Critical care nursing is a challenging field in which nurses must be frequently confronted with ethical dilemmas. One of the most frequently encountered dilemmas that occur in this field is the management of care for terminally ill and actively dying patients. When providing care to such patients, it can become emotionally burdensome for the nurse to carry out medical interventions that may be uncomfortable or painful to the patient while not providing much of a benefit. Nurses in these environments often feel the desire to relieve the patient’s suffering and a sense of accountability for their comfort. When aggressive medical interventions are implemented for patients that are actively dying, it is important to recognize if any worthwhile benefits are achieved by the interventions. Sometimes in the ICU setting, the provided aggressive medical treatments do not offer notable medical or palliative benefit to an actively dying patient. The question that arises in these situations may be: Should aggressive treatments be continued when they can be considered medically futile?
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One of the biggest challenges that surfaces when considering medically futile interventions is that there has been no universal agreement between medical professionals on how futility should be defined. For the most part, futility in relationship to medical interventions is defined as any clinical action which no longer serves a useful purpose in reaching a given patient’s goals and outcomes (Kasman, 2004). If a certain treatment only has the potential to prevent bodily death while not improving the health status of the patient or providing palliative benefit, it may be considered medically futile.
When planning the care of terminally ill clients, it is important to weigh the effectiveness of the medical interventions against the benefits the treatment will bring as well as potential harms. The health care team must look at the patient as a whole instead of simply focusing on treating their specific diagnosis. Many factors come into play when considering which treatments may be appropriate and effective for these patients. Each patient’s unique goals should be evaluated thoroughly when the health care team creates their plan of care. For example, if an actively dying patient’s goal is to have a dignified and peaceful death, it may be considered maleficent to implement aggressive treatments such as intubation and cardiopulmonary resuscitation (CPR) (Kasman, 2004). It is important for the wishes of the patient and the patient’s family to be documented and known to the healthcare team when planning care. The problem of providing medically futile care has the potential to affect everyone involved with the care on an emotional and intellectual level. This includes the patient, their family members, and members of the health care team involved.
There are four ethical principles that must be considered when providing care to critically ill patients. These principles include beneficence, veracity, justice, and autonomy. The principle of beneficence in this context may be described as acting in a way which promotes the wellbeing of the patient. Veracity may be described as the truthful communication between healthcare providers and patients. The idea that all patients deserve to be treated equally according to their needs and that they should receive the appropriate level of care for their conditions describes the principle of justice. Autonomy is the principle that a patient has the ability to make their own individual decisions regarding their medical treatments.
Beneficence is a commonly referenced principle in the context of providing interventions that may be considered medically futile. Because this principle is based on the idea of acting in a way that will have a positive impact on the patient, it would not be beneficent to provide care that is considered medically futile. This kind of care may succeed in prolonging the life of the patient, but it will likely have no net improvement on the patient’s quality of life, and may even result in a decreased quality of life.
Veracity is a very important principle to implement in the critical care setting. Health care providers should be communicating with patients and their families in an honest manner about their medical condition. In some cases, providers may continue with life-sustaining treatments that will not result in a patient’s meaningful recovery for primarily emotional reasons including having concerns regarding the family’s reaction to the actual medical status of their family member (Suprising reasons for continuing futile treatment, 2012). This is an example in which the provider is not practicing veracity. It is important for the patient and their family to be given realistic expectations on the outcome of any treatment, even if it is a difficult discussion to have.
Justice may be practiced in this setting by the careful consideration of each patient’s case individually. The healthcare team should evaluate each patient’s situation and consider what treatments will improve their condition as opposed to simply prolonging the life of their body. Even if a patient has decided they no longer desire to receive aggressive medical treatment, they still should be receiving adequate care and attention to their needs by the principle of justice.
Autonomy is a vital component in providing care to critically ill patients. If at all possible, it is important for the patient to make their own decisions regarding their wishes during the end of their life. If the patient is not mentally competent or physically able to declare their decisions, the durable power of attorney would make these decisions if this person has been assigned prior to the patient’s incapacity. If there is no durable power of attorney, then the court will appoint a proxy that must act in a morally valid way and will make decisions with the patient’s best interests in mind (Kasman, 2004).
When caring for critically ill patients, it can be challenging to understand the difference between interventions that are actually benefiting the client and interventions that will simply prolong the life of the client’s body. This is a concept that is especially difficult for family members who may not understand the severity of the patient’s medical status to understand. In some cases, the opinions of the healthcare providers and the opinions of the family members differ regarding what treatment options should be carried out for the patient. If this occurs when the patient is unable to make decisions for themselves and they have a surrogate appointed, the surrogate will make decisions on behalf of the patient. If the decisions made by the surrogate are not congruent with those of the physician, the physician may deny to carry out requested treatments if there are concerns of potential risks associated with them. If the surrogate continues to insist on the controversial treatment, the patient’s case may be presented to other physicians. If the physician has serious concerns regarding the surrogate’s decisions, they have the right to request the court to replace the patient’s surrogate with one that has morals that are more sound.
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A recent case regarding medically futile care involved a man named David James who was originally hospitalized due to complications that arose with his stoma. During his stay at the hospital, he suffered from multiple organ failure. He was moved to the critical care unit with cardiovascular failure, respiratory failure, and renal failure where he was put on a ventilator. The patient’s medical condition was so bad that even aggressive medical treatments were unlikely to benefit him. As his condition continued to worsen, the hospital used the principle of beneficence and decided to place a Do Not Resuscitate (DNR) order in the patient’s medical record. The family disagreed with this decision, and the medical team took the case to the Court of Protection (Griffith, 2013).
The court originally decided that treatment for this patient would not be futile and therefore withholding treatment would not be in the patient’s best interest. The ruling was not well accepted, and the case then moved to the Court of Appeal where the original decision was overruled. Here, it was decided that the results that the proposed treatments sought out would not be able to be produced in this patient’s case. The treatment that could be provided would likely not offer any therapeutic benefit to the patient or palliate the patient’s condition, so it was ruled to be medically futile treatment (Griffith, 2013).
The decisions made in the care of critically and terminally ill clients are not usually obvious or straightforward. It seems as though as technology develops further, death appears to become viewed more as an option rather than a fact (Paris, Angelos, & Schreiber, 2010). Because of the principle of justice, patients will still receive quality medical treatment for their illnesses even if they have a DNR status. It is important for all patients, especially those who do not have a long life expectancy left, to be knowledgeable about their options for end of life care. Everyone deserves the right to making autonomous decisions regarding their health. For a patient that does not desire to endure aggressive medical treatments at the end of their life, an alternative option could be either palliative care or hospice care depending on their individual case. The client would still be treated and more effort would be put towards relieving the symptoms of their illness rather than implementing aggressive medical treatments that could prolong their life at the risk of decreasing their quality of life. This could allow the client to have a more peaceful, dignified death, rather than having to endure several medical interventions that may be intrusive and painful such as intubation, ventilation, and CPR. It is important for the family to understand that just because many life-prolonging options are available due to modern medicine, it is not always the best choice to implement these options.
Some opponents of the idea of medical futility claim that physicians aim to overpower less knowledgeable patients and their families. This leads opponents to believe that healthcare providers who have end of life discussions with families regarding medically futile care are consequently delivering paternalistic care. Some also believe that the idea of medical futility is simply a decoy used by physicians to convince patients and families to withdraw medical treatments in order to lower the costs associated with end-of-life care and to help ration the hospital resources (Kasman, 2004). There are many examples of professional literature exploring this topic, which discuss the reality of medically futile care, some of which have been cited throughout this paper.
I believe that aggressive medical treatment should not be carried out if multiple health care providers share the same opinion and have decided that the interventions will not provide any foreseeable therapeutic medical or palliative benefit to the patient’s condition. Through researching this topic, it has become clear that with the advancements in medicine, death is becoming a fact that is not as accepted as it once was. Many people want their loved ones to live as long as possible at any given cost. Death is a fact of life, and once that is better understood and accepted by family members it may be easier for them to let go of their loved ones once the time arrives. The last moments of some actively dying patient’s lives may be of higher quality if they are able to spend time with their families and have the chance to say goodbye, rather than having the health care team fight the inevitability that is death (Ufema, 2001).
This decision does not come in any conflict with my value system. I realize that death is an inevitable part of life, and at some point, this should be accepted by patients and their families. The quality of life for patients who are actively dying, yet still receiving numerous medical interventions simply to keep their body functioning as long as possible, does not seem just. I would like to think that patients have the right to die a dignified death without having to suffer from extensive medically futile interventions.
Planning the care of terminally ill clients in the critical care setting can be a challenging and emotional process for everyone involved. It is important for providers to be honest with those affected by end-of-life decisions regarding the patient’s medical status. Although death can be very difficult to discuss and accept, all patients deserve the right to die a dignified death. As technology in medicine continues to advance, it is likely that people will view death increasingly as an option. Patients should be educated on deciding and documenting their end-of-life decisions while they have the chance to state their wishes so that they can experience the last moments of their lives in the manner that they desire.
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