Reply to two of your classmates seperately. In each your reply posts, Compare and contrast your ethical viewpoint (see attached), using a minimum of two new scholarly sources (readings and/or other evidence-based research articles no more than 3 years old) using APA style per reply.
Classmate #1 (Audrey K.)
Margaret Bentley, a retired nurse, stated in a living will executed in 1991 that if she were ever to become completely disabled from a physiological or psychological standpoint, she would want all nourishment withheld in order to not prolong her life (Siegel, 2015). In 1999, just eight years later, Bentley was diagnosed with Alzheimerâ€™s disease, and by 2004 she was living in a nursing home. Bentleyâ€™s family desired to abide by her wishes, as she was no longer able to care for herself, but the nursing home staff refused and continued to spoon feed Bentley, despite the statements made in her living will (Siegel, 2015). This case brings to question â€“ how much autonomy does an individual have over their state of health once they are no longer competent? Are nurses/health care providers displaying autonomy by not abiding by the wishes of the advanced directive? Wilkinson (1997) describes the concept of autonomy as involving three defining attributes: an individual practices within a professional, self-regulating environment, uses professional judgement and education to make decisions and act on them, and is aware of potentially swaying forces, subsequently recognizing when to act and when not to act. Bentleyâ€™s case can be used as an example of a borderline case in relation to the concept of autonomy. The nurses caring for Bentley are employed as staff nurses in a licensed facility, which satisfies Wilkinsonâ€™s (1997) first defining attribute. The nurses caring for Bentley, continuing to provide her with nourishment, are doing so based off their clinical judgement, as when they raise the spoon to Bentleyâ€™s mouth, she responds. This specific instance satisfies Wilkinsonâ€™s (1997) second defining attribute. Nurses caring for Bentley are seemingly unaware of external forces, such as abiding by a patientâ€™s previously stated wishes in the form of a living will and are therefore not satisfying the third defining attribute as described by Wilkinson (1997), making this example a borderline case.
If the nurses caring for Bentley were fully aware and cognizant of the internal struggle Bentleyâ€™s wishes were causing not only the nursing staff but also the patient and her family, they would be satisfying Wilkinsonâ€™s (1997) third defining attribute, making this a model case. The nurses and healthcare providers involved in this case would need to identify the need to potentially challenge this practice of spoon-feeding, as they are not abiding by the patientâ€™s previously stated wishes and could potentially be prolonging her suffering. Recognizing this attribute would allow the healthcare providers to further educate themselves on the situation at hand in order to best care for the patient. In challenging this practice, several ethical issues would be brought to light: are the healthcare providers force-feeding the patient? Are the healthcare providers going against the patient and familyâ€™s wishes? Are they prolonging her life wrongfully? Is the patient suffering unnecessarily?
The Margaret Bentley case raises several ethical issues. Although Bentley had previously stated in her living will that if she were ever disabled with no chance of recovery she would not want to continue eating or drinking, is abiding by her wishes assisting patient suicide or even negligent homicide? The Voluntary Stopping Eating and Drinking (VSED) is defined as â€œa conscious and deliberate decision, by a capacitated patient suffering from advanced illness or an extremely debilitating medical condition, to intentionally refrain from receiving food or fluids by mouth, to hasten deathâ€ (Eleuteri et al., 2021). VSED raises several ethical questions: does suggesting or following this practice encourage or assist patient suicide? VSED has become increasingly accepted in the healthcare community to honor these wishes in a capacitated adult (Pope, 2019), so should the same grace be given to patients who have endorsed VSED in an advanced directive but are no longer competent? By not abiding by the wishes of the patients, are healthcare providers prolonging the patientâ€™s suffering? Many ethical issues have arisen, and many healthcare providers have differing opinions. Wilkinson (1997) identifies the autonomous struggle between nurses and patients, as for nurses to have true autonomy in their care patients autonomy would suffer. The case of Margaret Bentley provides the reader with an example of both nursing and patient autonomy at odds, as the patient had clearly stated wishes, though the nurses have differing opinions of what it means to abide by them.
Eleuteri, S., Caruso, A., & Pulle, R. C. (2021). End of life, food, and water: Ethical standards of care. Interdisciplinary Nutritional Management and Care for Older Adults, 261-271. doi: 10.1007/978-3-030-63892-4_21
Pope, T. M. (2019). Whether, when, and how to honor advance VSED requests for end-stage dementia patients. The American Journal of Bioethics, 19(1), 90-97. doi: 10.1080/15265161.2018.1544309
Siegel, R. (Host). (2015, February 10). If you have dementia, can you hasten death as you wished? [Audio podcast episode]. In All things considered. NPR. https://www.npr.org/transcripts/382725729
Wilkinson, J. (1997). Developing a concept analysis of autonomy in nursing practice. British Journal of Nursing, 6(12), 703-707. doi: 10.12968/bjon.1922.214.171.1243
Classmate #2 (Shannon S.)
Ethical and moral dilemmas are common in the healthcare setting. As nurses, it is our responsibility to respect and preserve patients’ wishes over their healthcare decisions. However, respecting and considering an individualâ€™s wishes can be tricky if their wishes conflict with what we consider to be morally wrong. In the NPR podcast, â€œIf You Have Dementia, Can You Hasten Death as You Wishedâ€, the author describes a perplexing situation where an advanced dementia patientâ€™s past end of life wishes conflicted with her current observed urges (Henig,2015). This situation is an example of a situation that threatened the nurseâ€™s ability to provide fully autonomous care. The purpose of this post is to discuss the ethical dilemmas of the NPR case and provide evidence to support how it meets the criteria and definition of a borderline case. In addition, I will describe the ethical issue that would arise if the situation were changed to meet the criteria for a model case.
Wilkinson (1997) describes the three attributes of an autonomous nurse as an individual that practices within a self-regulating professional position, is able to make professional decisions within their scope of practice, and has the awareness of the determining factors and understands when to accept or challenge these factors. A model case would illustrate all three attributes, while a borderline case would only partially represent the attributes. In the NPR story, the caregivers were employed in a nursing home and were responsible for providing complete care to their patients. Providing basic care, such as assisting in feeding patients, is within their scope of practice. However, they are unable to respect the patientâ€™s living will that stated if she were to be terminally mentally or physically ill, she did not want to receive nourishment even if it killed her. Therefore, this is an example of a borderline case. To be a model case, the nurses and caregiverâ€™s duty would be to respect the patientâ€™s living will and refrain from feeding her. Although it is important to respect the patientâ€™s wishes, this brings up major ethical concerns. If they uphold the patientâ€™s past wishes,that would mean they are withholding nourishment from the patient who is presently showcasing a non-verbal desire to eat and drink.The ethical dilemma the nurses are dealt with is which person-hood of the patient, the now or the past, should be respected (Noortgate & Humbeeck, 2021).
As patients with end stage dementia are unable to communicate their current preferences, caregivers thereby have to rely on past documented advance directives (Erel et al.,2022). Unfortunately, there is little understanding of neurodegenerative diseases and these patientâ€™s sense of well-being so providers often rely on intuition when providing care (Erel et al.,2022). This is demonstrated when the caregiverâ€™s instincts are to provide the patient with food when they observe her opening her mouth when she’s being fed.
As healthcare providers, we are professionally obligated to act as a representative and advocate for our patientâ€™s wishes (Erel et al.,2022). To assist in navigating our professional duties in ethically challenging situations, some hospitals offer clinical ethics support services. These services have been proven to be valuable in nursing home settings to assist providers in handling difficult and moral challenges in nursing (Magelssen & Karleson, 2022).
Erel, M., Marcus, E.-L., & Dekeyser-Ganz, F. (2022). Practitioner Bias as an Explanation for Low Rates of Palliative Care Among Patients with Advanced Dementia. Health Care Analysis, 30(1), 57â€“72. https://doi.org/10.1007/s10728-021-00429-x
Henig, R. M. (2015, February 10). If you have dementia, can you hasten death as you wished? NPR. Retrieved November 6, 2022, from https://www.npr.org/sections/health-shots/2015/02/10/382725729/if-you-have-dementia-can-you-hasten-death-as-you-wished
Magelssen, M., & Karlsen, H. (2022). Clinical ethics committees in nursing homes: what good can they do? Analysis of a single case consultation. Nursing Ethics, 29(1), 94â€“103. https://doi.org/10.1177/09697330211003269
Noortgate, N. V. D., & Humbeeck, L. V. (2021). Medical assistance in dying and older persons in Belgium: trends, emerging issues and challenges. Age & Ageing, 50(1), 68â€“71. https://doi.org/10.1093/ageing/afaa116
Wilkinson, J. (1997). Developing a concept analysis of autonomy in nursing practice. British Journal of Nursing, 6(12), 703â€“707. https://doi.org/10.12968/bjon.19126.96.36.1993