Ethical Issues of Palliative Care Nursing

Palliative care nursing is a speciality where you observe your patients in their most vulnerable moments. Whether it be watching a patient struggle to hold on until their last family member arrives to say good-bye, or accompanying them as they take their final breath. It isn’t solely about death, but rather about making your patient as comfortable and as dignified as possible as they transition into their final days of life. According to WHO, “Palliative care is an approach that improves the quality of life of persons and their families facing the problem associated with life-limiting illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual”. There are many health issues which arise in regards to patients who are dealing with a terminal illness or approaching end of life such as: pain management, respiratory distress, digestive issues, fatigue, difficulties involving elimination, depression, etc. Although it is impossible to alleviate all these health issues, it is crucial that we as palliative care nurses attempt to relieve our patients from as many negative symptoms that may accompany them as we can. Palliative care is an area of nursing which will always be around, as the circle of life will never come to an end. Because of this, it is especially important that we put a great deal of focus on palliative care nursing and how we can better it from a medical as well as ethical standpoint.

Palliative care nursing is not a speciality for all nurses. You must be especially empathetic, compassionate, patient and be your patients’ number one advocate. You also must have the ability to cope with the stress of being amongst death, grieving family members and daily loss without having it take a toll on your own mental state. As with most areas of nursing, there are a great deal of ethical issues that accompany being a palliative care nurse “Palliative care therefore requires many different competences, not only clinical but also relational, communicative and ethical”. You are included in many sensitive situations where decisions being made may not reflect your own personal values, however you must continue to provide the best care possible regardless of your own judgement. You not only have to meet the demands of your patients, often times you are also attempting to meet the needs of their loved ones as well, while simultaneously dealing with the personal stresses associated with this. Caring for patients nearing the end of their life poses many challenges as we strive to make decisions that meet our clients’ needs, while also being morally justified. “Where the wishes of patients, relatives and professionals’ conflict, and where care is limited by the scarcity of resources, it will often be impossible to satisfy all demands”. Some of the ethical issues palliative care nurses often find themselves having to address include: assisted death, addressing end of life issues and interventions, and respecting patients’ wishes as well as their families.

MAiD is defined in the Criminal Code of Canada as:” (a) the administering by a medical practitioner or nurse practitioner of a substance to a person, at their request, that causes their death; or (b) the prescribing or providing by a medical practitioner or nurse practitioner of a substance to a person, at their request, so that they may self-administer the substance and in doing so cause their own death”. It is a medical procedure which is becoming much more prevalent in today’s society, in particular in end of life care. However, for a nurse who has always believed in preservation of life, this could be particularly troublesome, especially when it may potentially cross a religious or personal boundary causing moral distress. “The intersection of personal and professional values about life, death, suffering, and nursing came to the fore when confronted by patients and families asking for information or preparing and waiting for an assisted death”.

Another subject which may pose some ethical issues is the conversation of addressing end of life issues and interventions. “All clinicians must make difficult decisions about withholding or withdrawing treatment; however, they are particularly common when caring for a patient entering the very terminal phase, as there are no longer any reversible causes of his deterioration. Symptom control and comfort are paramount, and all interventions must further this goal”. These could include: continuing IV hydration once end of life deems imminent, pain control and sedation, feeding tubes, code status and religious/personal practices. The health care professionals involved in this care must find balance in respecting the clients wishes regarding their expected care, as well as being open and honest about the realistic outcomes these interventions may or may not have, no matter how difficult they may be to address. “Instead, sensitive discussion can establish an individual patient’s awareness of his terminal disease and his preferences for attention to dignity and comfort measures should irreversible deterioration occur”. There will be circumstances in which your patients’ wishes do not coincide with beliefs you have as an individual, or even as a health care professional. Some examples include: a patient who wishes to be fed solid foods although they are high risk for aspiration, continuing IV fluids when death is quickly approaching, refusing pain medications in fear of speeding up the death process or requesting a feeding tube be inserted although it will have no impact in prolonging life and may actually cause discomfort. As a nurse it is not your job to agree with your patient, but to educate them along with the rest of the health care team so they have an understanding of the dying process and the importance in quality of life.

When it comes to health care, balancing the wishes of your patient against those of their family can be trying at times. Adding end of life care to this conversation, this balance becomes even more difficult to manage. This is especially true when family members opinions do not match those of their dying relative such as DNR status, requesting confidential information or placing blame on the health care provider for decisions made. “Our applicants also declared that some problems could be related to the families of dying patients, for instance they might have difficulty deciding on the continuation of treatments, or attempt to obtain information from unauthorized persons”. Although end of life care can be extremely stressing to family members, nurses must remember their patient’s care is their number one priority. During the end of their life the patient may not be in a state to be able to speak for themselves, and this is where advocating for your patient will have a significant impact. You must continuously respect your patient’s wishes, even when they may not be able to voice them for themselves. This may be especially distressing especially when you have multiple family members who’s wishes are conflicting with those of your patient.

As palliative care is an extremely sensitive subject, ethical issues will always arise no matter the resources or education. However, it is imperative that all nurses are educated on ethical issues, ethical dilemmas, moral distress and how to manage them all as an aide to assist with coping. End of life care is an area of nursing you do not realize the effect of until you are placed into a situation where ethical issues emerge for the first time. As much as it is your duty to provide the best care possible to your patients, you still have a duty to yourself to also focus on your own well-being. We must never allow ethical issues that may arise in our career to push us to a place where we are no longer content doing something we are so passionate about, or make us neglect our own personal core values.

This area of nursing interests me because I feel as though those who are dying deserve to be treated with just as much respect as those who are alive, fighting an illness they may overcome. Although they may not be receiving active care and may not recover, there is still so much knowledge and compassion that go into providing palliative care between effectively managing pain and promoting comfort, granting any final wishes, and consoling family members. It is definitely an area of nursing I would consider working in when I go on to graduate as a registered nurse. In recent years, I’ve experienced many close family members pass away and was truly inspired by those nurses who cared for my own relatives. The compassion, empathy and respect shown through as they went to such great lengths to make them comfortable in their final days is something that has always stuck with me. It would be an extremely humbling experience to be fortunate enough to provide care to those in their last days, as well as being a source of comfort and consolation to their family.

This area of nursing comes with a considerable amount of ethical issues, as well as an abundance of emotions whether it be those of your patients, their family members or your own. Even so, if one is passionate about end of life care and has the ability to keep their core values undisturbed, it is absolutely worth it. At some point we will each find ourselves in our final days of life and I would hope the nurse caring for us would provide us with the comfort, dignity and utmost respect we deserve.