Ethical Decision-Making in End-of-Life Care: Resolving Conflicting Values

QUESTION

Step 1: Is There an Ethical Dilemma?

The first step requires the team to identify if an ethical dilemma actually exists. Does the problem result from a differing set of values or a conflicting set of ethical principles? Does the problem have a clear right or wrong solution? By looking at these questions, the nurse can better determine if the problem is truly an ethical dilemma.

Step 2: Clearly Identify the Ethical Dilemma

The second step requires the team to clearly identify the ethical dilemma. This includes identification of who specifically is affected by the dilemma and the actual problem that exists. This is necessary before moving forward with a discussion of possible solutions.

Step 3: Identify Possible Solutions

The third step is to identify all of the possible solutions to the dilemma. This is not the time to decide on or automatically eliminate a solution. Instead, this is the time for the team to be open to the idea of all possible solutions, even if they are in opposition to your personal value system.

Step 4: Apply Ethical Principles to the Solutions

The fourth step is where the team applies ethical principles to each possible solution. Does one solution respect the client’s autonomy more than another? Is one solution more beneficent than another? Looking at the possible solutions in this way helps to identify the advantages and disadvantages of each solution.

Step 5: Include All Relevant Individuals and Factors

The fifth step is the time for the team to make sure that everyone who can contribute to the solution has been included. Hopefully, everyone who needs to be included, such as the client, provider, the client’s partner, and social worker, have already been a part of the team. If, however, the client expresses a wish to have their pastor included, then this is the time to do so. This is also the step in which the team should ensure that all possible factors, such as legal issues or facility policies, have been considered.

Step 6: Decide on a Solution

The sixth step is when the team decides on a solution. Because of the nature of an ethical dilemma, this decision may not be easy, and it is possible that not all parties will agree on the chosen solution. It is, however, important that the team agree to work together toward the chosen solution. If a decision cannot be reached, and if time allows, the team may need to revisit previous steps and attempt to reach a decision at a later time.

Step 7: Review the Decision

The seventh step requires the team to look closely at the decided-upon solution before putting it into action. Has everything been considered? Has anything changed? Has anything been overlooked? If new issues or concerns arise, then the team will need to revisit the previous steps of the process.

Step 8: Put the Decision into Action

The eighth and final step of the ethical decision-making process is to put the agreed-upon solution into action. This step requires effective collaboration with the team so that everyone knows their individual roles and responsibilities in implementing the solution. This step will then also include an evaluation of the effectiveness of the solution to ensure that the expected and desired outcome was achieved.

Scenario:

Cynthia Parker is a 19-year-old client who was in a motorcycle crash 3 months ago. Since the time of the crash, she has been in the ICU. She is unresponsive and is unable to breathe without the assistance of a ventilator. The provider spoke with her parents and informed them that she is not expected to ever regain consciousness. The recommendation to discontinue ventilator support was discussed. The nurse now enters Cynthia’s room to talk with her parents.

Nurse: Hello Mr. and Mrs. Parker, this news about Cynthia’s status must be very difficult for you. Do you have any questions or is there anything I can do to help at this time?

Cynthia’s Mother: Thank you. Her father and I were expecting this news, but we’re going to need some time to talk this over.

Nurse: Of course. I’m available to answer any questions you may have.

Cynthia’s Mother: Unfortunately, we can’t decide what to do. My daughter is only 19 and I feel she’d want us to continue doing everything possible to keep her alive. I can’t give up hope that she will someday recover.

Cynthia’s Father: I understand her mother’s feelings, but I can’t stand seeing my daughter like this and I don’t think she’d want to go on living hooked up to a machine. I’ve accepted that she’s not going to ever wake up.

Nurse: Making a decision like this is very difficult. Let me talk with Cynthia’s provider about your feelings.

Nurse: I just spoke with Mr. and Mrs. Parker and they do not agree on how to move forward with Cynthia’s treatment. It seems like there is a conflict between their values and what they feel Cynthia would want.

Provider: I’m going to recommend that the facility’s ethics committee come together to discuss this situation further.

The nurse initiates a referral for the ethics committee. The provider, nurse, and Cynthia’s parents are included, as well as the rest of the client’s interprofessional team.

Question 1: Cynthia’s team has completed Step 1 of the ethical decision-making process and has determined that an ethical dilemma does exist. Moving to Step 2 of the ethical decision-making process, identify the ethical dilemma.

Question 2: Identify at least three possible solutions that could be presented during Step 3 of the ethical decision-making process when addressing this ethical dilemma.

Question 3: Reflect on the ethical principles and how they apply to this ethical dilemma

ANSWER

Ethical Decision-Making in End-of-Life Care: Resolving Conflicting Values

Introduction

In healthcare, ethical dilemmas often arise when there is a clash of values and perspectives regarding a patient’s treatment or end-of-life decisions. The scenario presented involves Cynthia Parker, a young patient in an unresponsive state following a motorcycle accident. Her parents have differing views on the continuation of life-sustaining treatment. This essay follows the eight-step ethical decision-making process to address the ethical dilemma, explores possible solutions, and reflects on the application of ethical principles.

Step 1: Identification of the Ethical Dilemma

The ethical dilemma in this case centers around whether to continue or discontinue life-sustaining treatment for Cynthia. Her mother desires to maintain hope and continue all possible interventions, while her father believes that she would not want to live in her current state.

Step 2: Clearly Identifying the Ethical Dilemma

The ethical dilemma is the conflict between the parents’ differing perspectives on Cynthia’s treatment options. This disagreement poses challenges in determining the best course of action regarding the continuation or withdrawal of life-sustaining interventions.

Step 3: Identifying Possible Solutions

Potential solutions that could be presented during this step include:
Continued Life-Sustaining Treatment: Respect the mother’s wishes and continue all interventions to sustain Cynthia’s life, offering emotional support to the parents.
Withdrawal of Life-Sustaining Treatment: Honor the father’s perspective and engage in compassionate communication, emphasizing Cynthia’s quality of life and her previously expressed wishes.
Mediation and Conflict Resolution: Facilitate open dialogue between the parents, encouraging them to consider Cynthia’s best interests and engage in shared decision-making.

Step 4: Application of Ethical Principles

Ethical principles that can guide the analysis of possible solutions include:
Autonomy: Respecting Cynthia’s autonomy involves considering her previously expressed wishes, values, and beliefs.
Beneficence: Striving for the best possible outcome for Cynthia, including her well-being and quality of life.
Non-maleficence: Avoiding harm to Cynthia and minimizing her suffering during the decision-making process.
Justice: Ensuring fairness and equity in the consideration of Cynthia’s treatment options, considering her best interests and societal resources.

Step 5: Inclusion of Relevant Individuals and Factors

The ethics committee, comprising the provider, nurse, parents, and interprofessional team, should engage in the decision-making process. Their involvement allows for a comprehensive exploration of perspectives and expertise to reach a consensus that upholds Cynthia’s best interests.

Step 6: Decision-Making

After deliberating on the available information, the ethics committee will decide on the best course of action. This decision may involve continued treatment, withdrawal of life-sustaining interventions, or an agreed-upon compromise that respects Cynthia’s autonomy and best interests.

Step 7: Reviewing the Decision

Before implementing the chosen solution, the ethics committee should review the decision to ensure all factors have been considered. Any new information or concerns should be addressed before moving forward.

Step 8: Implementation of the Decision

Once the decision is finalized, the chosen course of action should be implemented effectively, ensuring clear communication and collaboration among the healthcare team. Regular evaluation and reassessment of Cynthia’s condition and the decision’s impact should occur.

Reflection on Ethical Principles

This ethical dilemma reflects the principles of autonomy, beneficence, non-maleficence, and justice. Respect for Cynthia’s autonomy requires considering her previously expressed wishes. The principle of beneficence seeks to maximize her well-being, while non-maleficence aims to prevent further suffering. Justice demands a fair consideration of available resources to ensure equitable decision-making.

Conclusion

Addressing ethical dilemmas in end-of-life care requires a structured and systematic approach. By following the eight-step ethical decision-making process, healthcare professionals can navigate conflicting values, engage in shared decision-making, and prioritize the best interests of the patient. In Cynthia’s case, involving the ethics committee and applying ethical principles can help guide the decision-making process, respecting her autonomy, and ensuring compassionate care aligned with her wishes.