End-of-Life Issues

Cover Titles

Dilemmas that center on death and dying are prevalent in medical surgical nursing practice and frequently initiate moral discussion. The dilemmas are compounded by the fact that the idea of curing is paramount in health care. With advanced technology, it may be difficult to accept the fact that nothing more can be done, or that technology may prolong life but at the expense of comfort and quality of life. Focusing on the caring as well as the curing role may assist nurses in dealing with these difficult moral situations.

Pain Control

The use of opioids to alleviate a patient’s pain may present a dilemma for nurses. Patients with excruciating pain may require large doses of analgesics. Fear of respiratory depression or unwarranted fear of addiction should not prevent nurses from attempting to alleviate pain for the dying patient or for a patient experiencing an acute pain episode. In the case of the terminally ill patient, for example, the actions may be justified by the principle of double effect. The intent or goal of nursing interventions is to alleviate pain and suffering while promoting comfort. The risk of respiratory depression is not the intent of the actions and should not be used as an excuse for withholding analgesia. However, the patient’s respiratory status should be carefully monitored and any signs of respiratory depression reported to the physician. The administration of analgesia should be governed by the patient’s needs.

Do Not Resuscitate (DNR)

The “do not resuscitate” (DNR) order is a controversial issue. When a patient is competent to make decisions, his or her choice for a DNR order should be honored, according to the principles of autonomy or respect for the individual. However, a DNR order is at times interpreted to mean that the patient requires less nursing care, when actually these patients may have significant medical and nursing needs, all of which demand attention. Ethically, all patients deserve and should receive appropriate nursing interventions, regardless of their resuscitation status.

Life Support

In contrast to the previous situations are those in which a DNR decision has not been made by or for a dying patient. The nurse may be put in the uncomfortable position of initiating life-support measures when, because of the patient’s physical condition, they appear futile. This frequently occurs when the patient is not competent to make the decision and the family (or surrogate decision maker) refuses to consider a DNR order as an option. The nurse may be told to perform a “slow code” (ie, not to rush to resuscitate the patient) or may be given a verbal order not to resuscitate the patient; both are unacceptable medical orders. The best recourse for nurses in these situations is to be aware of hospital policy related to the Patient Self-Determination Act and execution of advance directives. The nurse should communicate with the physician. Discussing the matter with the physician may lead to further communication with the family and to a reconsideration of their decision, especially if they are afraid to let a loved one die with no further efforts to resuscitate. Finally, when working with colleagues who are confronting such difficult situations, it helps to talk and listen to their concerns as a way of providing support.

Food and Fluid

In addition to requesting that no heroic measures be taken to prolong life, a dying patient may request that no more food or fluid be administered. Many individuals think that food and hydration are basic human needs, not “invasive measures,” and therefore should always be maintained. However, some consider food and hydration as means of prolonging suffering. In evaluating this issue, nurses must take into consideration the potential harm as well as the benefit to the patient of either administering or withdrawing sustenance. Research has not supported the belief that withholding fluids results in a painful death due to thirst. Evaluation of harm requires a careful review of the reasons the person has requested the withdrawal of food and hydration. Although the principle of autonomy has considerable merit and is supported by the Code of Ethics for Nurses, there may be situations when the request for withdrawal of food and hydration cannot be upheld. For patients with decreased decision-making capacity, the issues are more complex. Some of these cases have reached courts of law, and different states have different case law
precedents forbidding withdrawal of sustenance. Although an advance directive may provide some answers, at present there are no firm guidelines to assist nurses in this area.