In this case, the three important ethical issues to consider are ethical distress, ethical dilemma, and locus of control. I believe that ethical distress is one of the main ethical issues in this case since the patient desires to remain on a ventilator to avoid losing her life. She makes it very clear to the staff that she wants to live by interacting with them and answering “no” when asked if she wants the tubes to be removed. On the other hand, her primary care physician along with two of her close friends insists that she’d be taken off the ventilator.
They believe that she is currently confused, and that she would have never agreed to remain in that situation if she was aware of it. An ethical dilemma is also present when the critical care team believes that beneficence is the right choice, while the patient’s primary care physician believes in autonomy based on the patient’s original will. A locus of control is also seen in this case since the primary care physician is the one in control of the situation.
While the critical care unit along with the neurologist believe that the patient has the potential to recover from her state, the primary care physician with support from the psychiatrist try everything to comply with the patient’s will. He ended up transferring the patient to another hospital in order to be able to comply with the will since the critical care team would not allow him to do so. The three ethical principles that seem to be of most relevance in this case are beneficence, fidelity, and autonomy.
In regards to the patient, I believe that beneficence and autonomy apply to her situation because she was alert and oriented. Although she was diagnosed as “confused” by the psychologist, she kept answering “no” when asked if she wanted the ventilator to be removed, thus, demonstrating that she understood the meaning of that action. The critical care team honored beneficence and fidelity when they argued with the primary care physician about removing the patient from the ventilator. They believed that she was able to make her own decisions, and that we should respect her current wishes.
Autonomy and fidelity were honored by the primary care physician since he believed that the patient was confused, thus, not able to make conscious and reasonable decisions. He decided to carry on and defend the patient based on her previous living will along with the opinion of the patient’s two best friends. One of the nurse’s main duties is to be a patient’s advocate. The rules of deontology include stating the predominate principle, knowing that duty more important than outcome, having in mind that the only person who counts is the individual, and know that we cannot show any emotion.
In this case, the predominating principle is autonomy over beneficence. By honoring autonomy, the nurse would respect the patient’s wishes; however, the patient stated in her living will that she would like to be taken off the life support. Currently, she is also indicating that she would like to remain on the life support measures, which in this case is the ventilator. The patient has two contradicting wishes, so it is important to be clear about which autonomy should be honored.
In this case, since the patient’s most current wish is to remain on life support, it is the nurse’s duty to support and advocate on the behalf of the patient’s wishes. Moreover, the patient was diagnosed with manic depression when she executed her living will, which means that it may not be valid. In that case, the nurse can carry out the patient’s current request without having the feeling that they are disregarding their duty. As a result, the nurse is fulfilling her duty, which is more important than the outcome. This decision is solely focused on the individual, which is the patient.
The patient’s friends, physician, and the critical care team are not the focus of this case. Regardless of what decision the nurse made, he or she did so using an ethical rationality and his or her emotions did not interfere with the choice making. The right thing to do is to follow the patient’s current wishes, which in this case, she does not want to be taken off the ventilator. As a nurse, I would advocate for my patient. I would allow her to remain on life support mechanisms until the day she decides her time has come. I believe that since she was already diagnosed with maniac
depression at the time she wrote her will, nothing tell me that she still feels this way today. Her ways of thinking may be different than they were back then. In my opinion, the best outcome for the patient is for her current wishes to be fulfilled. She is currently alert and oriented, interacts with the staff, and responds “no” when asked if she wants to be taken off the ventilator. The rules of teleology include stating the predominating principle, knowing that outcome is more important than duty, that the good of the “whole” is the one that counts, and that no emotions are tolerated.
In this case, the predominating principle is beneficence over autonomy. Since we are focusing on the outcome over duty, the idea of a “white lie” can be done by rejecting the patient’s living will as the patient has been diagnosed with manic depression, hence she is not stable enough to make a responsible decision. Moreover, the patient wants to remain on life support, meaning that her best outcome would be to sustain her as well as respecting her wishes. However, there are other people taking part in the case whom might play a role in this decision-making.
In this case, we have to think about whom are the stakeholders. If those other people were the stakeholders, then the “whole” would be them and the patient. However, if they were not the stakeholders, then the “whole” would be the patient. In terms of benefit and loss and by knowing what their relationship is to the patient, I can or cannot designate them as a whole. By focusing on the outcome, I would disregard the patient’s living will and comply with her current wishes, which is the sustainment of life support.
In this situation, the “whole” is the patient before the incident, as well as the patient in the condition she is right now. In this situation, the main stakeholder is the patient. However, other stakeholders include the critical care team along with the primary care physician. The person who has the most to gain and to lose is the patient herself. She could gain her liberty to live, gain her life back, while at the same time, she could lose her life. It is hard for me to decide whether the patient’s two best friends are also stakeholders since they were not included in the patient’s living will.
It is hard to decide whether they have a lot to lose or gain, apart from a friend. They could very easily lose a best friend by enforcing the patient’s original living will. The patient’s primary care physician insists on following her original living will. He could easily lose a patient, meaning that he would not be responsible for her after her death. We cannot know for sure if he wanted to act in the best interest of the patient or his. He could very easily be doing this from annoyance with this patient, wanting for that burden to end.
The critical care team is also named as stakeholders since they could have an emotional connection as well as a reputation to hold. They try their best to keep that patient alive since it is their duty as a critical care team while at the same time, although it is not allowed in decision-making, they were able to develop an emotional connection with the patient from the time she spent on that unit. I feel that the fact that the patient does not have a husband, any children, or any relatives alive makes this ethical situation unique, although it probably happens very often.
However, the fact that this patient is fighting for her life, fighting her primary care physician from taking her life-support measures away is unique. I believe that the most unique feature of this case is the fact that the patient contradicts herself in her decisions. First, she wrote a living will stating that she does not want any extraordinary life-saving measures; today, she refuses to follow her own living will and insists that she remains on life-support. In this situation, primary care physician is guiding his care and decision based on the patient’s living will that was written over five years ago.
The patient has also been diagnosed with manic depression, which does not make this living will trustworthy to the hundred percent. The fact that both of her life-long best friends are supporting her living will decision instead of her current decision also makes this situation quite unique. I believe that the patient’s primary care physician and best friends might think that she is currently unable to make appropriate decisions based on her status, but the patient is probably more aware of her situation now than ever in the past.
The conclusion I reached for the deontology theory ended up being the same one as my teleology one. I utilized two different methods to determine the best outcome for my patient, and the best way to treat her care. The final conclusion that I obtained was to keep my promise to the patient by fulfilling her current wishes in continuing her life support measures. As a nurse, it is my duty to respect my patient’s current will and best outcome. By using the teleology theory, I am favoring my patient’s outcome over my duty as a nurse.
Since the predominating principle is beneficence over autonomy, my duty as a nurse would be to reject the patient’s living will since she has been diagnosed with manic depression; hence she is was stable enough to make a responsible decision when she wrote that living will. By using the deontology theory, I am favoring my duty as a nurse over my patient’s outcome. Since the predominating principle is autonomy, my duty would be to fulfill her request and let her remain on the ventilator since it is her most current wish.
The most important and best outcome for my patient in both theories is for her to live. As a client’s advocate, I would comply with her current living will, not the one that is on file. If the patient is alert and oriented, if she is able to interact with the hospital’s staff, and if she is able to accurately answer “yes” or “no” when asked if she wants to keep her life-saving measures, then I would comply with her wishes. As an effort to stop the patient from being transferred to another facility, I would ask to have a meeting with the ethics committee.
I would ask to re-assess her mental status, ask to see a copy of her official living will, where and when it was written, in what condition she was when it was written knowing that she has a history of maniac depression. I would make sure that she wasn’t suicidal or depressed when she wrote that living will. Based on the information that she changed that living will twice in the past, I would enforce a review and assessment by several different healthcare practitioners. References Dresser, R. & Astrow, A. An Alert and Competent Self: Hastings Center Report, Vol. 28, Issue 1, p. 28, (1998)