1. Module 4 Ethical Issues in Palliative Care Nursing
Core Curriculum
Module 4 Ethical Issues in Palliative Care Nursing

2. Sound Familiar?
36-year old wife and mother of 3 refuses further chemo for stage 4 ovarian cancer. Husband insists chemo continue.
58-year old man with ALS refuses ventilator and peg tube placement.
78-year old woman with dementia and Parkinson’s rushed to ER from nursing home without attention being paid to her advance directive. Family is furious that she is now on a ventilator.

3. Sound Familiar? (cont)
Patient confides in you that he does not want any further hospitalizations/treatment for stage 4 prostate cancer, as he knows he will bankrupt his family. Oncologist insists on clinical trial.
52-year old woman with heart and renal failure + diabetes has been admitted to the hospital 4 times in as many months. You have asked the cardiologist for a palliative care consult—she refuses.
32-year old man with sickle cell disease, begs you to help him commit suicide so he can be free from pain.

4. Responding to Ethical Issues in Palliative Care
Ethical dilemmas emerge daily
Changes in social/family systems have added to complexity of care
Landmark cases influence legal/ethical history
Attention to help patients make fully informed decisions

5. Common Ethical Dilemmas in Nursing
Euthanasia, Assisted Suicide, and Aid in Dying
Nursing Care and Do Not Resuscitate (DNR) and
Allow Natural Death (AND) Decisions
Forgoing Nutrition and Hydration
Registered Nurses’ Roles and Responsibilities in Providing Expert Care and Counseling at the End of Life

6. Clinical Practice Guidelines: Ethical/Legal Aspects of Care
Goals, preferences, and choices are respected
Palliative care program identifies, acknowledges, and addresses complex ethical issues
Provision of palliative care occurs in accordance with professional, state, and federal laws/regulations
NCP, 2013

7. Standards of Professional Nursing Practice
Scope of practice & standards of care
Codes of ethical conduct
Guidance for responsible end-of-life / palliative practice
ANA & HPNA Standards

8. Organizational Ethics
Mechanisms to resolve ethical issues:
Ethics consultation
Ethics committees
Education
Policy development
Case consultation

9. Ethical Principles
Autonomy: Making one’s own decision
Beneficence: Intending to do good
Nonmaleficence: Intending to do no harm
Justice: Providing equal access

10. Issues of Communication and Shared Decision-Making
Disclosure
Confidentiality
Informed consent
Decision-making capacity
Disclosure - Includes:
The patient’s current medical status, including the likely course if no treatment is provided
The interventions that might improve prognosis, including a description and the risks and benefits of those procedures, and some estimation of probabilities and uncertainties associated with the interventions
A professional opinion about alternatives open to the patient
Recommendation that is based on the physician’s best clinical judgment.
Confidentiality - the sensitive personal information that a patient discloses to a nurse may be of interest to parties outside the medical relationship. That information is traditionally, ethically, and legally guarded by confidentiality. Nurses are obliged to refrain from divulging information obtained from patients and to take reasonable precautions to ensure that such informtion is not inappropriately divulged by others to whom it might be professionally known.

11. Issues of Communication and Shared Decision-Making: Marginalized Patients
Decision-making capacity for marginalized groups
Patients with dementia/mental illness
Patients with developmental disabilities
Prisoners

12. Patient Self-Determination Act
Issues of Communication and Shared Decision-Making: Laws, Acts, & Documents
Patient Self-Determination Act
Advance Care Planning
Natural Death Acts
Advance
Directive

13. Issues of Communication and Shared Decision-Making: Laws, Acting, & Documents (cont.)
Durable Power of Attorney for HealthCare/Healthcare Proxy
Surrogate
Court-Appointed Guardians

14. Physician/Provider Orders for Life-Sustaining Treatment (POLST)
Standardized medical orders
Specific types of life-sustaining treatment
Applicable in life-limiting disease states
A legal document and part of medical record
Travels with the patient
Honored across all care settings
POLST/MOLST/MOST/POST/SMOST/TPOPP
California HealthCare Foundation, 2011;
The California Coalition for Compassionate Care, n.d.

15. Ethical Issues in Palliative Care
Prolongation of life: Balancing benefits and burdens
Withholding/withdrawing medical interventions
DNR/code status

16. Ethical Issues in Palliative Care, cont.
Medical futility
Principles of double effect
Assisted death
Euthanasia
Research-regulations

17. Preventive Ethics Proactively prevent occurrence of conflicts
Early identification of issues
Knowledge of the natural history of many illnesses
Understand wishes
of patient/family
Attention to culture
and spirituality
Build communication skills

18. Facilitating Ethical and Legal Practice
The Four Box Method
Clinical Indications
Patient Preferences
Quality of Life
Contextual Features
Jonsen et al., 2015

19. Four Box Method: Clinical Indications
Indications for and against the intervention
Reflects the goals of care
Common ethical dilemmas

20. Four Box Method: Patient Preferences
An ongoing, dynamic process of assessment that decreases chance of conflict
Cultural, ethnic, and age-related differences
Common ethical dilemmas

21. Four Box Method: Quality of Life (QOL)
Evaluation of prior QOL
Expected QOL with and without treatment
Common ethical dilemmas addressing QOL

22. Four Box Method: Contextual Features
Social, legal, economic, and institutional circumstances
Context features must be determined and assessed
Common ethical dilemmas

23. Conclusion Ethical discernment, discourse, decision-making
Address values and understanding of needs
Advocate for patient/family rights
Work closely with other disciplines