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Ethically Speaking: The Nurse’s Role in Advanced Directives By Joe Darrah
Date Posted: 31/Jan/2019
When it comes to addressing ethical dilemmas, proactive communication can be a valuable asset in various ways. Editor’s Note: This article is a follow up to recent interviews conducted by ADVANCE on the ethics of end-of-life (EOL) care. To view the previous article, click here
 
While hardly predictable, difficult situations that call into question how nurses should ethically conduct themselves may be eased by engaging in ongoing preemptive measures. ADVANCE For Nurses recently interviewed three nurses about some of the more challenging experiences they have faced from an ethical standpoint related to EOL care and other examples, and asked them to share advice with their peers who may be confronted with similar occurrences.
 
Scenario 1: Patient and family’s fear of inadequate care due to having a “no code” status
Michelle Moccia DNP, ANP-BC, CCRN, GS-C, a senior program director in the emergency department (ED) at St. Mary Mercy Livonia (MI) Hospital and past president of the Gerontological Advanced Practice Nurses Association, describes the response to a call by first responders and pre-hospital care providers from a nursing facility about a resident who experienced a deficit during their primary survey who was also cognitively impaired.
 
“During transport the resident is unable to control their airway and breathing, and suffers sudden cardiac arrest from a dysrhythmia, requiring electrical therapy followed by cardiopulmonary resuscitation, Moccia shared. “Upon arrival to the emergency department (ED), the patient has a pulse but requires intubation for airway management. The family arrives and ED staff explains the sequence of events, providing comforting assurance that their loved one received prompt care, is sedated, and appears comfortable. The patient’s son is in disbelief, shakes his head, and asks ‘why?’ The ED nurse begins to explain what happened, using soothing words but the son continues to say, ‘I promised my mom I would let her die a natural death.’ Unfortunately, the sending facility failed to send the resident’s do-not-resuscitate paperwork.”
 
Scenario 2: Confusion about the severity of dementia
Another common dilemma, Moccia explained, is when a patient’s family does not understand that dementia is a terminal disease and that insertion of a feeding tube when advanced dementia is present is not recommended. “Oral assisted feeding is recommended, per the American Geriatrics Society,” she continued. “Careful hand-feeding is as good as a feeding tube for the outcomes of aspiration pneumonia, functional status, patient comfort, and death. Food is the preferred nutrient. Plus, comfort-feeding allows for social interaction.”
 
Scenario 3: Displaying sensitivity to maintaining a person’s autonomy and right to self-determination
This example may be coupled with respecting the needs and capacity of families when they are confronted with making healthcare decisions with and/or for their loved ones, according to Deborah Dunn, EdD, MSN, GNP-BC, ACNS-BC, GS-BC, a part-time private practice gerontological nurse practitioner who works in the Greater Detroit region (and is a dean/professor/and former nurse practitioner program director at Madonna University College of Nursing and Health in Livonia). Dunn provides an example of a patient she cared for in a long-term care facility.
 
“‘Mr. S,’ was a 92-year-old male who had been admitted to a rehabilitation facility following hospitalization for respiratory distress and pneumonia,” Dunn related. “He had a history of multiple hospitalizations in the past year for heart issues, myocardial infarction, congestive heart failure, chronic atrial fibrillation, and chronic renal insufficiency. I was completing his examination and his son was in the room. I explained [to the patient]that I needed to ask him questions about his advanced care directives – what he would like done in case of an emergency. 
 
I asked if he had discussed his wishes with his son. His son said they had never talked about it because he didn’t know how to bring up the topic. He sat quietly as I asked ‘Mr. S’ about his care preferences, would he like to go back to the hospital if he were to develop difficulty breathing or chest pain that could not be managed at the nursing home. ‘Mr. S’ said, ‘no – I don’t want to go through that again.’ I asked him what he would like done if he were to stop breathing or his heart were to stop beating. He asked me to explain exactly what would be done to restart his breathing or his heart. I explained CPR. His son was quietly crying. ‘Mr. S.’ said he wanted to keep full resuscitation on his chart, because he did not want people to not pay attention to him. I assured him that he would be closely monitored and our medical service would be called if there were any changes in his condition, and that he could ask for us to be called if he felt he needed urgent medical attention. We talked more and I asked again about returning to the hospital if he developed symptoms that couldn’t be managed in the nursing home. He changed his mind and said that he would like to go back to the hospital if he developed symptoms that couldn’t be managed, he maintained his code status as ‘full code.’”
 
Scenario 4: Ventilator care confusion
Robin A. Hertel, EdS, MSN, RN, CMSRN, a nursing education specialist for Ascend Learning, Leawood, KS, and president of the Academy of Medical-Surgical Nurses, described a recent experience about a patient with end-stage COPD who was placed on a ventilator after coming to the ED in respiratory failure. “The healthcare team sat down with the family and had a discussion about her status, and it was decided to keep her comfortable until all of the family could arrive and then discontinue the ventilator,” Hertel said. 
 
“Once that decision had been made, family members felt that patient care seemed to become less comprehensive and infrequent. The family became increasingly frustrated and angry at the perceived lack of caring on behalf of the healthcare staff. Eventually, a meeting was held with the palliative care team and family goals were discussed, resulting in increased communication between the staff and the family.”
Scenario 5: Family quarreling
In another instance, Hertel discussed the care of a patient with advanced Alzheimer’s disease who was admitted with aspiration pneumonia. “The children, one of whom was the patient’s medical durable power of attorney, decided that they wanted the patient to have a feeding tube placed. The patient’s wife (the children’s step-parent) insisted that the patient had indicated he didn’t want such measures taken. She preferred the patient be kept comfortable but have nutrition withheld. This issue was discussed with the healthcare team and the facility ethics committee. In the end, a feeding tube was placed and the children requested the patient’s wife no longer be informed of the patient’s condition. The nursing staff became divided and experienced moral distress as a result.”
 
Potential Solutions
The nurses who spoke with ADVANCE for this article shared a variety of suggestions for being better prepared for similar situations. 
 
Here are a few summarized action plans:
. Host community events to address the importance of end-of-life planning and completion of advance directives.
. Encourage local physician offices to appoint surrogates for patients who will be their voice (consulted) if they lose the decision-making capacity. Also, stress that decisions may change over time and warrant periodic review, including if there is decline in condition, divorce, death of a loved one, or new diagnosis.
. Seek out continuing education and special interest groups
. Ask hospital administration to provide resources to the nursing team in the way of education about EOL care.
 
ABOUT AUTHOR
Joe Darrah is a freelance author based in the Philadelphia region who has been covering the healthcare field since 2004. He may be reached at [email protected]
Source: ADVANCED PRACTICE PROVIDERS

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