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Meyers and Gridiron 1991; Hodges and Tolls 1994) and decisions around Its use at the end of life have raised significant clinical, ethical, and legal concerns (Del ROI et al. , 2012). By law ANN. constitutes medical treatment (Airedale NASH Trust v Bland, 1993) and as such does not have to be given if deemed to serve no purpose (I. E. , the futility argument). However, food and water are widely held symbols of caring and suggestions that ANN. be withheld may be perceived by the patient or family as neglect (Von Gunter, Ferris and Emanuel, 2000). Will discuss a scenario that enervated debate around this issue and consider implications for patient care. Personal Identifying factors have been changed according to the NC Code of Conduct (NC, 2010) and The Data Protection Act (1998). Mary was a 93 year old woman with end stage chronic obstructive pulmonary disease (COOP). Since Mart’s admission to hospital 2 weeks prior, family members had been constantly at her bedside. Her daughter Jane had Power of Attorney. Mart’s symptoms e. G. Dysphasia and dispense, led to her having difficulty swallowing (and being given a dietician-recommended soft diet) followed by her appetite spearing.
She drifted in and out of consciousness and the doctor believed her death was imminent. Jane requested that ANN. be commenced and the doctor subsequently prescribed It, via the NASA-gastric route (the Insertion of a tube directly from the nose to the stomach). A discussion commenced between the duty nurses. Some believed that, as Marry death was imminent, Inserting a tube was not In her best interest, others believed that if ANN. was not commenced they were effectively letting Mary starve to death, and still others thought that regardless of the medical tiffs’ opinions, Marry family should decide as they would know best what she would prefer.
The controversy surrounding ANN. is becoming more significant as the number of elderly patients Increases (Goodwill, 1997). Healthcare professionals Involved In the planning of care for these patients walk a tightrope between overstatement and neglect. If they are to be able to defend their Judgments they need to employ ethical theories, Nursing and Midwifery Council (NC) and the General Medical Council (GUM) (Fine, 2006). The two broad ethical theories which influence healthcare are Demonology ND Utilitarianism.
These conflict on what actions should be Judged as right or wrong. Utilitarianism, formulated by Jeremy Beneath (1748-1832), sees an ethical decision as that which produces the greatest positive balance of value over negative balance of value for all persons affected (Mills, 1975). Reasoning is based on consequences, not the means by which they are achieved, and it is therefore said to be a ‘consequentiality theory. In contrast with this, Cant’s Deontological viewpoint states that some acts are wrong and others right independent of consequences (Frederick, 1977).
Utilitarianism is essential in the provision of healthcare where availability of resources is limited and has to be apportioned in a way beneficial to the greatest number of people (Willow 2003). Utilitarian’s would question the morality of artificially maintaining the terminally ill because of the associated drain on resources. They might also argue that when it is difficult to determine whether any benefit is being bestowed and the infliction of harm cannot be ruled out, there are no ethical reasons why ANN. should be administered. This view may appeal to planners in the NASH, whose Job it is to get the most from the resources they nomad.
However, doctors and nurses may feel their professional responsibility is to save the lives of their patients whatever the cost of doing so. Utilitarianism can be criticized as it fails to respect autonomy and to articulate a satisfactory conception of justice or respect for persons. Almost any action (Act Utilitarianism) or policy (Rule Utilitarianism) compared with an alternative, puts some persons at a disadvantage; in this case, the terminally ill. Parallels can be drawn between Demonology, the law and professional bodies such as the Nursing and Midwifery Council and the General
Medical Council, which impose a duty of care on healthcare professionals (Code of conduct, performance and ethics, NC 2010, and Duties of a Doctor, GUM 2010). Demonology proposes that healthcare providers have a moral duty to maintain and preserve life. Emphasis is placed upon sanctity of life and a sense of individual duty. Ethnologists might argue that Mary should receive ANN. because food is essential for life and she might or might not return to health. They would err on the conservative side (do their duty rather than rely on possible, but unknown consequences).
Demonology employs the categorical imperative “act in such a way hat it is possible for one to will that the maxim of one’s actions should become a universal law’ (Guttenberg, 1995). However, many would reason that a blanket policy regarding ANN. is ethically indefensible and, in the case of incapacitated patients, prohibited under the Mental Capacity Act (2005) (National Council for Palliative Care, 2007). Neither Demonology nor Utilitarianism have circumstantial flexibility nor are they totally appropriate or workable in healthcare and it is Principles (B??chamel and Childless, 2008) that is now the commonly used approach.
Principles attempts o bring together the best elements of ethical theories which are compatible with most societal, individual or religious belief systems. It emphasizes four key principles; Beneficence requires that actions must benefit the patient, indicating that it is appropriate to provide ANN. if it will help the patient meet clinical and quality of outweigh the potential benefits, then ANN. should not be initiated; Autonomy refers to a patient’s (or authorized surrogate’s) right to self-determination, which in this case would necessitate determining what Mary would want (or Cane’s right to make decisions about ANN.).
Finally, Justice refers to the fact that healthcare providers should make decisions in a non-discriminatory manner. ANN. should not be dependent upon factors such as chronological age or economic situation (Expert, Andrews and Drayman, 1980). The Hippocratic Oath emphasizes that the underlying principles of healthcare are beneficence and non-maleficent (GUM, 2010). These underpin everyday practice and provide consistent guidelines for professional behavior and decision-making (NC, 2010). The appropriateness of ANN. must be determined in terms of harm and benefit.
However, nurturing and caring for tenants, providing that which is essential, lies at the heart of nursing (Ebb, 2000) and withholding nutrition and hydration (even if it is clinically suggested) may lead to emotional and psychological burden on those involved in the process (Sullivan Maillot, Potter, and Heeler, 2002). Being conversant with the latest medical evidence surrounding ANN. and being trained and experienced in its’ use can help nurses to feel comfortable with the situation (Mentor and Hook, 2009).
Undoubtedly ANN. has a valuable role to play in the outcomes for acutely ill patients who are unable to eat or drink for a short time. For terminally ill patients, some of the clinical arguments pro-ANN. are that it is a way of providing medication (Byron, Derrick De Castrate and Eastman, 2008), fluids, morphine or symptom control (Engrave, Brutal and Posted, 1996). However, there is considerable data indicating that it is not beneficial to provide nutrition support for such patients (Fine, 2006).
Further review even goes as far as to suggest increased suffering without improved outcome (Blakely and Milliard, 2007) making such nutrition support not only medically unjustified, but ethically dubious. Although advances in tube design and deeding technique and composition have reduced discomfort and risks (Dresser and Abusing, 1985), suffering may be due to diarrhea, nausea, vomiting, esophageal perforation, infiltration of formula into the lung, edema, secretions or dispense (Mitchell et al. 1998; Fiancee et al. , 1999).
A patient who repeatedly removes the tube will possibly need restraints (in Marry case a NASA-gastric bridle). Many people assume that death from starvation or dehydration is painful. However, numerous case reports demonstrate that forgoing nutrition and hydration near the end of life leads to greater comfort. A study of terminally ill patients who declined food and drink showed that they generally did not experience hunger or thirst. The result of lack of nutrition and hydration is typically a gradual slip into a coma rather than any form of suffering (Gaining et al, 2003; L’, 2002).
Ketosis and the body release of endogenous voids are thought to block pain and discomfort (Sullivan, 1993; Print, 1992). The medical evidence is quite clear that dehydration at the end of life is a very natural and compassionate way to die (Hall, 1994). Gem’s guidance for ANN. in ‘adults who lack capacity and are expected to die within hours or days’ states that if he burdens or risks of providing outweigh the likely benefits, it is not usually patient are sure this is what the patient wanted, their wishes must be given weight and, when the benefits, burdens and risks are finely balanced, will usually be the deciding factor.
The patient’s condition must be kept under review and care reassessed if there are changes. Lowdown (2002) defines autonomy as a person’s right to self determination, liberty and privacy hence individual choice. Mary was unable to communicate any choice regarding her treatment and, as no advance directive had been executed, the principle of autonomy could not be referred to. In cases like this, the legal, ethical, communication, family, and decision-making issues involved become increasingly complex and challenging (Broody, 1993; Shrewish, Quill and Meier, 1999).
Although physicians have the primary decision-making responsibility in starting or forgoing ANN. (Pappas and The, 2004) they often do not have the time or factual material to undertake decision on where best interests lie. Nurses carry out the feeding and, of all caregivers, have the closest and most trusting relationship with patients and their families during the care process at the end of life (Bernard, Hollowing and Heartfelt, 2006). Mary had been in hospital for several weeks, with a member of her family at her bedside 24 hours a day.
A good nurse would learn about her relationship with her family, her everyday life, her personality, normal modes of expressions, habits, and choices. Through having this knowledge, and enabling family members to express their thoughts and fears, a nurse can help them to understand treatment options in the context of the situation and in light of Marry values and beliefs. It should be ensured that they understand that it is the COOP that is causing Marry problems, and ANN. will not alter the course of the disease.
If Marry values about life ND the way it should be lived; and her attitudes towards sickness, suffering, medical procedures, and death are considered, a substituted Judgment on whether or not to use ANN. can be made (Erase, 2003; ANA 2010). If consensus cannot be achieved between families and healthcare staff, recourse to legal process may be required. The Mental Capacity Act (2005) and the Human Rights Act (1998) require the court to take into account the wishes of a patient when determining best interests. A balancing exercise weighing up factors on each side of the issue is carried out.
In practice, a trial of nutritional treatment often offers a compromise. Provided specific objectives and a finite time limit have been agreed (with criteria established for moving to supportive care), most relatives will come to terms with the inevitable if no improvement has occurred. This is what was decided for Mary. The final relevant ethical principle is Justice, which suggests that every patient has equal rights to treatment, and that decisions about how resources are deployed be made in the fairest possible way (equity) (Holmes, 2010).
In an environment with limited resources, it has been suggested that cure medicine should have priority since the IM is to maintain life which can be economically and socially useful as well as productive. When a high-cost treatment will not restore or enhance the quality of life for a dying patient, using available resources to provide comfort and dignity usually (Schulz, R. Et al. 2003). I have demonstrated that ethics, law and professional codes can be used to guide decision-making. However, this scenario shows that extremely complex situations can arise where the best decision is far from clear.
The provision of ANN. at the end of life is a clinical decision that is complicated by the images associated with this technology. However, the decision-making process equals that involved in the provision of any other life-supporting treatment. The question being: what outcome can we reasonably expect from medical treatment, given the patient’s current condition? After a goal is agreed between all those who have the patient’s best interests at heart, the healthcare team can determine how best to achieve that end (Dunn, 2001).
Clearly when we know someone has reached their final hours or days of life, almost all of us would choose ‘preparing for a comfortable and dignified death’. We would not wish to prolong the dying process. Mary was still in hospital, receiving ANN., when I completed my placement. Therefore, I do not know the outcome of this particular case. However, for all patients, regardless of any treatment choice regarding feeding tubes, excellent nursing care, pain medication (and any other treatment deemed necessary to ensure comfort) should be provided until the end of life.