Ethical Analysis
Author
Institutional Affiliations
Author’s Note
Ethical Analysis
Ethical Dilemma
An ethical dilemma is a moral situation where difficult decisions have to be made between two completely undesirable or mutually exclusive alternatives. It leads individuals to either compromise over a few ethical principles or violate ethical values. Ethical dilemmas arise due to certain behavior, attitude, personal character, and conflict of individual beliefs. They may also occur due to clash among organizational goals and social values. The individuals involved in ethical dilemmas are called as agents who are forced to choose between morally conflicting options. The three conditions that must be present in any ethical dilemma are; the agents of moral actions obliged to choose best course of action; multiple courses of action to choose from; some ethical principles are always compromised no matter what course of action is taken. Thus, an ethical dilemma implies that the agents are ought to do somethings wrong and fails on one moral requirement while choosing another.
Summary
Cardiovascular diseases are the most prevalent in United States thus, a large number of patients have cardiovascular implantable electronic devices (CIEDs) including pacemakers and implantable cardioverter defibrillators (ICD). Patients may suffer from other cardiac or non-cardiac diseases but these devices act as a barrier to natural death. However, some of these patients and their surrogate decision-makers often request for deactivation of devices in case of serious and painful illnesses ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"DmZHRyOX","properties":{"formattedCitation":"(Buchhalter et al., 2014)","plainCitation":"(Buchhalter et al., 2014)","noteIndex":0},"citationItems":[{"id":676,"uris":["http://zotero.org/users/local/OnfrXiA2/items/HM3EX7RB"],"uri":["http://zotero.org/users/local/OnfrXiA2/items/HM3EX7RB"],"itemData":{"id":676,"type":"article-journal","title":"Features and outcomes of patients who underwent cardiac device deactivation","container-title":"JAMA internal medicine","page":"80-85","volume":"174","issue":"1","ISSN":"2168-6106","journalAbbreviation":"JAMA internal medicine","author":[{"family":"Buchhalter","given":"Lillian C"},{"family":"Ottenberg","given":"Abigale L"},{"family":"Webster","given":"Tracy L"},{"family":"Swetz","given":"Keith M"},{"family":"Hayes","given":"David L"},{"family":"Mueller","given":"Paul S"}],"issued":{"date-parts":[["2014"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Buchhalter et al., 2014). There is a reduced number in reimplantation after battery depletion, device malfunction or implantation related infections. Patients receive excruciating high voltage shocks that cause great distress to patients as well as their families. However, only a few hospital facilities have device deactivation policies.
There are serious ethical and legal implications and few ethical principles that govern policies and decision-making processes of deactivation of ICDs are autonomy, informed consent, beneficence, non-maleficence and justice. The deactivation is considered similar to the concept of euthanasia thus, similar ethical and legal concerns are raised for this issue ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"fFL2IAoY","properties":{"formattedCitation":"(Gura, 2015)","plainCitation":"(Gura, 2015)","noteIndex":0},"citationItems":[{"id":677,"uris":["http://zotero.org/users/local/OnfrXiA2/items/4J58J8CT"],"uri":["http://zotero.org/users/local/OnfrXiA2/items/4J58J8CT"],"itemData":{"id":677,"type":"article-journal","title":"Considerations in patients with cardiac implantable electronic devices at end of life","container-title":"AACN advanced critical care","page":"356-363","volume":"26","issue":"4","author":[{"family":"Gura","given":"Melanie T."}],"issued":{"date-parts":[["2015"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Gura, 2015). About one in three ICD recipients suffer from multiple shocks at the end, prolonging the dying process that is extremely painful and deprive patients of a comfortable and honorable death. Nonetheless, patients and their families do not receive complete information about the functioning and deactivation of ICDs for making informed decisions ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"FpuwdJuX","properties":{"formattedCitation":"(McEvedy et al., 2018)","plainCitation":"(McEvedy et al., 2018)","noteIndex":0},"citationItems":[{"id":678,"uris":["http://zotero.org/users/local/OnfrXiA2/items/TP6QQI74"],"uri":["http://zotero.org/users/local/OnfrXiA2/items/TP6QQI74"],"itemData":{"id":678,"type":"article-journal","title":"Implantable cardioverter defibrillator knowledge and end-of-life device deactivation: A cross-sectional survey","container-title":"Palliative medicine","page":"156-163","volume":"32","issue":"1","author":[{"family":"McEvedy","given":"Samantha M."},{"family":"Cameron","given":"Jan"},{"family":"Lugg","given":"Eugene"},{"family":"Miller","given":"Jennifer"},{"family":"Haedtke","given":"Chris"},{"family":"Hammash","given":"Muna"},{"family":"Biddle","given":"Martha J."},{"family":"Lee","given":"Kyoung Suk"},{"family":"Mariani","given":"Justin A."},{"family":"Ski","given":"Chantal F."}],"issued":{"date-parts":[["2018"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (McEvedy et al., 2018). By providing an appropriate amount of knowledge about implantation, potential risks, reimplanation and deactivation of devices, patients can easily make critical medical decisions ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"IiUHPwND","properties":{"formattedCitation":"(Eiser et al., 2018)","plainCitation":"(Eiser et al., 2018)","noteIndex":0},"citationItems":[{"id":679,"uris":["http://zotero.org/users/local/OnfrXiA2/items/U3G22GWA"],"uri":["http://zotero.org/users/local/OnfrXiA2/items/U3G22GWA"],"itemData":{"id":679,"type":"article-journal","title":"Putting the “Informed” in the informed consent process for implantable cardioverter‐defibrillators: Addressing the needs of the elderly patient","container-title":"Pacing and Clinical Electrophysiology","page":"312-320","volume":"41","issue":"3","author":[{"family":"Eiser","given":"Arnold R."},{"family":"Kirkpatrick","given":"James N."},{"family":"Patton","given":"Kristen K."},{"family":"McLain","given":"Emily"},{"family":"Dougherty","given":"Cynthia M."},{"family":"Beattie","given":"James M."}],"issued":{"date-parts":[["2018"]]}}}],"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"} (Eiser et al., 2018).
Ethical Decision-Making Framework
Nurses face constant ethical dilemmas in their clinical practices and research. The ethical dilemmas encountered by nurses are faced in all of their roles including health providers, clinicians, medical researchers, public health specialists, health care advocates, administrators and policy makers. Developing an ethical decision making framework is imperative in contemporary nursing practice. The four-box framework is used in the context that underlines four basic approaches including clinical indications, patient preferences, quality of life and contextual features. These approaches are based on the ethical principles of autonomy, justice, beneficence and non-maleficence.
Clinical Indications
As per the case study of Theodore Gray, the clinical indications will deal with the medical problem and its implications. Gray was diagnosed with bradycardia at the age of 83 years. He received his primary health care from a personal nurse practitioner named Frank Loras. His health started to deteriorate and he developed dementia in the next seven years. He developed hernia which needed surgical treatment. His cardiologist recommended him implantation of pacemaker. The battery life of pacemakers was 10 years that could get him to live longer but he refused. After his diagnosis of hernia, his surgeon Dr. Petty refused to perform surgery until pacemaker implantation. The probability of success of pacemaker was extremely successful, as it would help reduce the negative implications of both cardiac disease and hernia. The implantation could help him alleviate his suffering due to hernia and provide cardiac care.
Patient Preferences
Gray was mentally capable and competent to make informed decision when he was first diagnosed with bradycardia and he refused to receive pacemaker implantation as he thought he had lived a long and healthy life. However, after the disease progression in the following years, he developed dementia and hernia and became incompetent. Gray was provided with information about the battery life of the pacemaker but was not given detailed information about the implication, potential risks and deactivation of device. His surrogate decision-maker was his wife Flora and she respected his autonomy about not having implantation. Albeit later, she took a decision reluctantly without having consult their family nurse to go for Gray’s implantation before his hernia surgery as she wanted him relieved of his pain. Later, when his health deteriorated to unbearable levels and she was exhausted of taking care of him, she made a decision for deactivation of device.
Quality of Life
With the pacemaker implantation, there were chances of returning to normal life as majority of cases are successful. However, the patients may suffer from high voltage shocks, problems due to device malfunctioning or infections due to implantation procedure. The care provider’s personal beliefs may hinder the process of care delivery and patients’ or his family’s informed decision. Gray’s situation when his wife requests the physicians to deactivate his device was undesirable as he was going through excruciating pain. As his wife consulted Loras, he took her appeal to the Ethics Consultation Group at Victory Medical Center where the case would be analyzed to make an ethical decision.
Contextual Features
In the case of Gray, there were no families issues that hindered his treatment decisions, rather his choice was respected by his wife and practitioner. However, after his diagnosis of hernia, his surgeon made it compulsory that he would only perform the surgery after the implantation. There were no financial or economic, religious or cultural constraints in his case. There were no issues with the patient confidentiality or allocation of resources. The healthcare laws ensure patient autonomy by giving right to the patients to make decisions for themselves or assign a surrogate decision maker. The healthcare providers would consult ethical and legal committees for making any decision about device deactivation.
ANA Code of Ethics
The provisions of ANA code of ethics that are applicable to the case of Mr. Gray would provide an ethical baseline to develop his medical case. The provision number 1.4, ‘the right to self-determination’, can be applicable to his case such that his nurse respected his decision. The provision number 2.3, ‘collaboration’ with the patient during the care process is also applicable. The provision number 4.3, ‘responsibility for nursing judgments, decisions and actions’, is also applicable in this case. The provision number 6.2, ‘the environment and ethical obligation’, is also applicable in Gray’s case.
These provisions are applicable in Gary’s case as nursing actions were based on his self-determination and his choice for treatment. Such a practice ensure patient satisfaction and provides due respect to the patient’s autonomy. The collaboration of nurse with Gray helped him achieve what he wanted for himself albeit after his severe illness, this could not remain the same for him. As Dr. Petty took the matter of implantation in his hands to ensure Gray’s health and provision of optimal health, he fulfilled his professional responsibility. Moreover, as Lary took the case to the ethics consultation group about device deactivation decision, he gave preference to the system’s ethical obligation.
Recommendations
The ethicists will follow up Gray’s case by contacting his nurse Lary and surgeon Petty. They will also include his wife who is his surrogate decision maker, in analyzing the case and come to any sound conclusion about having his pacemaker deactivated. The physicians and nurses who have been giving him care related to his hernia and cardiac health will follow up his condition for 24-48 hours. The termination plan will be based on the provisions of ANA code of ethics. The final plan will be shared with Gray’s wife to avoid any future complications or misunderstandings. The ethicists will consult with Gray’s nurses in order to analyze if they have any queries concerning ethical conflicts as per their primary commitments to their patient or any other concern regarding the course of action from an ethical perception. After the completion of plan and informed consent, the plan will be executed.
References
ADDIN ZOTERO_BIBL {"uncited":[],"omitted":[],"custom":[]} CSL_BIBLIOGRAPHY Buchhalter, L. C., Ottenberg, A. L., Webster, T. L., Swetz, K. M., Hayes, D. L., & Mueller, P. S. (2014). Features and outcomes of patients who underwent cardiac device deactivation. JAMA Internal Medicine, 174(1), 80–85.
Eiser, A. R., Kirkpatrick, J. N., Patton, K. K., McLain, E., Dougherty, C. M., & Beattie, J. M. (2018). Putting the “Informed” in the informed consent process for implantable cardioverter‐defibrillators: Addressing the needs of the elderly patient. Pacing and Clinical Electrophysiology, 41(3), 312–320.
Gura, M. T. (2015). Considerations in patients with cardiac implantable electronic devices at end of life. AACN Advanced Critical Care, 26(4), 356–363.
McEvedy, S. M., Cameron, J., Lugg, E., Miller, J., Haedtke, C., Hammash, M., … Ski, C. F. (2018). Implantable cardioverter defibrillator knowledge and end-of-life device deactivation: A cross-sectional survey. Palliative Medicine, 32(1), 156–163.
