Nursing Ethics in Palliative Care: A Case Study on Impaired Decision-Making

This article discusses the ethical considerations in caring for a patient with a terminal illness and impaired decision-making. It explores the values relevant to the case, the influence of values in decision-making, healthcare professionals' role in ethical problem-solving, and the common law on patient autonomy. The article also discusses the Queensland legislation on potential decision-makers, requirements for a substitute decision-maker, and the principles of the Act on a person with impaired decision-making.

Running Head: NURSING ETHICS 1
NURSING ETHICS
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Introduction
A terminal illness has major impacts to the patient and their carers. Once diagnosed, the
patient experiences distressing and painful periods with adverse limitations in the lifestyle
brought about by the illness (Bosslet, et al, 2015). Coping strategies at times can also cause
friction between primary carer and other family members (Haughey& Watson, 2015). Ewing’s
case is already taking that direction. Health professionals can help in ethical issues when they
arise (Wallace, 2015).The person can continue to receive treatment to help manage the
symptoms but not cure their illness (Haughey& Watson, 2015). End of life care helps everyone
affected by the diagnosis have the best quality of life (Goodwin, et al, 2014). It also includes
additional support and help with legal matters.
Values relevant to the case
Eric being Ewing’s carer for the longest time now has a role in supporting Ewing as his
health and ability to care ofhimself diminishes. Being the principal carer he has to help Ewing in
all his activities of daily living which is a more intensive care. As a carer he has a duty to help
the patient to be healthy and well the best way possible (Goodwin, et al, 2014). Ewing’s health
has shifted from curative treatment to palliative care which shows an increase in need for more
support and physical care. This requires an informal carer who will provide physical and
emotional support to a patient with a life limiting illness (Horrell, Stephens &Breheny, 2015).
As a carer, Eric has values of commitment and care. Caring for a sick person is demanding and
exhausting and difficult and requires more patience(Horrell, Stephens &Breheny, 2015). As a
result, commitment needs to be built to improve patient’s care and experience while taking the
necessary actions to handle the challenges ahead. Eric is committed to care for Ewing with the

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assistance from Debbie, Ewing’s daughter.Care as a value is at the center when delivering help
to any sick person. It is a feeling of concern or interest towards them. It helps improve their
health and wellbeing. The type of care depends with the individual needs, choices and wishes in
every stage of their life (Goodwin, et al, 2014). Eric is committed in giving Ewing the best care
even as he nears his death. For this reason, together with Debbie they opt to buy a wheelchair
and a mechanical lifter to help the patient in easy movements around home. He wants the best
care for him and prefers him to be at home for the best palliative care rather than hospital where
the patient may feel lonely, not loved and less catered for. Being a carer to Ewing for nine years,
Eric has altered his own lifestyle to meet Ewing’s needs. It also means accepting the situations
and making adjustments in one’s own life(Horrell, Stephens &Breheny, 2015). Commitment to
care is about giving priority to other things other than oneself(Goodwin, et al, 2014).
Values and their influence in decision-making
Decision-making is about choosing a good choice from the options available through
weighing the positives and negatives of each option available and the outcome of each when
applied to the situation at hand(Holroyd-Leduc, et al, 2016). Based on this the best option is
determined. In relation to the case study, Eric’s decision-making is about what was beneficial to
Ewing at the moment. Ewing’s condition had no known treatment or any form of medication that
would alter the trajectory of the disease. All he needed was palliative care until his time came
(Bükki, et al, 2014). Eric and Debbie had already made a decision to care for him at home. There
was no need for him to be kept under hospital care when there was no proper attention required
at the healthcare. Eric had made a commitment about Ewing’s care and together with Debbie’s
assistance they went ahead and bought the necessary equipment they thought were the best for

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the patient. Out of commitment and care that Eric had created a long-lasting relationship with the
patient. Commitment is not a value for the weak(Holroyd-Leduc, et al, 2016). It requires
persistence, self-discipline and resilience. Eric having made a decision of taking care of Ewing
until his death, he had to stay committed to it. Commitment is about sacrifice. It binds one to a
promise, course of action, a firm agreement and a pledge (Holroyd-Leduc, et al, 2016). He had
made a sincere and a serious decision about the care and was determined to see to its completion.
He is happy when Ewing is discharged for home. He is concerned and more attached to the
patient and looking after him and providing for his needs is his priority (Sizoo,
Grisold&Taphoorn, 2014).
Healthcare professionals and ethical problem solving
The disagreement between the family members on Ewing’s treatment needs to be looked
into on both sides to enable proper understanding that can bring a consensus. The degenerative
neurological condition has already caused severe damages on him and no medication to cure or
improve the problem. Owing to this he can only continue to receive palliative care. The disease
is progressive and death can be reasonably expected.Treatment to Ewing through parenteral
hydration and artificial nutrition was a non-beneficial treatment (Houben, et al, 2014). This is
because the intensity of treatment and the expected degree of improvement in quality of life was
minimal (Haughey& Watson, 2015). The patient was also aware of his condition and felt no need
of going to the hospital though proper monitoring was essential. End of life treatment to him was
ineffective, costly and not in line with his wishes (Bosslet, et al, 2015). This limits medical care.
Veracity in healthcare is important to enable patients and families make informed
consent(Houben, et al, 2014). Patients and families rely on health professionals for information

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about their care. They need to be told the truth (Wallace, 2015). End of life and palliative care
helps patients with life-limiting or life-threatening illness(Haughey& Watson, 2015). It helps in
managing symptoms and providing assistance and comfort. The care offers emotional, mental,
social and spiritual needs. It also provides practical help with daily activities. End of life and
palliative care aims at improving the quality of life for the patient, family, friends and carers
(Wallace, 2015). The care is not only for people nearing the end of life but also for people with
chronic ongoing illness. The care is best begun early in the disease to help the patient have the
best quality of life, with his wishes, for the longest time possible(Houben, et al, 2014). Palliative
care can be received home, palliative care unit, or at a local hospital.
Common law on patient’s autonomy
To begin with, the degenerative neurological condition had impaired Ewing’s decision-
making capacity. The patient was not in a condition to make an informed consent but his son
requested the paramedics to further assess him at the hospital. If the patient lacks decision-
making capacity or lacks competence regarding their treatment, another person must make
decisions on treatment for them (Brazier & Cave, 2016). To have a capacity of decision-making
a patient must have understanding, appreciation, reasoning and the ability to express a choice
(Cartwright, et al, 2016). In cases where the patient lacks the capacity a surrogate decision-maker
can intervene (Callaghan & Ryan, 2014). They can be legally appointed or next of kin(Moye, et
al, 2013). Next of kin includes spouse, adult child, parent, adult sibling, close friend, or ethical
committee. Dean being the adult child gave the paramedics the directive to further monitor his
father.
Queensland legislation on potential decision-makers

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In reference to Queensland legislation, a substitute decision-maker is a person allowed by
the law to make decisions on behalf of a person who lacks the capacity to make informed
consent by him or herself (Chesterman, 2013). When it comes to substitute decision-making, a
person can have more than one. Decisions to be made can be on personal or financial matters
(Carter, et al, 2016). Health is a personal matter. When one has not appointed a substitute
decision-maker and their capacity is impaired, a statutory health attorney is appointed by law to
make health decisions for the person (Chesterman, 2013). Other culturally appropriate people for
the role are; a spouse or de facto partner with whom one has a close or continuing relationship, a
primary carer who is not paid and is above 18 years of age, a close friend or relative above 18
years and not being paid for the role(Carter, et al, 2016). Failure to meet the criteria, the law
appoints a public guardian as a statutory health attorney. An eligible substitute decision-maker
must be 18 years and above, have decision-making competence, follow the patient’s values and
instructions, readily available to for the role, willing to accept the decision-making
responsibility, and have the ability to make decisions even in stressful situations (Tilse, et al,
2014).
Requirements for a substitute decision-maker
Eric being a primary carer for Ewing, he has lived long enough caring for him and is
aware of all his needs. Eric and Debbie were well aware of Ewing’s condition. Before
considering palliative care for him, the healthcare had informed them that there was no option
treatment available for his condition. Knowing this, Eric was committed to caring for Ewing at
home until his time came. He is also able to observe the necessary requirements by the patient at
that particular moment to give him comfort(Then, 2013). The responsibility of a substitute

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decision-maker is that they must act in the best interest of the person, make decisions with the
capacity they would have made for themselves, have knowledge and understanding of their
medical condition and the expected complications in the future, have an understanding of future
medical care options which entails current and future treatments benefits and risks, carefully
considering the patient’s wishes and choices regarding their end of life care, talk about the
choices of the patient with his or her family(Then, 2013). Eric being a carer is always available
to take the role, he has a commitment to fulfill which means he would be willing to accept the
responsibility. He knows what the best for Ewing is and is happy when he is discharged even
when Dean does not want it. He also makes decisions in stressful in stressful situations.
Principles ofthe Act on a person with impaired decision-making
Ewing is impaired mentally and lacks the capacity to make decision regarding his health.
The Principles Act seeks to oversee the rights of a person with disability in decision-making is
independent and receives the needed support(Then, 2013). Ewing needs someone committed
towards his care to live the best life he wishes for in his health condition. The presumption
capacity highlights that adults are believed to have their own capacity of making decisions
except where it is found out that they cannot(Then, 2013). The degenerative neurological
condition has already impaired Ewing’s decision-making. Eric is already in a position to offer
the best palliative care to the patient. He is aware of his best needs. Irrespective of capacity in
decision-making, the basic rights are equal to all people(Carney, 2014). It is the duty of
substitute decision-makers to see to it that the person exercises their rights (Then, 2013). Their
human worth and dignity should also be respected despite their situation(Then, 2013). They
must also be encouraged and supported in to perform their social roles. Despite Ewing’s

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condition affecting him greatly, he still has the role to play as a home owner(Carney, 2014). A
decision-maker must also encourage the person to be self-reliant and autonomous physically,
emotionally, socially and intellectually the best way possible (Then, 2013). Eric spending most
of the time with Ewing, as a man he knows what he needs best to be self-reliant. He is also less
restrictive and offering proper care and protection that is consistent. He has been with him for a
long time and his plan is to take care of him at home until his final rest. A person’s environment
and values should also be maintained. The assistance given to the person should also be
appropriate and meets the current needs and suits their individual characteristics (Carney, 2014).
Eric wants the best for Ewing and needs him to be independent the best he can. To do this he
goes with Debbie to source for a wheelchair and lifter for Ewing. He knew he needed it for the
moment.
Conclusion
When it comes to caring for a patient, care should be at the heart of everything taking
place in improving health and wellbeing. Individual needs, wishes and choices should be
considered at every stage. To fulfill all these requires commitment. The core values should also
guide in deciding the best for the patient. Ethical dilemmas are frequent in patient care. Health
professionals can help resolve by maximizing benefits, respecting the preferences and reducing
pain and suffering to the patient and facilitating communication. Futile treatment is not ethical in
healthcare.If a patient lacks decision-making capacity another person can make decisions for
them.

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