Running head: END OF LIFE ETHICAL DILEMMA 1

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End of Life Ethical Dilemma

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Old Dominion University
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 END OF LIFE 2

End of Life Ethical Dilemma

Nurses will always be faced with ethical dilemmas in the inpatient care setting, especially

within critical care. An ethical dilemma involves a situation in which there are two choices to be

made, neither is right nor wrong but involves infringing a moral principal (Oxford, 2017). A

recent situation in the Intensive Care Unit (ICU) reveals the dilemma of whether to continue full

care. This is a dilemma many nurses have had to endure.

A 92 year old male was placed on ventilator shortly after admission to protect his airway.

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The patient presented with shortness of breath and hemoptysis. The patient had two

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bronchoscopies performed in the emergency department and was then sent to CT where a mass

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was seen in the right middle lobe. The patient was transferred to another facilities ICU due to the

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level of care required. The patient then under-went two more bronchoscopies with no definitive

finding. A biopsy was done of the mass revealing it was a hematoma.

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Two weeks after admission the patient was extubated to be given a chance to return
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breathing on his own. The patient was unable to tolerate any form of oxygenation device other

than Bi-level Positive Airway Pressure (BiPap) ventilation. Over the course of 7 days on this the
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patient developed a slow decline to his mental status but with no change to his arterial blood gas

or a head CT. The patients’ family wanted him transferred back to the original facility but was
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unable to because of not tolerating other sources for ventilation.

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The patient required reintubation and to have a tracheostomy and percutaneous epigastric
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(PEG) tube placed. The daughter verbalized that this is what the patient would want. After a

couple days on the ventilator the patient nodded, yes, that this is what he wanted. He also

nodded, yes, that he understood the procedures and what it meant. The unanswerable question is

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 END OF LIFE 3

the true mental status of the patient since he cannot be extubated. This brings the question,

“when does this become unethical for the patient?”

View Points

This patient has been in the intensive care unit for a month and now has significantly

impaired mobility and is unable to breathe without a ventilator. His daughter is his medical

power of attorney and has requested the patient recieve all life saving measures. The majority of

his admission this patient has been unable to communicate or even assist in turning. Myself and

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the other healthcare providers that I work with think that placing a tracheostomy and PEG tube is

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wrong and not beneficial. The patient’s clinical picture reveals there is very poor outcome of him

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returning to his health prior to admission.

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It is painful to watch as his health continues to decline, and we continue all measures to

keep him alive reducing quality of life. Other members of the patient’s family also do not agree
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with his daughter’s choice. This patient will need to go to a special facility where they take long
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term ventilated patients. This patient’s clinical outcome is poor and leads to the high likeliness

that he will need to be turned every two hours and will never regain mobility. This patient will
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have no quality of life.

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Ethics Committee Involvement

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A number of ethical dilemmas have taken place in the intensive care unit and only in a

couple situations has the ethics committee gotten involved. In this dilemma there is not much the
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ethics committee could do. The patient is nonverbal but able to answer yes or no questions. He

concedes that he wants all care which is what his daughter has communicated with the healthcare

team. It is undiscernible if this patient has a clear understanding of his medical condition. I do

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 END OF LIFE 4

feel that a meeting amongst the healthcare provider, ethics committee, and the family would be

beneficial.

It is often that the family does not truly understand the entire medical picture of the

patient. This could be for several reasons, but with a meeting it is more likely that the family will

have a better understanding of the clinical picture. The decision is ultimately with the family and

should be respected regardless of personal feelings. The involvement of the ethics committee is

documented in the chart and ensures continuity of care.

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Summary

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The patient will have a tracheostomy and PEG tube placement before being sent to a

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long-term care facility that manages ventilated patients. The doctors kept the focus on
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transferring the patient back to the facility close to the home of the family. The patient continued

to decline and not all healthcare providers gave a clear concise picture of the patient’s condition
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or communicated effectively. The patient continued to decline until the point of re-intubation in
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which the patient required surgical intervention for a tracheostomy before the date it had been

scheduled.
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There was lack of continuity of care and communication. The daughter was given hope at
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one point that the patient was recovering, when there was no clinical evidence to support this.
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The team should have focused on the clinical situation and not just transporting the patient to

another facility. Through the entire process, all staff continued to care for the patient regardless
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of how we felt. The patient was still treated with humanity and respect.

Discussion

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 END OF LIFE 5

As a nurse on a critical care unit it is my responsibility and standard of practice to

provide care in a non-judgmental and non-discriminatory manner. We are to always meet the

patient’s needs regardless of our feelings. In meeting the patient needs we assist the patient and

family in making an informed-decision and give them the ability to question certain healthcare

practices when necessary. This is to aid our practice in resolving ethical dilemmas and possibly

even preventing them (Bell, 2015).

When an ethical dilemma arises, it is so very important to maintain continuity of care for

the patient and the family. Maintaining continuity of care can place stress on the nurse. It is

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imperative that nurses when caring for the patient and the family also care for themselves. A

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nurse must be able to discern his/her feelings and use professionalism (Lachman, Swanson,

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Conclusion
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This ethical dilemma has been cumbersome to the healthcare providers, staff, and the
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family. The patient will continue to receive care to prolong his life and the healthcare team will

continue to provide it. Ethical dilemmas do not always conclude to what each person involved
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would want but it should affect our practice in how we manage our patients. This situation

demonstrates the importance of communication, collaboration, and involvement of the ethics

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committee.
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References

Bell, L. (Ed.). (2015). AACN scope and standards for acute and critical care nursing

practice.AACN. Retrieved February 11, 2017, from https://www.aacn.org/~/media/aacn-

website/nursing-excellence/standards/scopeandstandardsacutecriticalcare2015.pdf

Lachman, V. D., Swanson, E. O., & Winland-Brown, J. (2015). The new ‘code of ethics for

nurses with interpretive statements’ (2015): Practical clinical application, part II.MedSurg

Nursing, 24(5), 363-368.

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Matzo, M., & Sherman, D. W. (2015). Palliative care nursing: Quality care to the end of life (4th

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ed.). New York, NY: Springer Publishing Company.

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Oxford university press. (2017). Ethical dilemma. Retrieved March 1, 2017, from
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https://en.oxforddictionaries.com/definition/ethical_dilemma
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Winland-Brown, J., Lachman, V. D., & Swanson, E. O. (2015). The new ‘code of ethics for
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nurses with interpretive statements’ (2015): Practical clinical application, part I.MedSurg

Nursing, 24(4), 268-271.

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 END OF LIFE 7

Honor Pledge

“I pledge to support the Honor System of Old Dominion University. I will refrain from

any form of academic dishonesty or deception, such as cheating or plagiarism. I am aware that as

a member of the academic community it is responsibility to turn in all suspected violators of the

Honor Code. I will report to a hearing if summoned.”

Name: __Ashley Button____

Signature: ____Ashley Button______

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Date: __04/24/17_______

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