www.chitraltimes.com

Ethical and Moral rights

Life and death decisions are a matter of concern not only to those immediately affected by them but to every one of us as well. Ethical dilemma is becoming common in palliative care. Last week I received a patient named Mr. Khan, a 65 years old man suffered from a massive heart attack followed by stroke. He is a known diabetic since 15 years and has huge diabetic ulcers on his feet. His COPD is worsening and he seems to need ventilator support according to medical point of view. His family pressurizes to put him on ventilator but the doctors think that his existing condition and comorbids does not give him much chance to survive, so they want to with hold his treatment of ventilator support. Whereas, the patient�s wife is crying and begging to me to do some thing before any loss occurs. His son states �we don�t want to leave any stone unturned. Family wants to try and attempt all the possible interventions and if he doesn�t respond then we will withdraw his treatment but at least we feel we have done all that was possible�. Patient was a strong man although he was having multiple problems but still he doesn�t want to die.

While reflecting on the incident, I was thinking for the patient�s right. Is this ethically right to stop his lift support and not giving him or his family a chance to decide? I felt very upset after the doctor�s decision. Also, I was so angry on the doctor who had not given proper counseling and looks only task oriented. I was stupor for a while. Then I felt nervous and hesitant to answer, my tone was low that I had a lack of confidence while answering because patients family wanted him to lived I don�t know why it is happening. Since patient is still alive, why not given chance to take decision on their own it is their right to show their involvement in matter related to their loved one�s life. I was thinking if it could happen with my family member then how do I feel about it? What could be my response? My feelings are very biased with patient�s family member.

When I pondered over the reasons that, why this incident happen? I had so many things going in my mind. Why doctor did not explained to the family members regarding prognosis? Why he did not bothered about patient�s right? Why nurses didn�t take initiative to discuss with the doctor? The general perception of nursing profession and local nursing group is not appreciating. Usually they ignore their right of autonomy. Ignore patient�s feelings and family member�s thought. They are only task oriented; they don�t have psychological concerns about family feelings. These types of problem occur in other places also and they are not given proper attention towards patient�s right.

I can challenge the assumption that it is our responsibility because we have taken oath to fulfill our nursing responsibility to give patients right regarding treatment option. I could interpreted this event differently because may be doctor was in hurry and that�s why he was not able to explain patient�s family. There is a possibility that doctor was not aware of the patient right. May be the doctor didn�t get chance to communicate with family regarding prognosis. Or may be family don�t want to listen to the doctor as he was not in a favor of patient right. May be the doctor thought ventilator therapy was expensive for patient. Or may be it makes patient life more miserable due to its complications with COPD client. It may create further harm to patient as seen by comorbids. It also comes under ethical principal of non-maleficence as Prigmore (2006) says �whenever we try to help others we are at risk of harming them therefore it is sensible to consider the principles of beneficence and non-maleficence together�.

After critically analyzing, I found many solutions to prevent this incident. First of all, it was the responsibility of the doctor to provide necessary information about the present condition and the prognosis of the disease to gain support and cooperation from family. Further more non-invasive ventilator could be the choice of treatment according to British thoracic society guide line for the management of COPD patient as Prigmore (2006) says �non invasive ventilator involves the administration of ventilator support through the patient�s upper airway using a mask or similar device, but avoiding intubations.� In addition to this, health care profession should respect the patient autonomy by keeping the patient right in their mind toward the family wish. Although, I am hesitated to do thing but still I can take action and talk to the doctor about patient and family wishes as Taylor (2003) says �medical ethics are therefore concerned with the moral principles or rule of conduct with in which medicine and professions allied there to are expected to work�

On the other hand patient prognosis of disease is poor according to Phipps (2003) �prognosis of COPD is poor in acute exacerbation phase.� where as massive heart attack with stroke has also poor prognosis and last but not the least, complication and side effect of ventilator itself is very high in heart attack and COPD there is a high chance to develop aspiration pneumonia, actelactasis and infection for upper and lower respiratory tract can develop very fast. Adequate counseling should be done to gain positive support from patient and family. Compare the risk verses benefit of putting patient in to the ventilator and then leave the final decision on them because of their right of autonomy. I can handle this situation by proper counseling. I can recall my past experiences as I had came across a patient with COPD and needed ventilator support but the doctor suggested DNR for patient and the last moment we had not run the blue code and patient expired then family member called the doctor although his decision was correct but proper explanation was not given to patient�s family member, therefore, many problems arises. In my strength I can identify the situation but I feel hesitant to talk to the doctor regarding patient�s right, as Taylor (2003) said �nurse also need to feel confident that where debates occur provided they are seeking to act in patients best interest and to work cooperatively with their colleagues and respect their views, even where differences of opinion exist, they will have the support of their peer and national body (NMC, 2002)

From the above scenario, I have found that it is the matter of not taking care of patients� bill of rights. I have reviewed different literature on that. According to Patrica (2002) �Autonomy refers to the individuals right to choose. The principle of autonomy reflects the belief that every competent person has the right to determine his/ her own course of action.� According to patient bill of rights in 1973 by AHA �the patient has the right to make decisions about the course of treatment and to refuse a recommended treatment or plan of care�. Furthermore an article by Prigmore says �the decision of with drown care must be consisted with in Human Rights Act (1998): the right to life and the right to protection from inhuman and degrading treatment.� �Respect for personal autonomy is a basic principle of medical ethics. This principle reinforces the duty of hospital personnel to secure the consent of patients or their surrogates before initiating or discontinuing treatment� (Sara.1994.p51) By reviewing above literature, I have learnt the importance of patient�s right for autonomy. Patient came to us because they trust us. Firstly we should respect and keep this trust alive by keep aware of patient�s right. If we will not follow patient rights, we are eventually neglecting their rights. Secondly as a professional nurse, we have to adopt the role of an advocator in patient care as if anything goes wrong we should utilize ethical principle in a professional manner. Besides applying these principles in my daily practice, I will train other nursing staff nurse by reviewing ethical concept with them. In adding to that, I will arrange on going sessions for nurses, on how to become assertive for patient rights. Also request training and organization department, to arrange sessions for doctor on ensure quality care to patient.

On Email