Honesty versus withholding information

Ethical legal decision-making dilemma for the nurse practitioner  

In creating an ethical and legal decision-making dilemma involving an advanced practice nurse in the field of a family nurse practitioner (FNP) I will be choosing the practice dilemma of honesty versus withholding information. I am choosing this dilemma to show the ethical and legal quandary that NPs may face when dealing with patients who have requested physician assisted death (PAD) (Stokes, F., 2017). As a hospice nurse, and soon to be hospice provider I am aware of this request (recently had one) and the ethical and legal ramifications that can become unleashed due to this request. If I choose honesty, and I am practicing in a state that has legalized this practice, I am obligated to facilitate the request; regardless of my personal beliefs and opinions. In contrast, I am not advocating for my patient and their wishes by choosing to withhold information regarding their request for PAD; within my scope as an advanced practice nurse I can listen to them, counsel them, and refer them to a physician that can further assist them.  PAD is also known as death with dignity and it occurs when a physician provides interventions that intentionally assist a patient to die, for example, prescribing lethal medication to hasten death when suffering from an irreversible, excruciatingly painful disease. PAD should not be confused with euthanasia. Euthanasia occurs when a physician administers a lethal dose versus PAD which the patient self-administers the medication prescribed by the physician. Death with dignity is legal in Oregon, Washington, Vermont, Colorado, and California. It is available through court ruling in Montana and most recently New Mexico (Stokes, F., 2017). In Canada, a recent law was passed entitled MAID. MAID is Medical Assistance in Dying and allows NPs to participate in PAD. The law allows an NP to diagnose and prescribe the lethal medications to assist the patient. Situations in which PAD is requested are challenging for physicians and other healthcare practitioners because they raise significant clinical, ethical, and legal issues (AAHPM, 2015).

Code of ethics

The code of ethics for nurses is a vital tool that every nurse must follow. It is regularly updated to reflect changes in health care structure, financial elements, and delivery of care (AMA, 2015). The code of ethics supports nurses in consistently providing respectful, humane, and dignified care. There are nine provisions and interpretive statements which provide a concise statement of ethical values, obligations, and duties of every individual who enters into this profession. These statements serve as the profession’s ethical standards and expresses nurses’ own understanding of our commitment to society. The nine provisions mentioned are as followed: Provisions 1-3 are a clean and concise reminder of the values and commitments of a nurse. Provisions 4-6 describe and identify the boundaries of duty and loyalty.  Provisions 7-9 describe the duties of the nurse that extend beyond individual patient encounters.

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The most relevant code of conduct that applies in my practice dilemma of honest versus withholding information in my practice dilemma, in my field of FNP, would be provisions 4-6; the boundaries of duty and loyalty. One ethical principle that could be violated would be the code’s interpretive statements which provide specific guidance for practice (ANA, 2015). The code of ethics for nurse’s interpretive statement 1.4 states: “The nurse should provide interventions to relive pain and other symptoms in the dying patient consistent with palliative care practice standards and may not act with the sole intent to end life” (Stokes, F., 2017). My chosen profession as a FNP promises to provide and advocate for safe, quality care for all patients and communities. These codes bind nurse to support each other and make us accountable to their ethical and professional obligations.

Violation of ethical principle and law

The legal ramifications and violation of law for practicing PAD are as followed; FNP’s cannot legally or ethically make the diagnosis to determine terminal illness, for the purpose of qualification in PAD (Stokes, F., 2017. Federal law states, a NP can make the recommendation of hospice care but, they cannot sign the certificate of terminal illness (CTI). Only two physicians are a to sign; one being the primary care provider, and the other the hospice medical director.   Secondly, not all states have allowed NP’s to practice independently without a collaborative agreement; the role of the NP in PAD should be carefully considered.                Lastly, several states adhere to laws allowing for prosecution of persons who provide assistance in the hastening of one’s death. Nurse can be liable for negligence when they breach the standard of care. Additional consequences include; having restrictions placed on their license by the board of nursing, suspension, or loss of licensure (Stokes, F., 2017).

Decision to prevent violation of ethics and laws

Decisions that demonstrates integrity while preventing violations of ethical principles and prevent laws from being violated; simply avoiding your involvement in the practice of PAD. As a FNP you can choose to provide the patient with information on end of life care or PAD, terminate the NP-patient relationship, and arranges for a consultation. Keeping in mind, making judgements on when to offer full disclosure may serve to undermine the bond of trust between a patient and nurse (To tell or not to tell, 2017). Discussing and exploring other options such as; providing resources, comfort, and support for the patient and family allows you to remain involved in their care. The healthcare provider can reject the patients request for PAD without abandoning the patient and involvement in their care (Taboada, P., 2017). The advance practice nurse will refrain from judgement or bias against the patient based on their request for PAD and anticipate contemplations relating to the standards of care, your personal beliefs, and the law.

Recommendations to resolve moral distress

Three recommendations that will resolve advanced practice nurses’ moral distress in the dilemma would include initially; time spent developing and understanding the patient or families point of view (McCabe, M., Wood, W., and Goldberg, R., 2010). I can offer support to the patient while determining how to exercise their autonomy in regards to their illness. Secondly, I will promote and encourage hospice or palliative care to relieve pain and suffering while enhancing quality of life (AAHPM, 2015). Lastly, I will listen to questions and evaluate concerns during our conversation of PAD while acknowledging, addressing, and thoroughly investigating them.

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In conclusion, I find the topic of physician assisted death controversial, even to myself. I see both sides of this dilemma. I empathically relate to the patient who has an irreversible illness/disease process and intractable pain. I relate to the healthcare provider who understands and practices PAD, and those who oppose it based on their own values and beliefs. A recent situation tested my own beliefs and ethical values. As a hospice administrator, working amongst a varied population of residents; independent living, assisted living, and those in memory care. I met a gentlemen living in the independent living section who visited me regularly to talk about hospice as his wife and brother were both receiving hospice cares at their end of life. Two weeks ago, I received a phone call from this resident; he was asking for a visit. When I arrived he asked me if I was still doing hospice to which I replied yes. He then told me he was ready for hospice. I was confused as he looked healthy, thinner than when I had last seen him, but, still living and functioning independently.  He explained he was going to start fasting and that he knew what he was doing and that he had declined to point of not wanting to live like that anymore. He asked me to take care of him. I asked him why he was making this choice, to end his life. He stated he was 89, he had a great life, great marriage, but, didn’t want to continue as his health was declining and he was not feeling as good as he wanted to. I asked him if he spoke to his physician about his plan, he told me no as he didn’t want to involve him. I asked if he was depressed and he said no, as he was in the past, but, he wasn’t now. I explained while I respect his decision his doctor would have to be involved in the process. Not wanting to break his trust in me I proposed he have that discussion and share his thoughts with his doctor. I also elicited the help of our social worker who spoke to him about code status, legal, and ethical considerations. Thankfully, he told me he wouldn’t start fasting until he spoke to his PCP. I found relief from my ethical dilemma by merely talking it out while maintaining trust in our nurse-patient relationship.

References

American academy of hospice and palliative medicine (AAHPM) (2015). California medical association removes opposition to physician aid in dying bill. Retrieved from: Google Scholar. http://aahpm.org/positions/pad

McCabe, M. S., Wood, W. A., & Goldberg, R. M. (2010). When the family requests withholding the diagnosis: who owns the truth? Journal of oncology practice, 6(2), 94-6

Westrick, Susan, J., (2014). Essential of nursing law and ethics. (2nd edition). Burlington, MA: Jones & Bartlett learning.