Introduction
In medicine, end of life care is the kind of healthcare that a patient receives during his or her last days of life (Ellershaw & Ward, 2003). This may also refer to the care given to the terminally ill individuals whose conditions have deteriorated to an advanced condition or to the point where there is no cure. However, with the technological advancements in the medical field, a wide range of options exists in healthcare. Medical practitioners usually face ethical dilemmas when providing care to such patients. Many need to make difficult choices when it comes to the type of treatment that would ease the pain and suffering of the patient during his or her last days or hours. Some difficult decisions also need to be made when contemplating on whether to terminate treatment in order to let the patient die or whether to continue with the treatment. These tough situations are faced by people from all works of life.
Definition of death
One factor that makes it difficult to make such decisions is the point at which an individual is said to be dead. More recently, this point has been difficult to define. In the past, a person was pronounced dead the moment the heart and lungs stopped working. However, it is possible that the brain stopped functioning way before the lungs and the heart did. With the advancement in life support systems, the line between death and life is not as clear as before (Guglielmo, 2002). Cardiopulmonary resuscitation (CPR) technologies have enabled the resuscitation of near-death patients. This may be seen where the heart and lungs are restarted and their functioning maintained. This has made it possible to have an individual whose brain is not functioning but whose lungs and heart are. This explains why the Uniform determination of Death Act (UDDA) had to be established. It defined death in two ways. Firstly, an individual was considered dead if his respiratory and circulatory functions had ceased permanently. Secondly, a person was considered dead if all the functions of his brain (including brain stem) had ceased permanently. Medical practitioners can tell whether the brain is still functioning. They can check for the presence of electrical activity in the brain. If absent, the person’s brain is dead. They can also check for blood flow and the clinical brain functions such as the involuntary reflexes (Ellershaw & Ward, 2003).
Ethical challenges
It has been determined that access to hospice care may be unavailable to some individuals approaching the end of their lives. This has been attributed to unfair access to such services, which violates the justice system. In other hospitals, physicians and nurses may not have enough knowledge about end of life issues. Some do not know how to properly manage pain of the suffering patients. Therefore, nurses should understand the proper ways of managing diseases and pain. They should also be knowledgeable when it comes to end of life issues (Guglielmo, 2002).
Ethical issues may also arise during prognosis. It has been determined that many doctors are usually optimistic when giving prognostic information. Therefore, they may overstate how long an individual might remain alive. The accuracy of such information is important in making end-of-life decisions. It makes it easier for physicians and nurses to determine whether to use certain treatments or withhold them. However, it may be difficult to provide accurate information given the wide range of life-extending technologies and this may bring conflicts between health practitioners and the patient’s family. In addition to this, some people’s cultures do not allow open discussions about death (Caralis, Davis, Wright K, & Marcia, 1993). Therefore, it would be unethical for healthcare providers to communicate the prognosis with the patient. Therefore, nurses should know the patient and understand his or her culture before providing information about the prognosis.
Ethical dilemmas may also be experienced when it comes to palliative care. During the patient’s last days of life, certain symptoms tend to intensify. Pain, for example, may intensify. Therefore, nurses are required to provide medication in order to relieve pain. Pain relievers also tend to encourage rest. However, the use of narcotics to relieve pain may pose ethical dilemmas. When properly controlled, these substances may be use successfully for pain relief, alleviation of diarrhoea and reduction of coughs. They may also have some side effects. These include constipation and drowsiness. The most serious of these side effects is respiratory depression. Medical practitioners may face criminal charges if narcotics are prescribed in excess. Cases of providing narcotics to the wrong person also occur and this may be unethical and illegal.
One of the narcotics used in pain relief is morphine. It is also effective for relieving shortness of breath in terminally ill patients. However, respirator depression is one of its side effects. For fear of such side effects turning fatal, physicians may under-prescribe them. This may not be ethical especially if the patient is under intense pain (Guglielmo, 2002). Therefore, nurses need to examine the severity of pain and administer the correct amount in order to relieve the patient’s pain and, at the same time, ensure that the patient does not suffer from adverse side effects.
Ethical dilemmas may also arise when there is need for the use of CPR. This is one of the ways of increasing the chances of survival of patients from cardiac arrest. It is usually effective in treating heart attack. However, it might prove fatal when done on certain patients. Therefore, medical practitioners avoid it by all means. The patient or his family members may opt not to use CPR. Nurses should discuss with terminally ill patients and know their wishes concerning resuscitation. Some may place a do-not-resuscitate (DNR) order. Practitioners have an ethical obligation to honour them. However, arguments against this exist. Some believe that such orders may be unnecessary if the practitioners believe that resuscitation would be beneficial.
Use of nutrition and hydration during this critical time of a patient’s life may also cause ethical issues. Individuals who are nearing death may not process food and water normally. In fact, these elements might cause more complications. The United States laws treat the provision of water and nutrition as any kind of life-sustaining procedure. Therefore, it provides for the right to refuse such treatments. Nurses may be faced with a dilemma since water and nutrition are vital for survival and refusing to provide them may be similar to killing the patient. Therefore, nurses should asses the situation to determine whether provision of these elements is beneficial or burdensome.
Conclusion
End-of-life care is the care given to patients who are nearing death. Caregivers are usually faced with ethical dilemmas due to some of the decisions that need to be made. Ethical issues arise when it comes to prognosis, pain management, withholding or withdrawal of treatment and resuscitation. Therefore, health practitioners should have sufficient knowledge of the law, code of ethics and the patient’s condition in order to make informed decisions.
References
Caralis, P., Davis, B., Wright K., & Marcia, E. (1993). The influence of ethnicity and race on attitudes toward advance directives, life-prolonging treatments, and euthanasia. Journal of Clinical Ethics, 4(2), 155-165.
Ellershaw, J., & Ward, C. (2003). Care of the dying patient: The last hours or days of life. British Medical Journal, 326(1), 30-34.
Guglielmo, W. (2002). Assisted suicide? Pain control? Where’s the line? Medical Economics, 79(19), 48-59.