Nursing practice is led by both theory and science. The complexity of nursing makes its practice varied and underdetermined. Nurses are expected to have good clinical judgement skills. To achieve this, nursing research is crucial since it offers a nurse with evidence-based knowledge that can be used to effectively deal with patients. Considering this, nurses have the obligation to make clinical judgements based on a patient’s condition (Kemppainen, Tossavainen & Turunen, 2012). The institute of medicine (IOM’s) report indicates that nurses play a critical role in promoting healthcare and therefore it is in their place to improve healthcare by collaborating with other healthcare practitioners. Relevant factors in nursing practice which influence the health status of a given population are known as phenomena of interest (POI). In nursing practice, a POI is usually identified from practice situations and practice experience between a nurse and a patient. The purpose of this paper is therefore to examine the various effects of medical futility in care of critically ill pediatric patients. In addition to this, personal philosophic viewpoints in relation to the clinical problem will be addressed, as well as opposing philosophic viewpoints. Finally, the four ways of knowing will also be discussed, and the role that they play in advanced nursing practice will be established.
POI: Medical Futility in The Care of Critically Ill Pediatric Patients
One of the most complex issues in healthcare is to decide when to stop intensive care for a critically ill patient who shows no signs or hope of recovery (Schneiderman, 2011). Over the recent years, there has been an escalation of cases where physicians continue to offer intensive care to critically ill pediatric patients, even when there is minimal or no hope of patient recovery. This has been attributed to the recent technological advances in critical care (Needle, Mularski, Nguyen & Fromme, 2012). According to Nair-Collins (2015), “futile care” is a term used to describe the provision of potentially ineffective treatment that offers no benefit to critically ill pediatric patients. Medical futility has been defined as a phenomenon where therapy does not add value to patients well-being. This phenomenon usually draws contrasting opinions between the authority of the physician and the autonomy of the patient (Needle et al, 2015). There is no justification whatsoever, for a physician to prolong the suffering of children and their families. From both an ethical and an economic dimension, it is in a physician’s best interest to limit care that is deemed futile. The medical futility issue is a significant POI in nursing practice because it is a major issue of end of life ethical decision making (Morparia, Dickerman & Hoehn, 2012).
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For more than a decade, debates with regards to medical futility have been heated within the legal, ethical and medical communities, with each community having their own views. The main issue raised has been the right of a patient to self-determination, i.e. right to refuse non-beneficial medical treatment or overtreatment (Needle et al, 2015). The issue is more complicated in pediatric care because the right to self-determination does not apply to children due to their age. This leaves caregivers and parents of these patients with the burden of deciding whether or not to discontinue treatment. Many a times, families find themselves in conflict with physicians, which is certainly not in the best interest of patients (Kockler, 2015). Offering futile medical acre to critically ill patients is consequently associated with increased patient suffering, delayed palliative and comfort care, give the child’s family a false sense of hope and result to heavy financial burdens on the child’s family (Johnson, Browning, Gay & William, 2015). Additionally, this phenomenon results to moral distress among the healthcare providers who end up becoming dissatisfied with their jobs. This results to high employee turnover in the healthcare industry, which consequently leads to decreased quality of care (Morparia et al., 2012). Therefore, futile care in pediatric patients should be avoided not only because it is costly, but also because its costs are disproportionate to its benefit.
Personal Primary Philosophic Viewpoint
Continuing to offer medical treatment on the terminally/critically ill children affects both the medical professionals as well as family members financially and medically. It also prolongs suffering to the young patients, which is ethically not right. With regards to the quantitative component of medical futility; its pure ignorance for a physician to think any medicine can overcome an illness deemed too strong for the available remedies (Needle et al., 2011). What is the need of putting a patient through an intervention that has minimal or no likelihood of benefiting the patient at all? Over the years, the practice of medicine has been considered to be inherently uncertain (Kemppainen et al., 2012). This is because everything done in medical practice, is usually drawn from empirical evidence. Due to this fact, most physicians are usually more oriented towards pursuing the most unlikely treatments, while expecting a positive result. However, physicians can be taken out of this paralysis if focus is placed on the real definition of futile. A physician’s ordinary duty does not require offering a futile medical care, but rather it requires helping the sick, and offering futile treatment does not actually benefit the patient (Kockler, 2015). The number one medical duty of healthcare providers is to avoid unnecessary harm, while the main ethical duty is to consider proportionality. Considering the quantitative viewpoint therefore, it important to offer beneficial care to patients, one that does not prolong their suffering. The degree of autonomy of patients is however limited such that a physician has professional responsibility of offering beneficial care to the patient. Moreover, there is nothing that can justify the choice to prolong the suffering of a young patient, when the physician has the bottom-line knowledge that the likelihood of recovery is close to zero (Nair-Collins, 2015). Therefore, when providing care for the patient it is important to ensure that the care provided improves the patient’s quality of life.
Alternative Philosophic Viewpoint
The major role that healthcare providers play in the life of a patient is promotion of health and hence improvement of the quality of life. Moreover, medicine is designed to promote healing (Johnson et al., 2015). In the quantitative view point medical futility is described as that which the quality of benefit received from a certain intervention is exceedingly poor. This can be traced back to Plato & Hackforth (1981), where the statement below is found;
“ Asclepius (who is considered a legendary divine physician), did not attempt to offer a prescription to individuals who were always in an inner state of sickness, because a life preoccupied by illness and neglect of work is not worth living.” (Plato & Hackforth, 1981).
An essential point about medical practice is that unless one is conscious, and has the ability to appreciate it, that’s when it can be considered beneficial to the patient’s health. In the qualitative viewpoint, futile medical care leaves a patient unable to achieve any other life goals. The outcome that results from intensive critical care cannot be regarded as a success, but rather as a failure to the goals of medicine (Schneiderman, 2011). Though this viewpoint defines medical futility fully, it does not specifically define the POI in this case which is direct ted to young patients. It however adds to clinical knowledge and practice in that healthcare professionals should be focused in not only keeping one alive, but also in improving the ability of one to achieve future goals (Kockler, 2015).
Ways of Knowing in Nursing
Campbell, Penz, Dietrich-Leurer, Juckes, & Rodger (2018) describes the four fundamental ways of knowing as defined by Carper in 1978. Campbell et al. (2018), explains that knowledge and beliefs in nursing are developed from the four fundamental ways of knowing which are: empirical way which involves factual science knowledge that can be systematically organized into laws and theories. In nursing practice, empirical knowledge facilitates the use of evidence based practice. The second way of knowing is ethical knowing which facilitates the development of a moral code. Moral code is basically the sense of differentiating right and wrong. In nursing practice, ethical knowing guides an individual’s personal actions and decisions. Personal knowing is the knowledge that an individual acquires through observation reflection and self-actualization. Personal knowledge propels nurses towards wholeness and integrity. The last way of knowing identified by Campbell et al. (2018) is aesthetic knowing. This is what makes nursing an “art”. It is the integration of all these ways of knowing that leads to creation of a new understanding of a new phenomenon, i.e. discovery of a new perspective (Marrone, 2017). The four ways of knowing create a better understanding for nursing practice which is considered a holistic profession. Advanced nursing practice plays a critical role in patient care. To provide efficient care, nurses use their professional knowledge, evidence-based interventions and newly acquired knowledge while remaining within the moral code (Campbel et al., 2018). Marrone (2017) further explains that while conducting professional development on nursing, its essential to take the four ways of knowing into consideration. To be able to provide fundamental interventions to pediatric patients, one needs to utilize these ways of knowing to acquire knowledge relevant in nursing practice.
Conclusion
Medical futility is a controversial issue that has sparked heated debates over the last few years, most especially due to advanced technology which has encouraged the need to continue intensive medical care even when there is little hope for recovery. This phenomenon occurs across all ages including pediatric patients and the consequences in most cases are grave; it leads to reduced quality of life, increased healthcare costs and prolonged suffering. The four fundamental ways of knowing are important in nursing practice since together they lead to the development of cognitive, intuitive, experiential and personal knowledge.
References
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