Introduction
The recent advances in the area of life support have caused the line between being alive and the dead to become increasingly blurred. Improvements in medical technology have had positive ramifications due to the increase in healthcare options in treating diseases. However, when decisions arise regarding the treatment of patients in their last days, the options are usually clouded with complex ethical dilemmas. Medical practitioners have to face the tough choices that come with picking the most appropriate treatment to ease the suffering the patient experiences in their final days. Most significantly, termination of therapy altogether is a viable option that the medical professionals will assess. Medical ethics is the study of moral values as applies to the field of medicine. The role of ethics is to "provide guidelines and codes for physicians as for their duty, responsibility, and conduct" (Zhang, Nilsson, & Prigerson, 2012). Some of the values that physicians and nurses must leverage in their ethical practice include autonomy, beneficence, non-maleficence, justice, dignity, and honesty. In patients experiencing their last days or palliative care, the decision is always hinged on either withdrawing or withholding the treatment. In the wake of a patient's last days in the hospital, physicians and nurses must remain mindful of the ethical values in treatment as a way of emphasizing the importance of human dignity.
Problem
Improving the last days of life and advocating for good health has developed into one of the most significant missions of many organizations and a subject of research determined to initiate policy improvements. According to the Hastings Center Report, “too many Americans die unnecessarily bad deaths-deaths with inadequate palliative support, inadequate compassion, and inadequate human presence and witness” (Menzel & Steinbock, 2013). It is almost conventional for health professionals to ensure that terminally ill patients die with a sense of dignity. However, this assertion comes with two primary concerns. The first one involves the claim that lives without a sense of dignity should be terminated. Such actions might include either withholding or withdrawing of life-preserving treatment or in some instances, administering of life-ending medication. The second claim in this regard entails the fact that individuals should be given the opportunity to make choices regarding the nature of the death they want. Some of the options in this regard include voluntary euthanasia or assisted suicide. The main problem facing patients in the last days is the prospect of undignified or “bad death” that results from poor management of the debilitating symptoms of chronic illnesses that appear during the end of life (Zhang, Nilsson, & Prigerson, 2012).
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The proper understanding of undignified death requires one to critically appreciate the common elements associated with good health during palliative care. The first characteristic involves adequate symptom and pain management. The second primary element that determines good health during this period includes measures aimed at mitigating any treatment processes seeking to prolong the dying process. Adequate preparation of death must also take center stage not only for the involved patient but also for their loved ones. It is also imperative for the patient to receive a sense of emotional and spiritual completion and avoid any loneliness. According to research, the three most common types of symptoms associated with dying patients include difficulty breathing, pain, and depression accounting for 75%, 36%, and 25% respectively (Zhang, Nilsson, & Prigerson, 2012). In their report discussing the problems facing terminally ill patients, the Hastings Center Report continued by saying, “Deaths preceded by a dying marked by fear, anxiety, loneliness, and isolation. Deaths that efface dignity and deny individuals self-control and choice” (Menzel & Steinbock, 2013). In summary, one of the primary problems affecting patients in their last days of life is the prospect of undignified death characterized by poor pain management and unethical tendencies surrounding the treatment decisions.
Target
During palliative or hospice care, the medical practitioners aim to provide a sense of relief to patients with a series of life-threatening diseases including their families. Also, they have an essential duty to affirm death and ensure that patients regard death as a normal process. The first primary players in the well-being of a patient at the end of their life include the physicians and nurses. The two professionals are critical in five different types of cares including physical, medical, psychological, social, and spiritual care. The role of physical care in these types of patients is to ensure that they are kept as comfortable as possible until their ultimate death. Therefore, doctors and nurses have an essential role in ensuring successful pain and symptom management. Some of the weaknesses that these medical professionals will be tasked to manage include fatigue, weakness, mouth problems, ascites, and loss of appetite among others. The second vital intervention is the physical care where doctors and nurses must show the ability to provide psychological needs not only for the dying patient but also for the close family members. Jo & Kim, (2013) intimated that medical care involves the administering of appropriate drugs to the patient without necessarily shortening or prolonging life. Social and spiritual care is aimed at instilling a sense of hope and healing during the time of suffering.
Therefore, as potential targets for this ethical problem, doctors and nurses have an essential role to play in enhancing dignified death. Other than pain and symptom management, these professionals are usually met with ethical dilemmas in matters relating to deciding the course of a patient's life. Some of the principles that doctors and nurses must leverage in their work include autonomy, beneficence, maleficence, and informed consent among others. Some of the difficult ethical questions that physicians and nurses have to contend with include whether to withhold or withdraw treatment, the dilemma over who should make moral decisions in case the patient is incapacitated, and whether or not to initiate a physician-assisted death. As a result, understanding the essence of dignified death at the end of life care will ensure that physicians and nurses make the right decisions as pertains to patient care. The entire hospital system is also a viable target for this proposal especially the palliative and hospice facilities. Other than training their health professionals to deal with the end of life diseases properly, it is their essential duty to avail the necessary resources to manage pain and symptoms. Furthermore, these facilities must remain keen to ensure that they are aligned with ethical guidelines that guarantee that patients are handled in a manner that inspires respect to human life and dignity.
Reasonable Options
Patients in their end of life often experience immense pain and suffering that in most cases eventually lead to their deaths. During this period, the physicians, nurses, family members, and patient have to make ethical decisions to ensure that the patient experiences the best course of treatment. However, before delving into the options, several ethical guidelines must be put into consideration. The autonomy of the patient is one of the primary aspects that medical practitioners must factor. Despite its importance, autonomy is only limited in situations where the patient's capacity to make decisions can be verified (Huxtable, 2012). Alternatively, informed consent or a will that delegates the duty of decision-making to another party will also be an option. The second ethical consideration involves ensuring that the physicians do not harm the patient in principle known as non-maleficence. Thirdly, beneficence ensures that the patient receives only treatments and medications that have a benefit to their overall care. Consideration of the three ethical principles, therefore, leads the physician, nurses, family members, and patients (if applicable), to consider specific options to enhance a dignified death.
One of the solutions to solve the issue of undignified death in patients in their last days of life is to consider euthanasia or physician-assisted death. A celebrated South African-based bishop in support of euthanasia one said," As people have the right to live with dignity, they also have the right to die with dignity" (Battin, 2015). Most significantly, "some medical conditions are simply so painful and unnecessarily prolonged that the capability of the medical profession to alleviate suffering using palliative care is surpassed" (Battin, 2015). Extensive period of suffering denies the patients an opportunity to live a life of dignity. The advent of technology has also meant that it is increasingly possible to prolong life. As the patients continue to suffer, the family members and the health system, in general, continues to spend immense amounts of resources in a patient whose chances of survivability are low. Despite its advantages, euthanasia has been viewed by religious traditions as a dangerous act that goes against nature and the will of God. Regarding ethics, the Hippocratic Oath did not authorize it whatsoever. It also violates the principles of non-malfeasance that warns against any harmful intervention that a physician wishes to do.
The second option that can be assessed is the initiation of a process of life-prolonging. Some hospitals and care facilities have in many instances resorted to the life-support machine as a way of dealing with terminally ill patients in their vegetative states. It goes in tandem with the ethical principle of non-maleficence and justice as denying as euthanasia is viewed as injustice because it denies the patient an opportunity to live. Battin, (2015) noted that the first advantage of life-support treatment is that it provides the patient a chance to survive. Furthermore, it gives hope to the family members and gives them the much-needed time to come in terms with the traumatic events. Although the chances are low, there have been reported cases, where patients put on life support machine, have recovered. The second advantage of this strategy is that it provides patients who might have written a will to fight every step of their lives a chance to battle and regain their health. However, some of the cons of the procedure include the fact that it prolongs the agony and only works to extend death. Huxtable, (2012) intimated that studies have also shown that patients on life support care and artificial nutrition experience many side effects such as diarrhea, cramps, and artificial bloating. The patient must be injected with anesthesia and sedatives to ensure that some of these procedures become a success.
The third option would be for the physicians to consider the power of autonomy of the patient and if they lack the much-needed capacity to make decisions, then the assigned surrogates will determine whether the patient will be put in life-support machine or physician-assisted death will apply. Some of the advantages of this strategy include the fact that the physicians will be absolved for any perceived loss because the decision emanates from the patient or the surrogates (Winkler, Hiddemann, & Marckmann, 2012). It stresses the importance of autonomy and informed consent in care. However, it also comes with several disadvantages. First, in some instances, it is difficult to ascertain whether patients in the last days can make a sound decision regarding the most appropriate cause of action to take. Secondly, the surrogates are prone to make decisions charged with emotions without looking at several issues that come into play including the possibility of healing, costs, and the well-being of the patient.
Recommendations
Physicians and nurses must first understand their role at the end of life care. As such, this can call for training to enhance capacity building not only to bolster their skills in treatment but also their moral standings. Euthanasia, physician-assisted death, and informed consent among other common ethical considerations such as autonomy and non-maleficence should be critically understood in a bid to guarantee that the patient experiences a dignified death. The health facility should further ensure that it adheres to the various ethical standards as stipulated by multiple physician and nursing bodies such as the American Nursing Association among others.
The second recommendation is to ensure that the hospital or care facility acquires various health resources that minimize pain and suffering during the end of life treatment. This is in tandem with the previously discussed option where patients can opt to go to the life-support system to battle for their lives as the loved ones come to term with the reality of death. Acquisition of the necessary resources including machines and medications will work to ensure that the patient receives the best form of treatment before they ultimately die.
The third recommendation would seek to achieve success through initiating policy changes to ensure efficiency in decision-making to avoid any unethical practices. Any terminally ill patient admitted to a hospital will be required to possess an informed consent signed by an attorney containing two critical pieces of information. First, it should identify the surrogates who will make decisions on behalf of the patient in case of incapacitation. Secondly, it should identify the will of the patient and whether they would want to consider physician-assisted death or treatment in a life-support machine.
Implementation
The first process in implementation will require adequate funding to facilitate the training of physicians and nurses to properly deal with the end of life professional and ethical requirements. The funds will also ensure that the hospital acquires the much-needed resources that will enable proper management of patients during their end of life care. The second step will require the meeting of all top hospital stakeholders and government officials to initiate the process of policy change. Thirdly, the policy change will be communicated to the hospital employees and the general public to ensure prompt compliance. The hospital management will collect feedback from the public and use it for possible future changes. After public participation, the policy will be gazetted and begin its full effect on the end of life patients coming to the facility.
Conclusion
In the wake of a patient's last days in the hospital, physicians and nurses must remain cognizant of the ethical values in treatment as a way of emphasizing the importance of human dignity. Although death is regarded as part of normal human life, the circumstances surrounding the event should inspire a sense of respect and dignity. For the terminally ill patient, the critical ethical decision has also been either to withhold or continue with treatment for a patient who has shown little signs of survival. Some of the available options in managing terminally ill patient include euthanasia or physician-assisted death, life-support treatment, or basing decisions depending on the will of the patient or the surrogates. In preventing undignified deaths in hospitals, physicians and nurses must ensure that all their choices are in tandem with ethical principles of autonomy, beneficence, and non-maleficence. As such, all actions and strategies must be inspired by the need to manage pain and avoid unnecessary prolonging or shortening the life of a patient.
Works Cited
Battin, M. P. (2015). Physician–Assisted Suicide: Safe, Legal, Rare? In Physician Assisted Suicide (pp. 63-72). Routledge.
Huxtable, R. (2012). Law, ethics and compromise at the limits of life: to treat or not to treat?. Routledge.
Jo, K. H., & Kim, Y. J. (2013). The impact of nurses' attitude toward dignified death and moral sensitivity on their end-of-life care performance. The Korean Journal of Hospice and Palliative Care, 16(4), 223-231.
Menzel, P. T., & Steinbock, B. (2013). Advance Directives, Dementia, and Physician‐Assisted Death. The Journal of Law, Medicine & Ethics, 41(2), 484-500.
Winkler, E. C., Hiddemann, W., & Marckmann, G. (2012). Evaluating a patient's request for life-prolonging treatment: an ethical framework. Journal of Medical Ethics, Medethics- 2011.
Zhang, B., Nilsson, M. E., & Prigerson, H. G. (2012). Factors important to patients' quality of life at the end of life. Archives of Internal Medicine, 172(15), 1133-1142.
