Case study of Autonomy VS Beneficence
Going through end of the life experience and saying good by forever to a loved one both are very sensitive issues. A 70 years old female cancer patient is counting her last breaths in oncology department. Her extreme pain does not allow her to tolerate even a simple procedure. Her nutrition status is very poor because she is continuously refusing the food, questioning that, "will it alleviate my suffering?" even she is so reluctant to naso gastric tube which was in placed to fulfill her nutritional requirements that she has pulled it out too. She is saying that she wants to die and we are prolonging her agony. Her daughter is requesting the doctor again and again to reinsert the N/G tube as her mother is becoming dehydrated. She also wants me to do every possible thing for her and save her life at least for a week because the son of the patient is supposed to come with in a week. The doctor has written do not resuscitate orders and reinsertion of N/G tube after restraining her if she tries to pull out the N/G tube. As a primary nurse I am hesitant to do any thing for her except comfort measures, because I feel that the patient wishes to die in peace. This situation stands out for me because when I came across this scenario, my memory flashed 4 years back when I was not a nursing student. My best friend who was my neighbor too and we both were like sisters. Her mother was diabetic due to which she went into CRF and she became blind. She was admitted in hospital for 2 years in very painful condition. She used to say that she wants to die but her children did not allow her to go. They kept on providing the best treatment option they had. One day when my friend went to see her she said that you are giving me pain I am not happy with it. When her children heard that, they stopped the treatment and with in a week she died. When I heard of her death I was very upset. I was feeling too bad that why did they let their mother go because my friend was the youngest of her 8 brothers and now she had no one to share her feelings with. But on the other side I was happy too that her mother went with peace. Secondly, I am always interested in ethical issues. And especially this scenario is talking about autonomy and beneficence therefore; this scenario has attracted my interest. As a nurse I am feeling very helpless at this time because I have encountered a situation where my thoughts have been divided into two directions. If I think as a nurse I feel that we should respect patient's autonomy but when I keep myself at the place of her daughter I can not suppose my mother on that bed. I will never let her go leaving me alone in this world.
When I analyze the scenario I question my self that why doctor has written DNR orders in Patient's file? Does he have a right to decide for the patient against the family's wish? Why the doctor wants the patient to be restrained? Is this not the violation of the patient's right of autonomy? Why the doctor wants to insert N/G tube? Is N/G tube increasing or decreasing her suffering? Does he have a right to go against patient's last wish? On the other hand why the patient wants to die? Is she not aware that her son is coming next week? Why the daughter wants her mother to live? Is the importance of her brother is more important than her mother's pain? And I as a nurse what comes in my responsibility? Should I respect patient's wish or should I respect her daughter's wish? Should I go for the autonomy or the patient's right to refuse or I should fulfill beneficence?
May be we as health professionals have become so much mechanical that we do not have feelings for our patients, we have become so busy that we hardly finish our daily task and we do not get time to think about such sensitive issues. When I keep myself at the place of patient I feel my self experiencing an extreme pain and that my loved ones for whom I have sacrificed my whole life, do not understand my feelings. Now I am getting at a developmental stage where I do not have strength to bear these difficulties so they should let me go in peace. Secondly, there is no use to spend so much of money on me for my treatment. I do not want to give them hard time if I am not able to give them something good. Investing so much of money is a burden on them also and it is giving me no benefit too. It is only increasing my pain period. When I think of her daughter may be she the only member of her family and as a girl she might be afraid of death of her mother. She might be also confused about the last ceremonies of her mother. Might be her brother had asked her that he wants to see his mother or may be they have had lost there father and now there mother is leaving them. And because of this she might have requested to save the life of her mother at least for a week so that she will not be alone.
But when I think a step further, the doctor should have asked the family about their wish. He should have listened for their concerns. Or at least he should have discussed what he was planning for the patient. Instead of restraining the patient they might have involved the daughter in her mother's care, which could have been a better option then, restraining her. The daughter should have talked to her brother to come early instead of prolonging the life of the patient. As a nurse I should have discussed the last wish of patient to the family members. Or may be I could have helped patient's daughter in talking to her brother about their mother's condition. I could also have talked to the doctor about patient's wish and also about family's wish and then collaboratively we would have taken any step.
If ever I will come across such a situation again in my life then although I will be in difficult position but I can handle the situation more appropriately. But the difficulties and hurdles will always be there because it is a dilemma in which both the sides of picture are equally important and true. Literature supports both the points that weather N/G tube is helping or increasing her suffering. Donna (1993) believes that: "tube feeding is a common form of long term life supportâ€¦ tube feeding may be ethically appropriate or inappropriate." (P.2)
It is not only the doctor who is responsible for the violation of patient's autonomy but the family and patient themselves hand over their rights to their physician. Amina and Fiona (2004) have highlighted this aspect as:
This is especially true of uneducated patients and their families, who defer to health professionals that 'doctors knows the best'. In effect, patient expect health professionals to make decisions for them and in addition they fear displeasing doctors, who are seen as powerful figures. (P.395)
In the light of above literature I came to the conclusion that it is a challenging task to just state in a phrase or two about the matters like patient's right to refuse, right of autonomy and beneficence etc. for such cases our care will be different in every situation.
This scenario has taught me a lesson that when ever in future I will come across such situation I can handle it in a better way. This scenario has developed a new insight in me. I will not only consider the patient as a focus but I will consider the whole family as a medium for care.
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