The Role of a Nurse
The Role of a Nurse
The code of professional conduct aims to equipped the nursing profession the highest standard of care possible to service users and to be their advocate .Nurses are more accountable for their actions and decision making due to modern medicine and society. It is important for the nurses to promote the image of people with intellectual disabilities that they are not second class citizens and they deserve to have equal rights to treatment and care. The purpose of this code is to provide a framework to assist the nurse to make professional decisions to carry out his/her responsibilities and to promote high standards of professional conduct. Nurses rule ABA (2000) Nurses in Ireland work under the scope of practice. To be competent in their field, to promote awareness of health promotion. Educators and obey and implement each framework and policy in aid of promotional care. Each decision is made by management then discussed within the multidisciplinary team.
Nurses are increasingly being given more authority and responsibility, so it’s necessary for nurses to question these powers especially when it relates to the care of the intellectual disabilities. Dokkum(2005,p.65) states that “the nurse is often called upon the patient advocate, caught in the middle of a power struggle between the doctor and the patient, and therefore the nurse must be aware of the dynamics of this power relationship, and the manner in which the law attempts to deal with it” When it comes to euthanasia the multidisciplinary team are in a difficult position. Effective communication and thorough procedures is necessary to deal with a complex decision. Under the Irish constitution, article 40.3 1l. The state guarantees in its law to respect, and as practicable, by its laws to defend and vindicate the personal rights of the citizen. Even if that citizen has an intellectually incapacity, the they have the right to speak their values beliefs and the nurse should provide up to date resourcements to help educate and to solve decisions.
Communication and education is essential to help aid the reasoning of euthanasia and reasons why service users express their reasons for wanting to end their life. They are in a lot of pain suffering and don’t fully comprehend their decision. It’s the nurse’s role to satisfy the needs of the service user while providing a rational and logical account of the reasons underpinning that decision. As Caulfield (2005 p32) suggests: ‘personal values held by an individual nurses are often subsumed by the need to be professional at all times as a nurse.’ Nurses play key roles in caring for people at the end of life. These roles involve assessing and managing pain and other symptoms; addressing psycho-spiritual needs; assisting patients and families in articulating their values, goals, and beliefs that influence the decisions made at the end of life; discussing treatment choices; and helping patients and families communicate their needs and wishes for care at the end of life.
Many resources are available to guide nurses in fulfilling these roles. Unfortunately, there are fewer resources to provide direction regarding assisted death. One reason for the deficiency of information is that much of the literature focuses on the role of physicians in assisted death. Another reason is that it is difficult to provide guidelines for clinical actions that are illegal in most jurisdictions. Moreover, many professional nursing and hospice organizations have published statements against the legalization of and professional participation in assisted suicide and euthanasia. These statements, while offering valuable perspectives, often are less useful in guiding clinicians in responding to requests for assistance in dying and for those practicing in Oregon and other places where assisted death is legal. Other published statements are neutral in their approach and tend to focus on maintaining an open dialogue and helping clinicians consider their responses to the issue. Several surveys have documented that nurses in diverse geographic and clinical settings receive requests for aid in dying. [19, 64–67] Asch  reported that approximately 17% of the 852 critical care nurses who responded to an anonymous, mailed survey said that they had received requests from patients or family members to perform euthanasia or assist in suicide.
Matzo and Emanuel  mailed anonymous surveys to a random sample of 600 registered nurses who were Oncology Nursing Society members. Thirty percent of the 441 respondents (75% response rate) reported that they had received at least 1 request for assisted suicide and 25% indicated that they had received at least 1 request for euthanasia. In Oregon, approximately 40% of hospice nurses responding to a questionnaire stated that they had cared for a patient who had explicitly requested assisted suicide since November 1997, when the Death with Dignity Act went into effect. Ferrell et al received 2,333 responses to an anonymous survey that was completed by a random sample predominantly comprised of oncology nurses. They reported that most respondents opposed the legalization of assisted suicide (70% opposed) and euthanasia (77% opposed). Since becoming a nurse, 20% had received 1 or more requests to assist patients in obtaining a prescription to end their lives and 22% had received requests from patients to administer a lethal injection to end the patient’s life.
In addition to receiving requests for assistance in dying, some nurses have apparently participated in this practice. Approximately 16% of Asch’s respondents stated that they had engaged in euthanasia or assisted suicide. Scanlon questioned the validity of the instrument and pointed out that the definitions for assisted suicide and euthanasia were vague. Moreover, she argued that some of the examples that Asch presented as euthanasia involved the administration of opiates to dying patients, a practice that generally is considered different from assisted death and morally acceptable. Matzo and Emanuel’s study circumvents many of these issues.
These investigators reported that 1% of nurse respondents stated that they had “…provided or prescribed drugs to a patient knowing the patient intended to use them to end his or her own life.”(p1729) Four and one half percent of those responding (20/441) stated that they had “injected drugs to intentionally end a patient’s life.”(p1729) Ferrell et al  found that approximately 3% of their sample had assisted 1 or more patients to end their lives by helping them obtain a lethal dose of medication, and 2% had administered a lethal injection in response to a patient’s request.
Three percent also reported that they had administered at least 1 lethal injection to a patient without a specific request. These studies highlight important issues. First, nurses are witness to tremendous suffering; they must be supported and educated in the ways to ameliorate suffering. They must also explore and identify their own responses to this suffering and practice self-care. If nurses do not identify their own distress, they will be unlikely to identify accurately whose suffering is being addressed through assistance in dying.  Second, the studies uncovered some confusion on the part of the respondents as to the differences among assisted suicide, euthanasia, and relief of suffering.
This confusion has been reported by other investigators. [4, 5, 70] If clinicians are unable to discriminate among these actions, they may unknowingly act in ways that place them at risk for unanticipated emotional and legal consequences. Schwarz  elaborated on this risk by describing nurses as “delegated providers” of assisted dying. At least one study has documented that physicians sometimes delegate to nurses the task of injecting lethal doses of medications to dying patients. 
In responding to this study, Schwarz posed several important questions. Did the nurses to whom these physicians delegated the task follow the physician’s order? If so, did they think about the legal and ethical implications of their actions? Was there open discussion regarding the decision to provide the lethal injection? Did the nurses consider whether or not they were obligated to administer the injection?  Third, nurses need guidance in discerning the moral and legal distinctions among various nursing actions at the end of life. They also need support in dealing with these difficult clinical situations and making their own decisions about specific interventions. This need is underscored by Matzo and Schwarz, who reported that 25% of nurses responding to their survey included written comments, many of which reflected the uncertainty and distress that nurses experience in the “gray and persistently uncomfortable” Third, nurses need guidance in discerning the moral and legal distinctions among various nursing actions at the end of life. They also need support in dealing with these difficult clinical situations and making their own decisions about specific interventions.
This need is underscored by Matzo and Schwarz, who reported that 25% of nurses responding to their survey included written comments, many of which reflected the uncertainty and distress that nurses experience in the “gray and persistently uncomfortable”(p67) area of relieving pain at the end of life. Finally, guidance is warranted to help nurses make ethical decisions that honour individual differences. Some nurses will decide to participate in assisted death regardless of the possible professional and legal sanctions. Others will choose not to participate in the legalized practice of assisting a patient to die. Nurses in both situations need to understand their rights, as well as the legal and ethical implications of their actions.  One fundamental step in helping nurses to make moral and legal distinctions about end-of-life nursing care is to describe specific roles and actions in responding to a patient’s request for assistance in dying. Scanlon was one of the first nurses to address this important issue. In several publications, she elucidated 6 key actions in responding to patient requests. [30, 72, 73] Figure 2 outlines these actions.
Scanlon asserted that the first 5 actions—dialoguing, assessing, evaluating the request, witnessing, and remaining—are all within the realm of nursing practice and, when carried out in a neutral manner, would generally be ethically justifiable. A neutral manner is one in which coercion, encouragement, or disengagement does not occur. In contrast, the last group of actions, ones that fall into the category of facilitating, are less likely to be ethically justifiable in the framework upon which the ANA Position Statements on Assisted Suicide and Euthanasia are based.[11,12,73] Although Daly et al imply that designating the actions listed under “facilitation” as morally unacceptable is arbitrary, Scanlon’s framework begins to address the real-life issues and decisions that nurses make and will continue to make regarding assisted death. Clearly, more reflection and discussion is needed to help nurses make choices and act in ways that are ethically and legally coherent while also addressing the individual values and morals of the clinicians involved. 
Other authors have described nursing roles in assisted dying. Scanlon and Rushton  elaborated the role of the nurse in assessing the patient who requests assistance in dying. Nurses should assess the person’s decisional capacity and determine whether or not the person can fully understand his or her options and the consequences of acting on the request. This information needs to be communicated to team members and family. Also important is the psychological state of the person making the request. Is the person suffering from unmanaged physical symptoms such as pain? Is the patient depressed? Untreated symptoms such as pain and depression need to be treated first. Another component of the assessment is to evaluate the context of the request; areas to include are the patient’s financial situation, spiritual and cultural influences, and the family’s attitude and response to the request.The Oregon Nurses Association (ONA) adapted the roles in light of the Death with Dignity Act. The ONA identifies specific acceptable and unacceptable actions, both for nurses who choose to participate and those who do not wish to participate in assisted suicide.
Another view on nursing roles in assisted death comes from Faber-Langendoen and Karlawish, physicians who challenged the idea that assisted suicide should only be “physician-assisted.” In this controversial, thought-provoking article, the authors argue that assisted suicide is best seen as a multidisciplinary issue, one in which nurses and other non-physician clinicians play important roles. They identify 7 central roles in providing assisted suicide and cite reasons why physicians often are not the best healthcare providers to assume many of these roles. Instead, the authors contend that nurses are well suited to fulfil most roles, including (in states that grant full prescriptive authority to advanced practice nurses) prescribing the lethal dose of medication. Nurses and nursing organizations must respond to this and other calls for expanded nursing roles by identifying and articulating the profession’s perspective on this issue.
Moreover, they should address an important issue that was raised but not fully addressed in Faber-Langendoen and Karla wish’s article. That is, are nurses being asked to extend their responsibilities in assisted death because they are better prepared and positioned to assume these roles, or because there may be a shortage of physicians willing to participate in assisted death?The preceding discussion underscores another role for nurses. As individuals and as a profession, nurses should take an active role in advocacy and policy development regarding assisted death and other end-of-life choices and practices. This involvement is important to ensure that patients have access to the full range of options at the end of life. It also is important in assuring that nurses, individually and collectively, direct the nursing role in end-of-life care and assisted death rather than allowing others to define it for us.|
Although nurses must consider the professional and societal perspectives regarding assisted death, ultimately, the individual clinician must decide for himself or herself whether or not to support and participate in assisted death. This decision requires careful ethical discernment, which includes sociocultural, professional, religious, family, and personal influences. Hospice and palliative care nurses need to develop their own moral stance on this issue, one that honours their personal values and beliefs while also considering professional and societal views.To find one’s voice regarding assisted death requires reflection on the meaning of suffering and death. Why does suffering occur? What happens when we die? What is meant by a “good death?” Given the answers to the preceding questions, where do assisted suicide and euthanasia fit (or not fit)? A detailed discussion on these enormously complex philosophical issues is well beyond the scope of this article.
However, guidance often is found within one’s religious and/or spiritual beliefs. Additional perspectives can be found in texts[57,74–76] and other writings.[77–80]In addition to offering a perspective on the nature of suffering, life, and death, many religions take official stands regarding withdrawing and withholding therapies at the end of life, assisted suicide, and euthanasia.  These viewpoints probably have marked influence; people who report strong religious beliefs are less likely to support assisted death.[1,66,82] Therefore, religion is a source of direction when considering the ethics of assisted death.Culture may also influence one’s views about end-of-life treatment options, including assisted death. [83-85] For example, Caralis et al  found that non-Hispanic Caucasians are more likely to want assistance in dying than Hispanics or African Americans. The reasons for these differences are unclear. Religion may play a role in determining attitudes. Distrust of the American healthcare system, which has been reported for African Americans, may also shape a person’s views of assisted death.[86,87]Professional viewpoints also must be considered.
It has been mentioned that several nursing and medical organizations have published position statements on assisted death, most of which oppose assisted death. Interestingly, these statements run counter to findings that suggest that many nurses support assisted death and that some participate, legally and illegally. In contrast to laws, position statements and professional codes of ethics are not legally binding; however, they do provide a standard from which to evaluate nursing actions. Therefore, it is imperative to familiarize oneself with these statements, realizing that they may assist a court or regulatory body in deciding what actions constitute or violate professional standards of practice.One aspect of upholding one’s personal morals is to recognize the right to conscientiously object to a specific practice. The principle of conscientious objection justifies an individual’s refusal to participate in an act because it violates his or her religious or moral beliefs. Using this right, nurses and other clinicians can decline participation in legally sanctioned clinical activities, such as abortion, or in Oregon, assisted suicide.
The Oregon Nurses Association has outlined recommended guidelines for nurses who choose not to participate. They should ensure that the patient’s care is transferred to another nurse who is able and willing to participate. Nurses also should respect the choices made by patients and their healthcare colleagues regarding assisted death. Finally, the confidentiality of patients and clinicians involved in the care should be maintained.In contrast to nurses who choose not to participate in legal actions (e.g., nurses in Oregon who choose not to participate in assisted suicide), there are nurses who will decide to participate in assisted death illegally. Civil disobedience requires that the person engaging in unlawful acts can justify his or her actions.  One clinician who has practiced civil disobedience is Jack Kevorkian. Kevorkian currently is serving a prison sentence for his repeated violations of Michigan’s law prohibiting euthanasia.
He was convicted of murder. His conviction is a reminder that clinicians who violate laws against participation in assisted death risk civil and/or criminal prosecution, loss of license, and imprisonment.[71,89] Nurses who support assisted dying, including those who commit acts of civil disobedience by participating in it, also have a duty to acknowledge their views publicly and work to change existing laws and policies.[71,90]One of the most important considerations in making personal choices about whether or not to support or participate in assisted death is eloquently described by Thomasma.  He reminds us that examining our intention is a crucial consideration.
Many authors argue that having the primary intent to relieve suffering is the only moral stance that can justify assisted death. Certainly, one can easily see that to end a patient’s life for other reasons (e.g., financial gain or revenge) would be immoral. Thomasma  insists, however, that we must carefully evaluate whose suffering we are attempting to relieve. The patient’s suffering? The family’s suffering? Our own suffering? According to Thomasma,  only an intention to relieve the patient’s suffering can ever be considered moral. Even when we are moved with compassion and sympathy for another person, we must be aware of our intentions.
University/College: University of California
Type of paper: Thesis/Dissertation Chapter
Date: 21 October 2016
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