Antoinette McNeil BSN RN CCRN Washington Adventist University Ethics and the Adult Educator Online NUED 545 Khadene Taffe DNP Student MSNNE BSN RN April 23 2013 Patients live longer due to technology of ventilators Cardiopulmonary resuscitation intensive care units and use o ID: 908270
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Slide1
The Ethical Dilemma of Advance Directives
Antoinette McNeil, BSN, RN, CCRN
Washington Adventist University
Ethics and the Adult Educator (Online)
NUED 545
Khadene
Taffe
, DNP Student, MSN-NE, BSN, RN
April 23, 2013
Slide2Patients live longer due to technology of ventilators, Cardiopulmonary resuscitation, intensive care units and use of antibiotics and feeding tubes (
DeWolf
Bosek & Savage, 2007).Patient’s Bill of Rights by the American Hospital Association of 1973: Patients had the rights to make autonomous healthcare decisions (DeWolf Bosek & Savage, 2007).
Introduction
Slide31990 Federal Patient Self Determination Act passed by Congress (
DeWolf
Bosek & Savage, 2007).Advance Directives focus on two principles: the right to die and death with dignity (Meehan, 2009).Introduction cont.
Slide4Purpose of Advance Directives: allow individual to express how much or how little intervention to be done when ability to make decisions no longer exists (Meehan, 2009).
Types of Advance Directives
Living WillDurable power of attorney for healthcare.Literature Review
Slide5Legal Case StudiesKaren Ann Quinlan 1976
Nancy Cruzan 1990
Terri Schiavo 2005Terri LawGovernor had the power to intervene where there is no advance direcive (Browning, 2010)
Literature Review cont.
Slide6Barriers to Advance DirectivesLack of communication
Lack of knowledge
ProcrastinationSkeptical it would be followed (Meehan, 2009)Attitudes, values and beliefs from different cultures (Zager & Yancy, 2011)
Literature Review
cont
Slide7A 73 year old male was admitted with a diagnosis of motor vehicle crash (MVC), closed head injury, rib fractures, and pulmonary contusions. The patient had a history of early dementia. The patient was admitted to the ICU. He was placed on a non-rebreather
. His family came in to see him and brought his advance directive/living will. It stated that he did not want to be on life support but did want nutritional support. After two days in the ICU he was in respiratory distress and needed to be intubated. The patient was sedated with
Propofol and treated for pain on a Fentanyl drip. The patient mouthed that he did not want to be intubated, he wanted the breathing tube out. The patient remained intubated for 4 days and was being weaned off the vent. Weaning parameters were done and the patient was extubated. When asked how he was feeling he stated that he felt better and was glad that the tube was out. His family came to see him everyday and his sister liked recording all conversations that staff had with the patient and with anyone who was in the room. No consent was given regarding recording conversation and the nurses began not wanting to care for the patient due to the sister who was very imposing and recording conversations.The patient confided to the Intensivist that he does not want to be intubated ever again. A nurse and physician assistant overheard the conversation that the patient had with the Intensivist. The patient was transferred to the medical-surgical floor. After two day on the floor he was in respiratory distress again and needed to be intubated again. There was not documentation in the patient’s record of the conversation he had with the Intensivist regarding no longer wanting to be intubated.
The patient was
reintubated
and returned to the ICU. The
Pallitive
physician was consulted regarding end-of-life wishes. A DNR paper work was initiated but not completed. The patient was allowed to have
pressors
if needed but not to be intubated. The patient’s family wanted everything done regardless of what his advance directive stated. The patient was
extubated
after several days and did well. The patient was transferred to the medical-surgical floor. Much debate occurred over the patient’s advance directive as to why it was not acknowledge and carried out. The directive was felt to address illness and not being in a MVC.
Ethical Dilemma Case Study
Slide8Ethical Principles Breeched
Beneficence-fidelity
Trust or obligation of a covenantLoyaltyAdvocacyDedicationKeeping promises = virtue of caringAutonomy
Free from the control of others
Informed choice
Respect
Slide9Ethical Theory
Feminist Ethics: each party will give special consideration to need of others when in a relationship (
DeWolf Bosek & Savage, 2007)Utilitarianism: what is best for people and value its usefulness looking at outcomes and consequences (American Nurses Association website, n.d.
)
Slide10Nonmaleficence
Do no harm
BeneficenceCompassionSolution by Using Ethical Principle
Slide11Federal Patient Self Determination ActProvide information to all patients
Educate staff and the community
Right to complete Advance directiveDocument in the patient chartEthical Policy
Slide12Provide experiences and guide studentsJournal
Role play
DiscussionAdult Educator: Implication or Nurse/Future for Practice
Slide13Ethics guide practice and dictate how we practiceHow we treat others in our daily living
Families need to talk about end-of-life
Advance directives need to be clearEducateDraw up advance directive before illness.Conclusion
Slide14American Nurses Association website. (n.d.). http://www.nursingworld.orgBrowning, A. M. (2010, September/October). Life-Support Technology and the Dying Experience Implications for Critical-Care Nursing Practice.
Dimensions of Critical Care Nursing
, 29(5), 230-237.Crump, S. K., Schaffer, M. A., & Schulte, E. (2010, November/December). Critical Care Nurses’ Perception of Obstacles, Supports, and Knowledge Needed in Providing Quality End-of-Life Care. Dimensions of Critical Care Nursing, 29(6), 297-306.DeWolf Bosek, M. S., & Savage, T. A. (2007). The Ethical Component of Nursing Education Intergrating Ethics Into Clinical Experience. Philadelphia, PA: .Deep, K. S., Green, S. F., Griffith, C. H., & Wilson, J. F. (2007). Medical Residents’ Perspectives on Discussions of Advance Directives: Can Prior Experience Affect How They Approach Patients? Journal of Palliative Medicine, 10
(3), 712-720.
Johnson, R. W., Zhao, Y., Newby, L. K., Granger, C. B., & Granger, B. B. (2012, September). Reasons For
Noncompletion
of Advance Directives in a Cardiac Intensive Care Unit.
American Journal of Critical Care
,
21
(5), 311-320.
Reference
Slide15Lynch, H. F., Mathes, M., & Sawicki, N. N. (2008). Compliance with Advance Directives Wrongful Living and Tort Law Incentives.
The Journal of Legal Medicine
, 29(), 133-178.Meehan, K. A. (2009). Advance Directives The Clinical Nurse Specialist as a Change Agent. Clinical Nurse Specialist, 23(5), 258-264.Morrison, E. E. (2011). Ethics in Health Administration A Practical Approach for Decision Makers (2nd ed.). Sudbury, MA: Jones and Bartlett.Stagg, D. (2010, April-June). Promoting Ethical Development in Nursing Education and Beyond. Journal of Christian Nursing, 27(2), 96-99.Watson, E. (2010, Winter). Advance Directives: Self-Determination, Legislation, and Litigation Issues. Journal of Legal Nurse Consulting, 21(1), 9-14.
Zager
, B. S., &
Yancy
, M. (2011, Fourth Quarter). A Call to Improve Practice Concerning Cultural Sensitivity in Advance Directives: A Review of the Literature.
Worldviews on Evidence-Based Nursing
, 202-211.
Reference cont.