Ethical dilemma in

palliative care

Erna Rochmawati, PhD

Overview
• Principles of bio ethic
• Ethical
issues and dilemmas in palliative care
and end-of-life care
• Roles of nurses in ethical decision-making
• Advance directive planning and their role in
preventing ethical dilemmas
Principles of bio ethics

Autonomy Beneficence

Maleficence Justice
Ethical issues in palliative care
Goals of
care

After death
issue

Patient and
family goal
 Cont…

•Physician and •Transitioning •Pain and

patient goal focus of care symptom
conflict management
 Cont…

• Euthanasia • Do not • Withholding

or physician- resuscitate and
assisted withdrawing
suicide treatments
Ethical decision in Islam
• Based on Qur’an and Hadist
• Theprinciple is avoiding or minimising
harm
Ethical decision in Islam (Leong et al 2016)
Advance directive planning and their
role in preventing ethical dilemmas

• Living will
• Do not resuscitate
• Proxy decision making
• Artificial hydration and nutrition
Advance directive planning and their
role in preventing ethical dilemmas
• The benefits is still debated

- Ability to guide health - Sometimes vague to be

professionals and family followed
members in making decision
- Time consuming
- Ability to increase patient’s
empowerment in medical - Not easily available when
decision-making and promote needed
discussion about death - Patient may change his/her
planning mind
- Alleviate patient’s anxiety
Roles of nurse in ethical decision
making
• http://www.nursingworld.org/MainMenuCategories/EthicsStandards/Resour
ces/Ethics-Position-Statements/EndofLife-PositionStatement.pdf

• https://www.magonlinelibrary.com/doi/abs/10.12968/bjon.2007.16.16.27078

• https://oda.hioa.no/en/nurses-role-and-care-practices-in-decision-making-
regarding-artificial-ventilation-in-late-stage-pulmonary-
disease/asset/dspace:10019/1325313post.pdf

• Still not optimum,

• Lack of discussion
• Lack of communication skills
Steps in ethical problem solving
1. Define the problem
• Differentiate clinical problems, such as uncertainty or
disagreement about prognosis, from ethical problems, such as
determining how to balance duties to provide benefit and duties to
respect autonomy; assure that everyone identifies the same issue.
2. Clarify facts and assumptions.
• Differentiate known facts from assumptions about the
situation, such as presumed motives of family members; assure
that all parties have access to the same facts.
Steps in ethical problem solving
3. Develop list of all options.
• Avoid collapsing options into “yes/no” absolutes, such as “continue all
treatment” and “discontinue all treatment”; assure that all possible actions are
evaluated, including intermediate steps such as continue all treatments and
escalate as needed; continue all treatments but do not add anything further;
discontinue ineffective interventions but continue non-invasive treatments;
discontinue all interventions that do not promote comfort.

4. Evaluate all options.

• Consider relevant laws, policies, and ethical principles; address rights,
duties, and interests of all involved.
5. Choose the optimal option and implement.