A t it’s very core, nursing practice “deals with issues and situations that have elements of ethical or moral uncertainty” (Burkhardt, Nathaniel, & Walton 2014, p. 21). In my limited experience, this has proved very true. I have encountered numerous situations that, in reflection, could be considered ethical dilemmas. As I was not necessarily able to recognize this in the moment, I feel that there is significant room for growth in my ability to confront these issues.
In this paper, I will discuss an ethical issue I was confronted with while working as a Registered Care Aide, analyze it using McDonald’s Framework for Ethical Decision-Making (2001) as well as the related nursing values from the Canadian Nurses Association (CNA) Code of Ethics (2008), and reflect on my own growth through this process. It is my hope that this will help me to better recognize when ethical issues present themselves in my nursing practice, so that I may provide equally excellent care for all of my future patients.
The Case McDonald (2001) outlines that to fully understand an ethical issue, the case must be stated clearly, with consideration given to the known and unknown information. In the situation that I will be examining, I assisted in providing care for an eightyseven-year-old woman who had recently been designated as ‘palliative’. For the purposes of this paper, I will be referring to her simply as “Helen”. Helen had two children, a daughter who lives locally, and a son based out of Edmonton.
Her daughter was the primary caregiver up until the time of Helen’s admission to residential care, and was still the Power of Attorney and substitute decision-maker for Helen. Though he was unable to visit often, the son supported Helen financially. This was significant as her savings had run out and the cost of the private facility was substantial. Unfortunately, Helen’s children did not get along well, and seldom agreed about what was best for their mother. Understandably, the change in Helen’s condition was difficult for her family.
Both of Helen’s children were present in the family meeting when Helen was designated palliative, the son via Skype. Not knowing how much time she had left, but recognizing that Helen scored at 10-20% on the Palliative Performance Scale, Helen’s daughter took a leave from work, and flew in Helen’s many grandchildren so that they would have the chance to say goodbye. Though it was difficult, she voiced to me in passing that she felt it was time for her mother to go, and she hoped that she would be out of pain soon.
Helen’s son, however, informed the RN manager that since his mother was refusing to eat, he wanted her to be offered Boost or Ensure in lieu of water or juice. Part of his justification of this was that it wasn’t a “good time for [Helen] to die”; his schedule just didn’t allow it. This was discussed with Helen’s daughter, and ultimately, she agreed to comply with her brother’s wishes. I felt that this was an ethical dilemma because of the reasons why the family chose to proceed with the course of action that they did.
I was unsure whether or not what was best for Helen was what was best for her family as a whole. Ultimately, they acted in ways that were best for them, but not necessarily what was best for Helen. The Unknown As my role in this situation was that of care aide, I was not privy to all of the information influencing the decision-making process, and I can only base my knowledge of this situation based on what I directly heard and observed. I acknowledge that the information that I received was mostly second-hand and mostly likely shaded with bias, or care plan memos as interpreted and dictated by the RN.
In recognition of this, there are several pieces of this story that I would have liked to know more about. Firstly, I would have liked to have a conversation with both of Helen’s children in order to clarify my existing knowledge, and gain a better understanding of the situation from both of their perspectives. My understanding of this case is based solely on what I presumed their perspectives to be, but that is not to say that my understanding is necessarily correct. What I perceived to be gross intolerance and self-centeredness in the behaviour of Helen’s son may have simply been grief and denial.
As well, I had no insight into any religious or cultural factors that may have influenced their decisions. Additionally, I would have liked to explore their reasons for choosing to proceed as they did in a safe and non-judgemental way. I think that it would have been important to establish whether or not this family made these choices because they believed that it was the best course of action for Helen, or if it was simply what was easiest and most convenient. If the family did believe that their chosen course of action was what was best for Helen, this situation would be much easier to resolve in an ethical manner.
All of this said, I felt that since my role in this situation was that of a (very green) care aide, soliciting this kind of information would be overstepping. Intervention and information gathering of this nature is very much in the scope of Registered Nurses. The Analysis In analysis of this situation, I will first consider the clinical issues (McDonald, 2001). Helen had advanced dementia, as well as a history of bowel cancer. Though diagnostic tests were not performed, it was postulated that Helen’s cancer had returned, and that it was responsible for her symptoms and change in status.
Specifically, Helen was prone to constipation, and in severe pain- so much so that she had been deemed aggressive due to her tendency to strike out at care providers. The goals of treatment as perceived by the health care team were to provide comfort measures and enhance Helen’s quality of life, in line with the CNA Code of Ethics nursing value of promoting health and well-being (CNA, 2008), but the goals of treatment from the perspective of the family were to prolong Helen’s life as long as possible, regardless of suffering. In this case, the wishes of the family challenge the nursing value of preserving dignity (CNA, 2008).
I believe that this is the discrepancy that forms the basis of this ethical dilemma. Another important consideration in ethical decision-making is patient preference (McDonald, 2001). While Helen did suffer from advanced dementia, and had been deemed incapable of making informed decisions for herself, she did have an opinion. She had specified her wishes for a DNR/ M1 MOST designation more than ten years previously. However, Helen’s son believed that his mother’s wishes only considered invasive life-sustaining treatment, and considered Boost to be non-invasive.
Helen repeatedly expressed that she was in severe pain and that she did not want to eat. Should Helen’s daughter approve her brother’s request to feed their mother sips of Boost, a life-sustaining treatment? If Helen is to be considered as the sole ‘patient’, it is my personal belief that the answer is no. However, Foreva & Assenova (2014) state that “provid[ing] care for the whole family has a definite positive effect in improving the patient’s quality of life”. Therefore, it is arguable that what is considered best for Helen’s children is in fact what is also best for her.
