FINAL EXAM

REVIEWER
NCM 108
• If pt is terminal but death is not imminent but the disease
is progresses slowly and granted the consent of the
pt/fam, it appears ethical to omit the treatment on the
ground that nothing can be accomplish in beating the
disease

• But it is NOT ETHICAL to omit Care , since human

dignity is to be respected
 DISCONTINUING treatment: Terminally ill
• Ethical Reasons:
• Health care provider has no obligation to prolong dying merely
for the sake of prolonging it.
• When treatment is only prolonging the agony of the patient, its
continuation is unethical as an insult to human dignity

• In such cases, the health care provider would be ethically

justified in D/C tx except when the pt insist tx,
Exceptions:

• Severe shortage of medical resources, the physician may

be justified in stopping nonindicated treatment, a shortage
really exist
• A problem in D/C if Fam objects
DIGNITY IN DEATH AND DYING

• It is always the obligation of the physician/ health care

provider to ensure that the patient receives proper
continues care.

• This obligation to care for the patient demands that every

ethical effort be made to alleviate these sufferings with
drugs and other methods that will not prolong life.
 FEEDING AND HYDRATION
• are nutrition and hydration medically indicated for terminal
patients?
• We are dealing medical procedures not with simple task of daily
living.
• the physician should determine whether the benefits of treatment
outweigh its burdens.
• At all times, the dignity of the patient be maintained
• The AMA Council on Judicial Affairs expressed the emerging
consensus/agreement that it is not wrong to withdraw these
treatment under appropriate circumstances:

• 1. the procedures are futile, since the procedures are unlikely to

achieve their purpose
• 2. the procedures would be no help to the patient even if
successful
• 3. The burden outweighs the benefits
• E.g.pp 98-99
Nutrition and Hydration

• Omission is based on the ethics of medical indications and

not on common sense notion
• N & H probably can not be withdrawn in time of sedation in
competent pt
• In some cases N&H are indicated on the compassionate
ground that such a death is sometimes painful than death
from particular disease
• Each case must be evaluated individually
• , and ultimately the choice of the manner of death belongs
to the competent patient.
 Cooperation with the refusal of nonterminal Patient
• The most emotionally difficult case s arise when the patient
refusing treatment is not terminal.
• It occurs when the pt chooses not to live at a level below his
ideal (not worthwhile living in respirator forever or fed artificially)

• In this cases, treatment is medically indicated from the care

provider’s point of view, but does not produce proportionate
good from the pt’s point of view

• Regardless of the emotional turmoil suffered by the provider,

the patient retains the right to refuse treatment
• Only a court order or court-appointed guardian has the
right to overrule the patient in these case

• The justice of even such court rulings is not beyond

question if the death will not injure society or third parties
• In case, the patient refused food and drinks, but asked to
be made comfortable in the hospital while she starved to
death.
• The healthcare provider can ethically refuse to cooperate
in such situations, not only on the ground of individual
conscience, but also the health care professions should
not be involved in helping nonterminal pts to shorten their
lives significantly
• continue care - abandonment
 PHYSICIAN INITIATIVE

• The Dr. is obligated:

• to take initiative in discussing termination of care for the pt
• Inform completely and clearly about pt’s condition inorder to
obtain consent for treatment
• To provide treatment that does not harm the patient
• Treatment that is not reasonably likely to work should not be
provided , it misleads the pt and waste resources
• These considerations lead to the issues DNR orders
 Difficult Decisions in End-of-life care
• Some of the difficult decisions that patients often need to make
in end-of – of life care:
• 1. Withholding/withdrawing of medical interventions
• One of the dilemmas that can occur relates to the cessation of medical
interventions in patients. Sometimes these interventions range from
minor, such as a non-life sustaining medication, to more complex, such
as mechanical ventilation. The rationale for stopping these interventions
is often based on the fact that the burdens are outweighing any benefits
the patient may get from it. Sometimes life-sustaining therapies may
prolong suffering at the cost of decreasing the patient’s quality of life.
• If a family member knows for sure that their loved one
would not have wanted a particular medical intervention
done, it may help to alleviate some of the burden they may
feel about making the decision. It also helps prevent the
initiation of some life sustaining treatments beforehand, in
which case no decision will be need to be made to withdraw
that intervention. It also can help reduce overall costs of
futile medical care (Coyne, Smith, & Lyckholm, 2010).
 2. Do not attempt resuscitation (DNAR)
• Electing to have or not to have CPR is a difficult but common
medical decision that patients nearing the end of life often
make. The success rate of CPR has been low, around 18%,
among all hospitalized patients who arrest over the past 50
years (Berry & Griffie, 2010), and it is well known that the
percentage is even lower among patients with advanced
illnesses such as terminal cancer or end stage heart failure. A
“do not intubate” (DNI) order often accompanies a DNR order,
which states that the patient elects not to be intubated with a
breathing tube if they go into cardiac arrest. Chest
compressions and the use of cardiac medications could still be
used.
3. Allow natural death (AND)

• Allow natural death is a more recent terminology some

health care institutions have adopted to use instead of the
traditional DNR orders. Whereas a DNR order states that
no attempts should be made to start CPR in a patient, an
AND order states that only comfort measures are taken to
manage symptoms related to comfort. An AND order
simply allows the patient to remain comfortable while not
interfering with the natural dying process.
4. Medical order for life sustaining treatment
(MOLST)
• Sometimes also referred to as physician order to life-
sustaining treatment (POLST), these newer forms of
advance directives were developed in order to improve
the communication of a patient’s wishes about life-
sustaining treatments among healthcare providers and
settings. It is currently in use in 26 states across the
United States (Polst Organization, 2014).
 5. Hastening death (Principle of double effect)
• The principle of “double effect” refers to some decisions that
clinicians have that will produce both desirable and undesirable
effects (ELNEC, 2010).
• The example given earlier for non-maleficence, in which the
nurse administers a pain medication in order to alleviate a
patient’s pain and suffering but this same intervention may also
contribute to a hastened death, is also an example of “double
effect.” The medication will reduce the pain but also further
reduce the patient’s respiratory rate to a level that is
inconsistent with life
• . In the case of double effect, the nurse or clinician should
always consider what the intended effect of the
intervention is. Is the pain medication being administered
to reduce pain and suffering, or is it being given to further
reduce the patient’s respirations?
 6. Terminal/palliative sedation
• Terminal sedation (more recently called “palliative sedation”) is
an intervention used in patients at the end of life, usually as a
last effort to relieve suffering (Knight & Espinosa, 2010). It
involves sedating the patient to a point in which refractory
symptoms are controlled. The goal is to control symptoms,
and the patient is sedated to varying degrees of
consciousness to achieve this. The intent is not to cause or
hasten death, but rather to relieve suffering that has not
responded to any other means. Often the patient is sedated to
a point at which they are unconscious. Table 8.1 shows the
four criteria required for a patient to be considered for
palliative sedation.
 Criteria Required for Palliative Sedation

• Patient has a terminal illness

• Severe symptoms present are not responsive to treatment and
intolerable to patient
• A “do not resuscitate” order is in effect
• Death is imminent (hours to days)

• Palliative care is specialized medical care for people living with a serious
illness, such as cancer or heart failure. Patients in palliative care may
receive medical care for their symptoms, or palliative care, along with
treatment intended to cure their serious illness.
End of life care and role of nurses

• PRIMARY PT
• SECONDARY

• Nurses are responsible for recognizing patients' symptoms,

taking measures within their scope of practice to administer
medications, providing other measures for symptom
alleviation, and collaborating with other professionals to
optimize patients' comfort and families' understanding and
adaptation.
• Generally speaking, people who are dying need care in four
areas:
• physical comfort,
• mental and emotional needs,
• spiritual needs, and
• practical tasks.

• Of course, the family of the dying person needs support as

well, with practical tasks and emotional distress.
• Nurses’ role in end-of-life care
• Nurses are a vital part of end-of-life life care, with general
responsibilities including:

• Assessing anxiety levels of patients and other mental and

emotional states
• Determining levels of perceptual or cognitive impairment,
as well as physical fitness
• Evaluating the progress of a patient’s disease or condition
• Aiding the families of patients to solve any issues that may
result from end-of-life care
• To meet these needs properly and professionally, a nurse
should have training in end-of-life care. This preparation for
dealing with death may include:
• Assessment skills: Every nurse should be able to assess the
patient’s needs and progress, as well as take note of every
discussion and expressed desire.
• Communication: The nurse should initiate or take part in
discussions that pertain to death and dying with the patients
and families.
• Coordination: A clear sequence and outline of the needs and
treatment of the patient is necessary.

• The nurse must have a coordinated record to avoid confusion

or lapses in treatment if another nurse takes over treatment
and patient care.
• Self-care: Every nurse should be passionate and sensitive
regarding their patient’s end-of-life care. However, they should
also extend this sensitivity to themselves. By focusing on their
own physical and mental health outside of patient care, they will
be better able to guide the emotions of their patients and patient
families. Certain mental health strategies for anyone involved in
end-of-life care include anticipatory grieving and mindfulness.
• The impact of death on nurses can often be ignored. However,
by better understanding and preparing for end-of-life care,
nurses will be ready for any challenge.
• Ethical issues in end-of-life care
• In anticipating all aspects of nursing care, the nurse needs to
know that legal issues may arise—especially in end-of-life
care. Some ethical and legal challenges include:

• Broken communication: Nurses may face this challenge during the

decision-making process, as the family and patient may find it difficult to
explain what they want.
• Shared decision-making: When a patient’s partner tries to go against
the patient’s wishes, the nurse may have to include other forces like
medical power of attorney, living will, and Physician Orders for Life-
Sustaining Treatment (POLST) to enforce the patient’s will.
• Poor symptom management: Every drug prescribed to
manage a symptom must have a benefit that outweighs the side
effects. Nurses must assess the best treatments for drug-
symptom balance.
• Patient autonomy: It is crucial to have regard for patient
autonomy, although, at this stage of life, it may have limitations.
You must be able to render the best end-of-life care to your
patient within their will.

• When a nurse is aware of all the possible hurdles they may face
in end-of-life care, they will be better prepared and ready to
offer the best possible care.
Application of the Principles of Bioethics
• Approach 1. Save the Youngest

• In choosing this, it maximizing the life span for the most

number of people
• It relates to the principle Maximize Benefits and Minimize
Harms aka (non-maleficence)
• Approach 2. Draw Straws

• ( or any randomize technique)

• This option values fairness

• It relates to the principle Justice

• Approach 3. Save the Weakest

• This option considers the special needs of vulnerable

population

• It relates to the principle Respect for Person or Autonomy

• Approach 4. Save the Most Useful

• Saving someone who maybe able to save others benefits

a larger number of people

• This relates to the principle Maximize Benefits and

Minimize Harms aka (non-maleficence)
• Approach 5. Respect Relationships

• Honoring the dignity of human beings acknowledging their

relationships

• This relates the principle Respect for Persons

• This approach also relates to care, an additional principle

which can be used alongside the other principles mentioned
The PREAMBLE of the Nursing code of ethics
SECTION 1.
Health is a fundamental right of every individual. The Filipino
registered nurse, believing in the worth and dignity of each
human being, recognizes the primary responsibility to
preserve health at all cost. This responsibility encompasses
promotion of health, prevention of illness, alleviation of
suffering, and restoration of health. However, when the
foregoing are not possible, assistance towards a peaceful
death shall be his/her obligation