Ethical dilemmas in

end of life care:

Balancing patient
autonomy and
beneficence
Presented to: Dr. Nadia Mohammed

Presented by:
Wejdan Omar alfuhaid 441050708
Noura Rashid Al-Quait 442051863
Afnan Rashed Alabdi 441050291
Jawaher othman Al-ablan441051753
section 1100
Outline

• Introduction
• Protecting Patients’ Rights
• Ethical Dilemmas
• Approaches to decision making at the end of life
• Specific challenges in end-of-life care
• Shared Patient Decision-Making
• Common end-of-life ethical problems
Introduction
Nurses frequently face ethical dilemmas while caring for their patients.
These dilemmas can take different forms, such as how best to respect a
patient’s decision to refuse treatment due to cultural or personal beliefs, or
what to do when conflicts arise between patients and their families in
making end-of-life care decisions.
End-of-life care is the term used to describe the support and medical care
given during the time surrounding death.
These kinds of ethical dilemmas often challenge nurses to deliver optimal
patient care while also adhering to professional boundaries.
Dilemma :
Protecting Patients
Rights
Dilemma : Protecting Patients’ Rights

Patient autonomy — the right of patients to independently make decisions about

their care based on their personal or cultural beliefs and values — is a

paramount principle of nursing.

This includes a patient’s right to refuse medications, treatments, or procedures.

In some cases, a patient’s right to autonomy may directly conflict with what

nurses or other health care workers believe is best.

Autonomy (respecting a patient’s wishes) and beneficence (doing

good), two fundamental ethical principles in nursing, are sometimes

in conflict. The nurse’s role is to strike a balance between the two

through open discussion, sharing information with the patient, and

negotiation. If addressed incorrectly, these situations can present not

only ethical or moral issues, but legal ones as well.

The concept of patient autonomy goes beyond merely a philosophical

or ethical consideration; it is considered a legal right throughout the

Western world. Legal precedents have placed patient autonomy ahead

of health care provider beneficence in many cases, arguably making

patient autonomy the foremost principle affecting patients’ rights.

Autonomy vs.
Beneficence
Advocacy
Nurses especially are expected to advocate on behalf of patients in these situations. These scenarios can

present a quandary for nurses, where they must balance their duty to respect and promote the interests of

their patient with their loyalty to their employer or colleagues. However, according to the Code of Ethics

for Nurses, the nurse’s primary commitment is to the patient.

The Code’s corresponding interpretive statements explain: “Nurses address such conflicts in ways that

ensure patient safety and that promote the patient’s best interests while preserving the professional integrity

of the nurse and supporting interprofessional collaboration.”

Ethical Dilemmas
Ethical Dilemmas

• Ethical dilemmas in healthcare are common and can occur when

there are two or more conflicting ethical principles or values. Patient
autonomy and beneficence often clash, as what is in the patient’s best
interests may go against their wishes, beliefs or preferences, or they
cannot make decisions themselves due to a lack of capacity.

• Here are some real-world ethical dilemmas where patient autonomy

and beneficence may conflict:
Ethical Dilemmas

1. A terminally ill child is on life-support and has sustained brain damage. Based on evidence, doctors
opine that withdrawing life-support is in the ‘best interests’ of the child, as there is minimal chance of
them regaining consciousness. If they do, they are likely to suffer from severe cognitive and physical
disabilities. However, the child cannot decide as they are unconscious and would be too young anyway,
and the parents disagree with the doctors.
Ethical Dilemmas

2. A mentally ill patient is in crisis and is threatening to harm themselves and others. Crisis intervention
has been unsuccessful. It is now an emergency and a real risk to the patient and others. Mental health
professionals break confidentiality to inform the police who detain (sections) the patient under the Mental
Health Act 1983 for their ‘best interests’. The patient is detained and treated without their agreement for their
safety and others.
Ethical Dilemmas

3. An older patient has dementia and a water infection (urinary tract infection), which has caused delirium.
They are unable to communicate how they feel, but they need to get the correct treatments quickly, as
infections can speed up the progression of dementia . Because of the delirium, they cannot understand what
is going on or the treatments they need. As they have no family, doctors consult an independent mental
capacity advocate (IMCA) and make a decision to treat the patient as it is in their ‘best interests’.
Ethical Dilemmas
• Balancing ethical principles can be complex, as it requires assessing and analysing individual cases, carefully navigating them and
thoughtful decision-making based on available evidence and information. Healthcare professionals must balance non-maleficence,
justice, autonomy and beneficence, especially the latter principles, as they are all cornerstones in healthcare ethics.

• Patient autonomy and beneficence are enshrined in law and human rights. They are a part of healthcare ethics, rules and standards,
which healthcare professionals must follow to remain registered, to be on the right side of the law and to avoid negligence and
injury claims. One of the most shocking cases of autonomy violation was when a surgeon branded his initials onto two patients’
livers during surgery and was struck off from the register.

• Healthcare professionals can also find the balance challenging when they have to make decisions for patients and their families that
go against their wishes, preferences and beliefs, which can be distressing, even though it is for the good of a patient.
Approaches to
decision making at
the end of life
Approaches to decision making at the end of
life
• Principles and decision-making framework
• A person's right to self determination is the starting point to many
ethical dilemmas.
• Respecting autonomy has limits, brought into focus by the Mental
Capacity Act 2005 1 and the increased emphasis on patient choice.
• The doctor needs to recognise these limits, being mindful of the other
responsibilities: to benefit and not harm the patient, and to use
resources justly.
Truth telling
• Truth telling is fundamental to respecting autonomy.
• Most patients wish to have full information, although this may decrease as
they approach the end of their lives.
• A doctor should have the skills to identify the patient's preferences and give
the information honestly yet sensitively.
• Paternalistic withholding of a life-threatening diagnosis from a patient has no
place in current healthcare, unless this is the patient's informed preference or
they lack capacity to understand and use the information.
Respect for autonomy and choice
• Respecting autonomy does not equate to choice. To ask ‘Would you like to die at
home?’ offers choice.
• To explain all the implications of such a decision, ensuring the patient has capacity and
has appreciated all the important consequences, demonstrates respect for autonomy.
• The doctor has a responsibility to ensure decisions are based on autonomous action,
requiring full information, freedom from coercion and with the necessary capacity
rather than simple choice.
• With choice being such a popular drive behind healthcare policy today, this distinction
is key in end-of-life decision making.
Specific challenges in
end-of-life care
Withholding and withdrawing treatment:

Ethical dilemmas approaching the end of life commonly revolve around decisions to withhold or
withdraw interventions or treatment.
When the patient and doctor agree there is no benefit in carrying on or starting a new
intervention the right action is clear, though skill is required on the doctor's part to manage these
discussions sensitively.

Respecting the autonomy of a patient who is requesting to continue or initiate a treatment needs to be
challenged when it would result in overwhelming harm, an unnecessary and unequal distribution of
resources or an action that requires the doctor to act against a professional code or the law.

The legal position is clear that a patient cannot demand a treatment that is not in their best interests and
that doctors need not strive to preserve life at all costs. However, when there is doubt the presumption
must be in favour of preserving life
The doctor may be justified in withholding or withdrawing an intervention which as a
result allows death to occur in the following situations:
1- it is the patient’s autonomous decision to withhold consent for a life-saving
intervention
2- the harms of a treatment outweigh any potential lengthening of life
3- the potential treatment is ‘futile’ – it will not achieve its specified aim (although,
strictly speaking, a truly futile treatment would not, by definition, influence outcomes).
Ethical approach to such decisions. All doctors should be able to describe an ethical
approach to decisions to withhold or withdraw therapy that takes into consideration the
law, guidance from official bodies, the evidence base and the resources available.

They must be aware of the patient, their capacity, beliefs and preferences as well as their
clinical condition and outlook. The doctor must then formulate clearly the ethical question
being asked, ensuring that their own perspective is not influencing the way it is put.

This enables the options available to be established, including the moral justifications and
practical solutions
Cardiopulmonary resuscitation

Attempts at cardiopulmonary resuscitation (CPR) are unlikely to be successful in restarting the heart as patients
approach the end of their lives or, if they are, may result in a short period of significantly impaired quality of
life.Agreement should be reached among the multidisciplinary team that this is the situation and a decision
carefully recorded.
When CPR is considered a futile intervention, to discuss it with the patient would appear only to bring unnecessary
distress. Discussion is, however, required about the patient's understanding of their general situation and outlook.
An explanation that they are now dying may make further discussion about CPR itself irrelevant. A chance to air
fears or concerns and make plans for their death would seem far more useful discussions to have, but the needs of
patients who want to know more detail should also be met.
For patients dying at home it is likely that more explicit discussion of CPR is required for them and their relatives
to ensure emergency services are not called inappropriately.
NOTE :

Decisions not to attempt CPR refer only to CPR and should not influence other areas of
decision making. Each potential intervention may be considered on its own merit as part of
advance care planning.
Shared Patient
Decision-Making
 Shared Patient Decision-Making

Not that long ago, health care was characterized by a paternalistic mindset: medical professionals acted in what
they thought was a patient’s best interests without considering the patient’s wishes. This outdated practice has now
been replaced by a far more ethical approach.
An extension of patient autonomy, the concept of shared patient decision-making empowers patients by providing
the opportunity to work collaboratively with health care professionals to make important decisions regarding care.
Shared Patient Decision-Making

In shared decision-making, patient and provider work together to make decisions about tests, treatments,
procedures, and overall care strategy.
In a sense, shared patient decision-making is a form of informed consent, and vice versa. As with
informed consent, nurses and others engaged in shared decision-making with patients are responsible for
educating them about treatment and discussing various options with them.
Common end-of-life ethica
problems
Offering top-quality care while keeping patients’ wants and needs in mind should always be a
nurse’s top priority. This can sometimes seem blurred, however, if you’re dealing with an ethical
problem, especially at the end of someone’s life. Here are some of the most common issues you
may face during end-of-life care:
Common end-of-life ethical
problems

1. Broken communication

Whether a patient can no longer speak for him or herself or family members have a hard time describing
what their loved one wants, nurses may face the breakdown of communication during the decision-
making process. End-of-life conversations are always difficult, but they need to happen. Asking patients
early about their wishes and providing them with accurate information and resources ensures a clear line
of communication. Gaining perspective from a registered nurse allows prospective nurses to understand
the value of strong communication.
Common end-of-life ethical
problems

2. Compromised patient autonomy

The Patient Self-Determination Act (PSDA) aims to increase the ability of health care providers and
patients to communicate. It gives patients the right to voice their choices for end-of-life treatment, but this
stage of life may come with limitations. As a nurse, it’s vital for you to respect patient autonomy while
keeping in mind the best treatment route without compromising the patient’s decision. Nurses should
encourage patients and their significant others to discuss end-of-life care and to use advance directives so
patients’ wishes can be maintained if patients lose their ability to make decisions about their care.
Common end-of-life ethical
problems

3. Poor symptom management

Symptom treatment is a major factor in nurses caring for patients at the end of their lives, as it brings up the question of
whether the benefits of using medication outweigh potential risk and side effects.”The relief of symptoms must be
balanced with the possible side effects of medications,” Erickson told the ONS. “Fortunately, we now have so many
good treatments for symptoms. The key is knowing that there is always a need for balance and to keep focused on what
is in the best interest of the patient’s quality of life.”
Common end-of-life ethical
problems

4. Shared decision-making
Known as one of the most important factors of end-of-life care, decision-making becomes an ethical issue when
more than one party is involved. When significant others attempt to go against the patient’s wishes, nurses face
the issue of trusting the intent of the significant others or respecting the patient’s wishes. Advance directives, such
as a living will, medical power of attorney, Physician Orders for Life-Sustaining Treatment and DNR orders
should be considered in advance to present during the decision-making process.
Significant others and patients should prepare for situations that may have seemed otherwise out of their control.
This makes shared decisions easier if a patient becomes unresponsive about making an important decision on his
or her own.
“An important role of the nurse is to help patients complete advance care plans to guide their end of life care by
listening and offering necessary information,” said Erickson.
Review questions
Review Questions :

The dying patient with terminal liver cancer says to the nurse, Im going to take a long time to
die, arent I? Im going to get sicker and weaker every day. The nurses best response would be:

a. Your type of cancer is usually fatal in 4 to 6 months.

b. I dont want to hear this kind of negative talk. Make use of the time you have.
c. We have many medications that can make you feel better.
d. What concerns you the most about dying?

ANS: D
Using an open-ended question but being honest about terminal illness creates an interpersonal
environment for effective communication.
Review Questions :

The nurse is aware that hospice care can be made available to terminal patients who:

a. have a life expectancy of only 12 months.

b. are Medicaid-qualified.
c. agree to palliative measures.
d. are hospitalized.

ANS: C
Hospice is a Medicare-funded program for the provision of palliative care for persons who have
6 months or less life expectancy. The service is extended to qualified persons at home, in a long-
term care facility, or in the hospital.
Review Questions :

The nurse notes that a cardiovascular sign of impending death is:

a. Cheyne-Stokes respiration.
b. bounding pulse.
c. bluish mottling of extremities.
d. widening pulse pressure.

ANS: C
As death approaches, there is vasoconstriction to the extremities to keep blood going to the heart
and brain. This causes mottling of the extremities. Bounding pulse and widening pulse pressure
are not seen in the dying person.
Review Questions :
The nurse emphasizes that the objective of pain control for the dying patient is to:

a. keep the patient unconscious and relaxed to avoid the perception of pain.
b. delay medication until the patient reports that the pain is intense.
c. find a control level that reduces pain but allows the patient to interact.
d. eradicate pain completely.

ANS: C
Finding a level of pain control that allows the patient to participate in care and communicate with
family is the goal of pain control. Analgesics given before pain becomes intense can keep pain at
a moderate level.
Review Questions :
To reduce the threat of aspiration in the unconscious patient who is near death, the nurse
should:

a. perform deep tracheal suctioning of the patient every hour.

b. place the patient in a side-lying position, with the head turned to the side.
c. slightly elevate the foot of the bed, with the patient in a supine position.
d. give the patient only thickened fluids

ANS: B
Side-lying is a safe position for reducing the threat of aspiration. The supine position is not
appropriate for aspiration reduction. Frequent suctioning is stressful to the patient, and fluids are
never attempted for an unconscious patient.
Review Questions :
Because of diminished vision in the person who is dying, caregivers should:

a. keep lights bright to increase visual acuity.

b. stand slightly away from the bed and identify themselves before speaking.
c. keep all lights on in the room, day and night.
d. come close to the bed and stand directly in front of the patient.

ANS: D
Putting oneself directly in front of the patient, as close as possible, helps the patient with
diminished vision identify the speaker.
 Thank you
Resources :
Regis College
https://online.regiscollege.edu/blog/ethical-dilemmas-in-nursing/
Royal Collegeof Physicians
https://www.rcpjournals.org/content/clinmedicine/10/3/282
BRADLEY University
https://onlinedegrees.bradley.edu/blog/what-ethical-issues-can-arise-with-end-of-life-care/
OnlineLearning College
https://online-learning-college.com/knowledge-hub/care/healthcare-ethics-balancing-autonomy-beneficence/