Introduction
In nursing, end-of-life care comprises healthcare services that nurses provide to patients with terminal illnesses and dying patients. Given that patients deserve respect during their life and death, nurses play a central role in promoting their dignity by complying with legal stipulations and professional ethics. In the provision of healthcare services, nurses experience numerous ethical dilemmas in making decisions. Nurses usually make decisions, which meet the interests of patients, physicians, and family members, as well as comply with the prevailing ethical and legal requirements. Hinshaw (2008) argues that autonomy, justice, nonmaleficence, and beneficence are four primary principles of healthcare ethics, which aid nurses in complying with ethical and legal requirements related to end-of-life care. In this view, the four principles enable nurses to make decisions regarding end-of-life care and offer appropriate advice to physicians, patients, and family members. Therefore, this essay argues that for nurses to uphold legal and professional ethics of end-of-life care, they must comply with the four healthcare ethics, namely, autonomy, justice, nonmaleficence, and beneficence.
Autonomy
Autonomy is an invaluable principle of healthcare ethics because it regards patients as having the autonomous ability to make informed decisions about the nature of end-of-life care they require. For patients to make informed decisions concerning their end-of-life care, they need appropriate information. Autonomy is invaluable to patients with good mental health, who have the capacity to make rational decisions. In this view, nurses have to educate patients so that they can make informed decisions, which would improve their end-of-life care. Informed patients can choose the nature of healthcare interventions they need or abstain from certain healthcare interventions. Entwistle, Carter, Cribb, and McCaffery (2009) explain that autonomy is a central principle of nursing because it promotes the dignity of patients. Autonomy upholds fidelity, informed consent, confidentiality, fidelity, honesty, and privacy of patients, and thus, promoting their dignity. Therefore, by advocating and upholding the autonomy of patients, nurses would comply with legal and ethical requirements in nursing.
Given that some patients are unable to make rational decisions owing to their mental illness, the principle of autonomy requires nurses to comply with the wishes of the patients expressed prior to their current state. The wishes of the patients can be verbal or written statements that form the basis of end-of-life care. Ethics and laws require nurses to comply with the wishes of patients to avoid violating the principle of autonomy. Based on information from nurses, a patient can provide an advance directive, which is a legal document. Advance directives express the wishes of patients when they are unable to make decisions regarding their end-of-life care (Herbert, Moore, & Rooney, 2011). As patients with sudden illnesses rarely issue advance directives, verbal statements become legally enforceable because they represent the wishes of patients. In essence, nurses should not overlook verbal statements that patients make in the course of treatment. Hence, nurses should consider advance directives and verbal wishes of patients in the provision of end-of-life care.
Justice
Justice is an invaluable ethical principle that requires recognition of the rights of patients in a healthcare environment. Since patients with terminal illnesses who require end-of-life care deserve respect and dignity, nurses apply the ethical principle of justice in the administration of healthcare services. From the legal perspective, nurses should consider that patients with terminal illnesses have inalienable rights, which protect their value and dignity as humans. According to Shahriari, Mohammadi, Abbaszadeh, and Bahrami (2013), nurses should consider the privacy, values, beliefs, and principles of patients during the administration of healthcare services. Given that patients with terminal illnesses or dying patients have unique needs, customization of healthcare services is paramount. In this view, nurses need to administer end-of-life care while considering the unique rights of patients.
The scarcity of healthcare resources requires the application of distributive justice in the delivery of healthcare services among patients with terminal illnesses or dying patients. Distributive justice holds that there should be a fair distribution of healthcare resources among patients based on their unique needs. Since patients with terminal illnesses or dying patients need advanced nursing care and equipment to sustain their lives, nurses have to make decisions regarding how they would distribute scarce resources among many patients. Shahriari et al. (2012) holds that the principle of justice advocates for fair distribution of healthcare resources and equal treatment of patients regardless of their conditions. In essence, the principle of justice enables nurses to distribute resources among all patients without concentrating on dying patients or discriminating against them. In this view, compliance with the ethical principle of justice would make nurses promote legal and professional ethics.
Non-maleficence
Non-maleficence is an ethical principle that requires nurses not to harm patients in the course of providing healthcare services. End-of-life care seeks to alleviate pain and suffering that dying patients experience owing to their chronic conditions. As nurses play a central role in alleviating pain and suffering among patients, the nature of healthcare services determines whether they comply with the ethical principle of non-maleficence. Healthcare interventions such as chemotherapy and surgery have side effects, which require careful consideration to avert avoidable harm to patients. For example, a patient with cancer requires palliative care and radiotherapy, and nurses should ensure that chemotherapy and radiotherapy do not harm the patient. Olsen, Swetz, and Mueller (2010) state that the principle of non-maleficence needs healthcare providers to assess their healthcare interventions and establish if they pose any harm to patients. Thus, nurses should approach end-of-life care while considering the principle non-maleficence to avoid legal and ethical implications.
The principle of non-maleficence is also applicable to family members. Given that the decisions that nurses make regarding the end-of-life care affect family members, there is a need for the principle of non-maleficence. Healthcare interventions such as palliative care and withdrawal of life-sustaining treatments have considerable effects on family members. According to Olsen et al. (2010), family members, healthcare providers, and patients should reach consensus on the appropriate treatment for end-of-life care. Essentially, the consent from family members is significant in making decisions about the appropriate healthcare interventions. A harm that emanates from the contentious healthcare interventions has serious legal and ethical implications. Hence, nurses should ensure that the nature of decisions they make for end-of-life care should not harm patients and their respective family members.
Beneficence
The ethical principle of beneficence requires nurses to implement interventions that benefit patients. Patients who require end-of-life care need special healthcare services, which are dependent on the efforts of nurses. Herbert et al. (2011) argue that nurses are effective advocates for patients requiring end-of-life care because they understand their conditions and unique needs. For example, nurses have to make decisions regarding appropriate end-of-life care by administering effective treatment interventions. In this view, it is apparent that nurses play a critical role in the administration of end-of-life care, and thus, they determine the nature of nursing outcomes. Therefore, nurses should ensure that treatment interventions that they apply have significant benefits to patients and improve the quality of life during the dying process.
Nurses should ensure that recommended healthcare services such as palliative care and life-sustaining interventions benefit caregivers and family members. If an intervention has no benefits on patients and family members, yet it is very expensive, nurses should terminate it. Essentially, the nursing care and healthcare interventions should benefit patients, caregivers, and family members. As end-of-life care comprises expensive healthcare interventions, patients, caregivers, and family members should obtain commensurate benefits. Olsen et al. (2010) assert that healthcare providers usually strive to balance benefits and losses that patients, family members, and caregivers that they incur when they adopt a certain healthcare intervention. Overall, nurses should ensure that healthcare services that they provide to patients have optimum benefits to avert violating the ethical principle of beneficence and attracting unnecessary legal and ethical implications.
Conclusion
Nurses constantly experience challenges in the provision of end-of-life care. Fundamentally, end-of-life care plays a central role in promoting the dignity of patients with terminal illnesses or dying patients. During the administration of end-of-life care, nurses experience legal and ethical changes. Hence, nurses should apply four main principles of medical ethics, namely, autonomy, justice, non-maleficence, and beneficence, in the provision of end-of-life care. Autonomy recognizes the ability of patients to make decisions regarding their health care while justice recognizes inalienable rights that patients should enjoy in accessing and utilizing healthcare services. Moreover, non-maleficence requires nurses not to cause harm whereas beneficence requires nurses to act for the benefit of patients.
References
Entwistle, V., Carter, S., Cribb, A., & McCaffery, K. (2009). Supporting patient autonomy: The importance of clinician-patient relationships. Journal of General Internal Medicine, 25(7), 741-745.
Herbert, K., Moore, H., & Rooney, J. (2011). The nurse advocate in end-of-life care. The Ochsner Journal, 11(4), 325-329.
Hinshaw, B. (2008). Ethical issues in end-of-life care. The Lebanese Medical Journal, 56(2), 122-128.
Olsen, M., Swetz, K., & Mueller, P. (2010). Ethical Decision Making With End-of-Life Care: Palliative Sedation and Withholding or Withdrawing Life-Sustaining Treatments. Mayo Clinic Proceedings, 85(10), 949–954.
Shahriari, M., Mohammadi, E., Abbaszadeh, A., & Bahrami, M. (2013). Nursing ethical values and definitions: A literature review. Iranian Journal of Nursing and Midwifery Research, 18(1), 1-8.