Ethical Dilemma in End-of-Life Care
An 80-year-old man with terminal lung cancer is admitted to a district hospital in Lesotho with severe dyspnoea and pain. He is alert and oriented but weak. His daughter, who is his primary caregiver, insists that he should be given antibiotics for a suspected chest infection and be resuscitated if his heart stops. The patient has told the nurse privately that he is tired of suffering and does not want any aggressive treatment; he wants to be comfortable. The doctor is unavailable, and the nurse must decide how to respond to the family's demands while respecting the patient's wishes. The hospital has no formal ethics committee.
1. What are the ethical principles involved, and how should the nurse navigate this conflict?
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The ethical principles involved are:
- Autonomy: The patient's right to make decisions about his own care, including refusing treatment.
- Beneficence: Acting in the patient's best interest, which may include providing comfort care.
- Non-maleficence: Avoiding harm, such as unnecessary or futile treatments.
- Justice: Fair allocation of resources.
The nurse should:
- Assess the patient's decision-making capacity: He is alert and oriented, so he likely has capacity.
- Facilitate open communication between the patient and his daughter, respecting the patient's wishes.
- Provide information to the daughter about the patient's condition, goals of care, and the benefits of comfort-focused care.
- Advocate for the patient's wishes while showing empathy to the family.
- Document the patient's expressed wishes and the discussions.
- Seek advice from a senior nurse or doctor when available, and follow hospital policy on end-of-life care.
Rationale: The patient's autonomy should be respected if he has capacity. The nurse's role is to support the patient and family through this difficult time, ensuring the patient's wishes are honored.
2. The daughter becomes angry and threatens to report the nurse for neglect. How should the nurse respond?
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The nurse should respond with empathy and professionalism, acknowledging the daughter's concern while clearly explaining the patient's rights and the nurse's obligations. Steps include:
- Listen actively to the daughter's fears and validate her emotions.
- Explain that the patient has expressed a wish to focus on comfort and has refused aggressive treatment, and that the nurse is legally and ethically bound to respect his decision if he has capacity.
- Clarify that the nurse is not neglecting the patient but is providing appropriate palliative care, including pain relief and dyspnoea management.
- Offer to involve a doctor or senior colleague to discuss the situation further.
- Document the conversation and the daughter's concerns.
- Follow hospital procedures for complaints or reporting.
Rationale: The nurse must maintain a therapeutic relationship with the family while upholding the patient's rights. Clear communication and documentation can prevent misunderstandings and protect the nurse professionally.