitis for which she receives heparin therapy. At this point, the patient is fatigued, dyspneic, and restless, and must sleep in a sitting position. However, she remains conscious, alert, and oriented. Her competency is never in question although she is partly sedated with lorazapam.


    Ethics

    • Ms. J. F. is reassured that everything will be done to make her comfortable. The intravenous line and heparin are discontinued. She is put on higher doses of continuous subcutaneous infusion of morphine;midazolam and haloperidol are given subcutaneously twice daily. She remains comfortable and dies peacefully 2 days later. She is conscious but sleepy until her death. During this difficult time she is accompanied by her loved ones. Everyone is at peace because they have the impression they could express their feelings and discuss issues freely. The door is left open for communication and support. Bereavement counselling is made available to both Robert, her companion, and Ms. J. F.'s son.


    Discussion questions3

    Discussion questions

    • How would you clarify this request? Is this withholding of treatment?

    • Is sedation acceptable treatment for relieving Ms. J. F.'s symptoms?

    • What is the ethical rationale for your decision?

    • How are sedation and withdrawal of treatment different from assisted suicide or euthanasia?


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