Legal and ethical issues are always evolving around us whenever we are nursing our patients. Hopefully, this article will keep you thinking and get you to recall events that you have encountered.
Whatever you are doing, whether they are ethically correct or you are just obligated to do what you are told to do or do what you peer expects you to do; you are answerable only to yourself.
Clearly state the problem
The problems faced here are: 1) whether to withdraw the feeding tube from Mr. M; and 2) who is the person to make that decision. Mr. M’s mother, who did not raise him, has vowed to remove his feeding tube, and has threatened to take legal action against the hospital over its refusal to stop feeding her son. However, Mr. M’s brother, who is a nurse, believed that his brother had responded to physiotherapy sessions and this has raised hopes for his recovery. He claimed that his mother had no right to decide his brother’s fate, and insisted on continuing the feeding. Who should decide Mr. M’s fate – his mother, his brother or the medical professionals?
Medical, Social, Legal and Ethical Issues Considered
According to the Multi-Society Task Force (1994), if the cause of the Persistent Vegetative State (PVS) is traumatic, it is considered permanent if the PVS persists beyond 12 months. For Mr. M’s case, his PVS was caused by a car accident and he had only been treated for PVS for six months.
Lo (2000), believes that an individual in a vegetative state is able to breathe on his own, but cannot experience pain or obey verbal commands. He or she has periods of sleeping and waking, and the eyes can be open but he or she is unaware of the environment. This can last for at least a month.
Mr. M had opened his eyes for up to seven minutes. Medically, no one could ascertain that Mr. M would never recover. If he were able to regain consciousness, would he be able to get back to his pre-morbid state? If not, who would take care of him? Who would bear the expensive medical cost in the long run?
Get the facts
Mr M suffered head injuries in a car accident and is in a persistent vegetative state (PVS). As defined by the American Academy of Neurology, PVS is “a clinical condition of complete unawareness of the self and the environment accompanied by sleep-wake cycles with either complete or partial preservation of hypothalamic and brainstem autonomic functions” (Multi-Society Task Force, 1994).
Although there is a possibility of misdiagnosis of PVS (Andrew, Murphy, Munday & Littlewood, (1996)), Mr. M’s brain scans have shown no improvement since he was hospitalized. If the feeding were to be stopped, he will be extremely dehydrated and starved. His body would be emaciated and shrunken. No one would know if he suffered greatly during the period of nutrition deprivation. The average length of survival of patients in PVS is 2 to 5 years. Only a few have been reported to survive for more than 15 years (Lo, 2000).
Mr. M and his brother were raised by his paternal grandparents, and this raises the question as to whether his mother knows what Mr. M’s wishes are. She vowed to remove his feeding tube but his brother, who is a nurse and has a close relationship with him, insisted to continue his feeding.
There was no mention of whether Mr. M had signed an advance medical directive (AMD), or whether he would want to end or sustain his life should he be in a PVS. It would be considered passive euthanasia if the feeding were stopped. This act is illegal unless an AMD has been signed and witnessed.
The case study does not mention Mr. M’s paternal grandparents’ views on this issue, but they are entitled to have a say since they raised the boys. Mr. M is also the single father of a child, who is about 15 years old. At this age, the child is not able to make any legal decisions. Ultimately the Courts may have to rule on who has to make the decision regarding Mr. M.
Four Major Ethical Principles
Autonomy
According to Staunton & Chiarella (2003, p.28), autonomy is “the right to self-determination, the ability to control what happens to us and how we behave”. A person should make his own decisions in life and that these decisions do not have consequences that violate another person’s autonomy. In this case, Mr. M did not have an AMD and is unable to consent to his treatment. Hence, only his surrogate guardian can make decisions on his behalf. Who should this be? A surrogate guardian should embrace Mr. M’s quality of life values rather than his/her own. Should this be Mr. M’s mother, who did not raise him, or his brother, who has grown up with him, or his paternal grandparents who has brought him up, or perhaps his child who is too young to know what is happening?
Beneficence
Beneficence is aimed at the wellbeing of the patient, and is the deliberate bringing about of positive actions or interventions (Hawley, 1977). Since only an autopsy can diagnose PVS in a patient, we cannot positively conclude that Mr. M is in that state. If he is indeed in a PVS, it can be concluded that he is unconscious and hence cannot experience pain and suffering (O’Mathuna, 1996). For argument’s sake, even pain can be experienced in a PVS, it would be more burdensome and more prolonged than any pain experienced with artificial feeding withdrawn. We cannot be sure that if Mr. M is ever going to recover and even if he does, what quality of life will be have? Is he going to be dependent on others for his daily activities till the end of his life?
Non-maleficence
The principle of non-maleficence means “above all, do no harm”, which serves to restrain one from causing hurt and by prohibiting actions which would cause harm (Hawley, 1997.). By withholding the artificial feeding for Mr. M, he will eventually die. Thus we are causing him great harm. Nurses have sworn to save lives, and most would not be able to stand idly by while the patient died a little more each day through their inaction. However, are there benefits to continuing the feeding? Perhaps this too causes harm to Mr. M. There are multitudes of reports in medical literature which document that delivering nutrition and hydration could cause discomfort in the dying process, such as vomiting, peripheral edema, and an increased risk of infection. Does that also mean that we are not causing any further complications and endangering the patient’s life? If he were aware of his current condition, would he continue to accept the treatment that we are administering? He may resist whatever is being done to him.
Justice
Justice is the fairness and equal distribution of burdens and benefits (Staunton & Chiarella, 2003). It is society’s expectations of what is fair and right. Healthcare professionals need to proceed with planning and giving care that incorporates the notion of ‘due care’ so that all persons – irrespective of socioeconomic status, race, gender or religion – are offered and given the appropriate health care according to their medical and nursing needs (Hawley, 1997). The justice for Mr. M is that he is entitled to receive the quality of care no matter whether the decision is to withhold or withdraw the feeding. However, with tight resources, will it be fair to prolong Mr. M’s life span at the expense of finance burden and emotional distress to the family? Moreover, how many PVS patients have recovered and do not need any subsequent medical attention?
Identify ethical conflicts
The main ethical conflict arises when one has to decide whether the preference is to stop feeding Mr. M after 6 months or to prolong his life by continuing the feeding. This is a dilemma for the healthcare professionals taking care of Mr. M and may require the intervention of the courts.
If the courts order the removal of the feeding tube, the question of the possibility of recovery may continue to haunt the healthcare professionals. They may also be guilt-ridden for causing him to suffer and die from hunger. Once the feeding tube is removed, Mr. M would probably die in 2 weeks.
On the other hand, if the feeding tube were not removed, what would be the cost of prolonging his life? The resources that are used to support vegetative patients could be allocated to other patients. Mr. M would also face repeated re-insertions of the feeding tube, possibly resulting in aspirations and infections, with no assurances that he would have a good quality of life.
Any potential conflicts need to be straightened out through family conferences where all parties are given the opportunity to air their views and address this ethical dilemma. A time frame of six months may not be sufficient to diagnose Mr. M with PVS. Studies have shown that there are many PVS cases that have been misdiagnosed (Andrews et al., 1996).
Considering the Law
When a patient has lost the capacity to make medical decisions for himself, there are laws that put the burden of consent to treatment on someone else. On the other hand, if the patient is aware of his current situation and has consented to discontinue the procedure of artificial feeding, the continuation of the feeding may be considered an assault or betrayal to the patient, when his interest is not being served by doing so.
According to the American Heart Association (2005), as soon as Mr. M lost the capacity to make medical decisions, a close relative or friend can become his surrogate decision maker. Surrogates should base their decisions on the patient’s previously expressed preferences if known; otherwise the justification for treating a patient who lacks the capacity to consent lies in the fact that the treatment is provided in his best interests. Surrogates should make decisions based on this, and the treatment should be discontinued where it is no longer in patient’s best interest to provide it (Mclean, 2001). The law will designate the legal surrogate decision maker for an incompetent patient who has not previously designated one through a durable power of attorney for health care. The order of priority for guardianship in the absence of a previously designated decision maker: (1) spouse, (2) adult child, (3) parent, (4) any relative, (5) person nominated by the person caring for the incapacitated patient, and (6) specialized care professional as defined by law (American Heart Association, 2005)
This order of priority makes Mr. M’s mother the legal surrogate. Her wish was to discontinue the feeding. If this was not done, she will threaten to sue on the grounds of battery and assault, because continued feeding would necessitate repeated re-insertions of the feeding tube. However, by removing the feeding tube, he will die from malnutrition and dehydration, and as a result, the hospital would have breached the duty to care for him. On the other hand, Mr. M’s brother is claiming that their mother has no right to be the legal surrogate as she did not raise them. He would sue the hospital for negligence if the hospital withdrew the feeding. According to Staunton and Chiare
