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Caring for a patient with terminal illness is challenging because most of the time the patient is unconscious thus remains a passive recipient of care. Health care professionals and family members are left to decide for the patient yet they do not experience the physical impact of the disease. With a view to the selected incident, two issues that arise are ethical and legal.

The rationale of selecting the ethical and legal issues is that Battes (2003) states that they interfere with decision making process in times of a dilemma. Autonomy is one of the ethical principles and it requires that the patient makes decision about the care that he wants (Gedge et al. 2007). In an event where the patient is unconscious, health care professionals compromise autonomy by deciding for the patient or letting the relatives decide. The right of a patient to live is one of the legal issues (Rhome 2004) that arise from the incident. The doctor is faced with a challenge of whether to take the patient’s life by withholding medications or letting him live and suffer.

Legal and ethical issues have an imperative impact on the delivery of care to the patients and carers because they influence the actions of the health care professionals. According to the law, the doctor can withhold treatment and let the patient die peacefully (Cook, 2008). On the other hand, Chantal (2006) explains that it is unethical to withhold treatment if the majority of the people concerned do not feel happy about the idea. For instance, if withholding treatment will annoy the family members, the doctor has no right of doing so. According to the ethical principles, health care providers should supply comprehensive and holistic care to the patient and the significant others regardless of whom they are.

Ethics is a way of examining morality. Singer (2010) states that clinical ethics dictate the professional behaviors of health care providers because they issue a framework for decision making process. Ethics in terminal care entail practical reasoning about the management of the patients. Occasionally, the health care provider may find himself in an ethical dilemma because the ethical principles which are autonomy, beneficence, non-maleficence and justice are in conflict (Matzo et al. 2004). For instance, the patient has a right to make decision but when he is unconscious, it becomes hard for the health care professional to decide who should play that role on the patient’s behalf. In such a case the health care professional should select a course of actions that he thinks is morally upright. By this, the health care professional can decide for the patient or allow the relatives to make an informed decision.

The ethical principle of autonomy dictates that it is a patient who should decide whether he wants to continue living or not. Autonomy is similar to self determination and Thomas (2009) states that every insane human being has freedom to choose what can be done to his body. The focus of autonomy is informed consent and health care professionals should explain to the patient about the disease process, management and outcome so that he can make a choice (Chantal, 2006). In the event where the patient has a cognitive problem the significant others can decide for him. With a view to the selected incident, the doctor explained the patient’s condition and management to the family members so that they decide on his behalf.

The ethical theories of beneficence and non-maleficence guide the health care professionals so that they provide quality care to the patients. Thomas (2009) explains that according to beneficence theory, health care professionals should provide care that is beneficial for the patient while non-maleficence states that the patient should be protected from harm. These theories form the goal of patient’s management which is to assist them in recovering or reduce suffering and thus prolong life (Gallagher et al. 2007). With the view to the selected incident, the issue that arises is withholding some treatment and life supportive assistance. The patient could not completely benefit from the hospital interventions but he was likely to experience more harm because of lack of treatment at the hospice. That is why the family members were confused when the doctor declared that he was going to stop the intravenous fluids and some medications. The question that comes out from the incident concerns the authority of sustaining or withholding life. Is it a doctor, a nurse, a patient or the family members who should make a decision about withholding treatment? According to Wright (2003), the patient should decide, but if he is unconscious the significant others can decide and the doctor has no authority of imposing forced treatment regimen.

Justice is an ethical principle that concerns fair and equal treatment of the patient, the relatives and the significant others (Battes 2003). It states that the nurse should treat every person equally regardless of their social status, culture and disease condition. With a view to the selected incident, the nurse respected the patient’s relatives by explaining them the patient’s condition and the treatment plan. The nurse’s action demonstrates distributive justice. On the other hand, the nurse was unfair in her attempts to withhold treatment and deny the patient his or her  right to live.

Analysis of Legal Issues

In the provision of care, health care professionals cannot assume legal issues since they affect care. Some actions may be allowed by ethics, while being not permitted by the law (Thomas 2009). According to the law, it is forbidden to take any human’s life while the ethical principle of autonomy permits it in case of patient’s request to take his life. With a view to the selected incident, the doctor could not have stopped the patient’s treatment if he had followed the  law that forbids to withhold someone’s life.  

According to Wright (2003) the law is minimal ethics because it operates under the values and principles of the society. The law is a reflection of the ideas of the majority concerning specific issue. If the health care professionals are to follow the law, they have to respect the voices of the family members and significant others (Cook 2008). This means that when it comes to matters concerning life and death, the family members and significant others should be given the first priority. With a view to the selected incident, the doctor should have asked for the family member’s opinion about treatment withdrawal instead of implementing the plan that only afterwards was introduced to them..

Most of the legal issues relating to care of the patients with terminal illness fall under the common and statutory law (Matzo et al. 2004). The court decides the common law and it involves issues like autonomy and treatment withdrawal while the statutory law concerns euthanasia (Thomas 2009). The law limits ethical actions that may be risky for the patient or the family members. Wright (2003) states that the law acts as a framework for decision making process and it helps the health care professionals avoid liabilities. With a view to the selected incident, the doctor could have prolonged the patient’s life for some days by not withholding treatment since the law states the patient’s right to live.

Rhome (2004) explains that the law provides guidelines for the health care professionals to balance between benefits and harm. Health care professionals should relieve any patient from the signs and symptoms of the  disease, inflicting  no harm. In the event that the patient’s relatives doubt the treatment regimen and are worried about the side effects, the health care professional should prioritize the law about harm prevention (Matzo et al. 2004). On the other hand, if the benefit is imperative in comparison to the prevention of harm then the health care professional should prioritize the law of benefits. With a view to the selected incident, the doctor followed the law of benefits by withholding treatment. This is because being allowed to continue living, the patient could have suffered more.

The law provides guidelines that assist the health care professionals in dealing with two harmful situations. If the health care professional cannot compare the danger of prolonged treatment with the side effects of medical care, he should select one action that is less harmful to prevent the occurrence of a more serious harm (Battes 2003). With a view to the selected incident, the prolonging of the patient’s life could have a negative impact on both the patient and the family members. The patient could have suffered for a long period of time while the family members would continue experiencing psychological and emotional difficulties while caring for him. This is the reason why the doctor decided to take an action with a lesser harm that  is to withhold the treatment.

How Nursing Practice Can Be Improved In Relation To Ethical and Legal Issues

In relation to ethical and legal issues nursing practice can be improved by the application of ethical-legal theories while providing care to the patients and the significant others. The ethical-legal theories include deontology, utilitarianism and natural law (Wright 2003). Although these theories will assist the nurse in making a rational decision while in a dilemma, a moral reasoning is important. Therefore, a nurse should learn how to establish a therapeutic relationship with the patient, so that the moral skills develop (Chantal 2006). Moral skills will assist the nurse in making an ultimate decision about the care of the patient. With a view to the selected incident, the nurse could have refused to stop the medication if she considered it to be unethical.

Utilitarianism is an ethical-legal theory that operates under the principle of making many people happy regardless of the consequences to an individual (Gallagher et al. 2007). Application of this theory to the nursing practice is important because it will reduce the prevalence of self interests. Singer (2010) explains that according to utilitarianism, a nurse should provide quality care because that is what the hospital institution is aimed at. With a view to the selected incident, the nurse could have provided holistic care to the patient till death because it is in line with the hospital guidelines. By so doing, the nurse could have alleviated the distress that the family members underwent while observing their relation die peacefully. On the other hand, it was ethical for the nurse to stop the medication, having explained the treatment plan to the relatives. This is because the relatives accepted the treatment plan.

According to the deontology theory, common sense is important and nurses should perform their duties fairly that is to treat every person with integrity and apply the ethical principles without discrimination (Wright 2003). Ethical principles that are deontological in nature include autonomy, beneficence, nonmaleficience and preservation of life (Chantal 2006). A nurse should provide services that are beneficial for the patient and avoid any source of harm, preserving his life. Considering the selected incident, the nurse should have provided holistic care to the patient and the significant others because it is her duty. Additionally, the nurse could not have stopped the medication because the theory of deontology states that a nurse should preserve life.

The natural law of ethical-legal theory states that an action is morally good if it is in line with the human goals and it does not harm a person (Singer 2010). According to this law, it is unethical for the nurse to refuse to care for the patient. The nurse should help the patient to become independent,providing a collaborative care that addresses his needs. With a view to the selected incident, the nurse could have collaborated with the doctor and provide comprehensive care to the patient. Withholding of the treatment decreased the patient’s ability to progress into a different stage of recovery.

Potential Barriers

The application of the ethical-legal theories in the nursing practice can be interfered by a number of barriers concerning the patient, the significant others, health facility and the health care providers. According to Wright (2003), a patient’s beliefs, disease condition and financial status can be a barrier to application of ethical-legal principles and theories in the nursing practice. A patient who believes that intravenous medication is the best solution may refuse other treatment modalities. In the event that a certain drug does not have an intravenous preparation it may be hard for the nurse to provide beneficial services for the patient is likely to refuse treatment.

In a study done, Singer (2010) explains that approximately sixty eight percent of the patients with terminal illness were willing to allow the doctor to end their lives because of financial difficulties. Many of them preferred to die because they could not afford to support their families financially. This shows that financial inability can be a barrier to application of ethical theories in the nursing practice. For instance, the aforementioned patients can refuse nursing care because they want to die. Lastly, the disease condition of the patient is a potential barrier to nursing practice because it influences the decision making process (Matzo et al. 2004). A patient with cognitive abnormalities cannot make a rational decision concerning his management. In the event that such a patient refuses treatment, the nurse is in a dilemma of whether to force the patient to take medication or follow his wishes and command. With a view to the selected incident, the nurse had to follow the family members’ commands because the patient was unconscious and could not decide about his care.

The patient’s family members and the significant others can be a barrier to the application of ethical principles in the nursing practice because they influence the management of the patient (Gedge et al. 2007). When a nurse wants to provide a comprehensive and holistic care to the patient and the significant others want the nurse to withhold treatment, it becomes hard for the nurse to apply the ethical-legal theory. Rhome (2004) explains that the culture and social values of the family members are potential barriers to provision of nursing services. For instance, people who believe that the nurse should not administer narcotics to a patient with a terminal illness can interfere with the nursing practice by prohibiting the nurse from administering medication to the patient.

The potential barriers to application of the ethical-legal theories that relate to the health facility include lack of enough supplies, the hospital policies and the human resource (Wright 2003). A nurse may want to support the patient’s life but if the hospital does not have the necessary supplies, it becomes impossible. For instance, lack of protective devices like gloves and masks can prevent a nurse from providing the patient with a quality care. The hospital guidelines play an imperative role in the application of ethical-legal theories in the nursing practice. If the hospital rules dictate that the doctor is the final decision maker in the management of a patient, the nurse is unlikely to provide quality services (Chantal 2006). With a view to the selected incident, the nurse had to withhold treatment yet the nursing ethics states that a nurse should assist the patient until he dies.

Finally, inadequate human resource is a potential barrier to provision of nursing care (Wright 2003). For instance, if the nurse is under pressure because of understaffing, she is likely to withhold treatment so that the patient dies and relieves her from the excessive workload. Besides, lack of knowledge about application of ethical-legal theories can be a potential barrier to the nursing practice (Rhome 2004). A nurse who is unaware of ethical principles is likely to harm the patient in case of a dilemma. Thus, if a patient wants a pain relieving medication while the relatives are against it, the nurse should apply the principle of autonomy and the deontology theory and is to give the patient the medication instead of following the relatives’ command. A nurse who is not aware of the principle of autonomy and the theory of deontology is likely to follow utilitarianism theory and deny the patient the medication. This will cause harm to the patient as it makes him suffer.

Policies and Guidelines that Affect the Ethical and Legal Issues

The national, international and local policies and guidelines that apply to ethical and legal issues concern the nursing care of a patient who is terminally ill. The nurse should provide care to a patient who is terminally ill so that he can have control over his management (Gedge et al. 2007). This policy is related to the ethical principle of beneficence and it means that the nurse should not withhold treatment but continue caring for the patient.

Cook (2008) explains that the management of a person with terminal illness should be in line with his beliefs as well as the culture. This policy coincides with the principle of autonomy and the ethical-legal theory of deontology. The nurse should respect the dignity of the patient and provide care not discriminating his culture or beliefs. This also means that the nurse should not harm the client because going against his beliefs and culture can interfere with the healing process. With a view to the selected incident, the nurse could have listened to the views of the patients relatives and act accordingly instead of following the doctors instructions and withholding medication.

The nurse should know about conditions like mental disabilities and beware of the side effects of medications that can affect the decision making process of a patient who is terminally ill (Rhome 2004). This policy is important because it affects the nurse’s choice about the autonomy of the patient. It influences the selection of a person who should decide on the behalf of the patient. The nurse should explain the progression of the disease, the management and possible outcome to the person acting on behalf of the patient ,so that he can make an informed decision (Singer 2010). With a view to the selected incident, the nurse acted ethically explaining the treatment regimen of the patient to the family members.

The nurse who is taking care of a terminally ill patient must know the patient’s wishes as well as expectations regarding his management (Gallagher et al. 2007). The nurse should develop a therapeutic relationship with the patient so that she probes him to express his feelings and thoughts about the disease. By so doing, the nurse will know the patient’s wishes and expectations. This policy is important because it provides a solution in case the relatives’ or the health care’s wishes are not compatible with the patient’s expectations. With a view to the selected incident, ethical and legal issues arose, since the patient was unconscious and no one knew either his wishes or expectations.

The nurse who is responsible for the patient with terminal illness must know the outcome of the doctor’s management and document it accordingly (Cook 2008). This means that the nurse should discuss the patient’s care and progress with the doctor.. This policy is in line with the principle of beneficence and nonmaleficience. When a nurse knows the rationale behind the doctor’s management, she is likely to provide the service, beneficial to the patient, and avoid harm. With a view to the selected incident, the nurse could have discussed the patient management with the doctor, so that they explore other possibilities instead of withholding treatment because it was distressing for the family members.

It is essential for the nurse to provide palliative care to a patient with terminal illness (Chantal 2006). The care should include physical, psychological, social and emotional support. Physical care involves provision of medication that relieves the distressing symptoms of the disease process. Psychological and emotional care involves counseling the patient about the disease process, so that he comes to term with it. Social support entails talking to the patient and encouraging him so that he does not feel lonely. This policy relates to deontology and utilitarianism theories. According to the deontology theory, the nurse should provide palliative care to the terminally ill patient because it is her duty. On the other hand, utilitarianism theory will restrict a nurse to provide palliative care to the terminally ill patient if many people do not feel happy about the idea. With a view to the selected incident, the nurse withheld treatment instead of providing palliative care because the majority accepted the outcome.

Conclusion

In conclusion, ethical and legal issues are imperative in the care of a patient with terminal illness. This happens because they influence the decisions of the health care providers concerning the management of the patient. With a view to the selected incident, the ethical issues that arise are autonomy, beneficence, nonmaleficience and justice. Legal issues concern the law and they assist the health care professional to make a rational decision when the ethical principles are in conflict. One of the legal issues is the law that prohibits killing and when a patient wants his life be taken the nurse can disrespect his autonomy because the law forbids killing. Nurses should apply the ethical-legal theories in the nursing practice if they want to provide a comprehensive and holistic care to the patients with terminal illness.

Recommendations

Nurses should strive to know the ethical and legal issues concerning patients with terminal illness by reviewing relevant literatures about the issues. This will assist them in making a rational decision when faced with an ethical dilemma. Battes (20003) states that a nurse who is knowledgable about ethical and legal issues is likely to provide comprehensive services in times of an ethical dilemma than the one who does not know anything about it.

Hospital institutions should organise seminars or workshops for the nurses to attend and learn about ethical and legal issues. This is important because as nursing continues to evolve, the legal and ethical issues keep on changing (Rhome 2004). Attending such seminars, they get to know the current practices of taking care of the patients with terminal illness.

Nurses should conduct research about barriers to ethical and legal issues and then address the findings accordingly. For instance, if the barrier is understaffing then the hospital should employ more health care professionals. In case of the knowledge deficit, the nurses should be taught about ethical principles and theories. According to Thomas (2009), research enables the nurse to gain more insight about legal and ethical issues. Through research, a nurse can get introduced to the new ways of solving ethical legal dilemmas. This will assist the nurse in providing beneficial services when faced with a conflict.

Finally, nurses should educate the relatives about the care of the patient and the outcome. This will assist them in making a rational decision about the patients’ care in the event where the patient is unconscious and cannot decide. Cook (2008) states that educating the relatives about care of the terminally ill patient alleviates the negative belief and culture that they usually hold. A patient’s relative who knows about the management of a terminally ill patient is unlikely to interfere with the management of the patient by prohibiting the nurse to provide care because he knows that rationale of the management. 

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