Question: how ethical is it for a nurse to refuse to care for a patient on the grounds that it is unethical to prolong care? I'm talking about cases where families, doctors, or both abolutely refuse to give up and insist that everything
be done despite clear evidence that it is only prolonging the inevitable.
Most nurses who have been in critical care know what I'm talking about and have cared for patients like this. Hospice isn't an option because that would be "giving up", as would "comfort care". So, these poor people are being dialyzed, fed with TPN and having lines inserted into every possible artery to keep them alive.
Is it OK for a nurse simply to say, "I am refusing this patient as my assignment on the grounds that I find continued treatment unethical?"
(Yes, I'm aware that many hospitals have an ethics committee for this sort of thing, but I'm interested in this particular situation.)
This is not a current dilemma with me, but I was thinking ...
I have often been angry at physicians and surgeons for not refusing to do a procedure or surgery that is futile. ("Well, if the family/patient wants it, who am I
to refuse?") That got me thinking, I shouldn't be so quick to judge if I can't do that myself...
Any thoughts would be appreciated.
Oct 7, '01
If the patient had made any indication that they did not want those extreme measures, then YES, I think it is unethical to prolong care. And if the doctor isn't VERY straightforward about the chances of a positive effect, then YES, it is unethical to prolong care. But some families have a deep need to know that they have tried absolutely EVERYTHING. I don't agree with it, but that's where they are at. Many times it seems to arise out of guilt that they didn't do enough for the person before they were sick.
If they have a strong faith I sometimes ask the chaplain to talk to them about the idea that if God wants to perform a miracle then he will do it, with or without all the invasive procedures. Sometimes that is all they need to let go of that idea of doing everything possible. They put it in God's hands instead of the Dr.'s.
Just adding a note here to say that I don't think I would ever refuse a patient because I didn't think it was ethical to continue extreme measures. I think I would use the opportunity instead to try to do some gentle educating of the family that might help to change their viewpoint.
Last edit by aimeee on Oct 7, '01
Oct 7, '01
ana position statement: withholding/withdrawing tx
withholding, withdrawing and refusal of treatment:
honoring the refusal of treatments that a patient does not desire, that are disproportionately burdensome to the patient, or that will not benefit the patient can be ethically and legally permissible. within this context, withholding or withdrawing life-sustaining therapies or risking the hastening of death through treatments aimed at alleviating suffering and/or controlling symptoms are ethically acceptable and do not constitute active euthanasia. there is no ethical or legal distinction between withholding or withdrawing treatments, though the latter may create more emotional distress for the nurse and others involved.
the ana code for nurses provides guidance for ethical conduct and explicates the values and precepts of the profession. it is within the context of the code for nurses that nurses make ethical judgements and discharge their responsibilities. the principal axiom that directs the profession is respect for persons, and this respect is extended to patients, families, nurse colleagues and team members.
historically, the role of the nurse has been to promote, preserve and protect human life. the code for nurses asserts that respect for persons "extends to all who require the services of the nurse for the promotion of health, the prevention of illness, the restoration of health, the alleviation of suffering and the provision of supportive care of the dying. the nurse does not act deliberately to terminate the life of any person." this ethic of moral opposition to actively taking a human life prohibits the nurse from participating in active euthanasia.
the profession's opposition to nurse participation in active euthanasia does not negate the obligation of the nurse to provide proper and ethically justified end-of-life care which includes the promotion of comfort and the alleviation of suffering, adequate pain control, and at times, foregoing life-sustaining treatments.
ceu article: how do we withhold or withdraw life-sustaining therapy?
nursing management october 1999
withholding and withdrawing life-sustaining treatment
october 1, 2000 - american family physician
includes patient handouts on artificial nutrition and hydration http://www.aafp.org/afp/20001001/1562ph.html
and cardio pulmonary resuscitation
withholding & withdrawing life prolonging medical treatment: guidance for decision making.
british medical assoc.
hospice ethics and issues : multiple links
end of life decisions: bibliography
Last edit by NRSKarenRN on Oct 7, '01
Oct 8, '01
Sent your question to ANA's Center for Nursing Ethics as I couldn't find a current source/ article. Here is the reply I received from Gladys White PhD RN:
In answer to your question:
Is it OK for a nurse simply to say,"I am refusing this patient as my assignment on the grounds that I find continued treatment unethical?"
Our new Code of Ethics for Nurses with Interpretive Statements says the following: (p. 20)
"Where nurses are placed in situations of compromise that exceed acceptable moral limits or involve violations of the moral standards of the profession, whether in direct patient care or in any other forms of nursing practice, they may express their conscientious objection to participation. Where a particular
treatment, intervention, activity, or practice is morally objectionable to the nurse, whether intrinsically so or because it inappropriate for the specific patient, or where it may jeopardize both patients and nursing practice, the nurse is justified in refusing to participate on moral grounds. Such grounds exclude personal preference, prejudice, convenience , or arbitrariness. Conscientious objection may not insulate the nurse against
formal or informal penalty. The nurse who decides not to take part on the grounds of conscientious objection must communicate this decision in appropriate ways. Whenever possible, such a refusal should be made known in advance and in time for alternate arrangements to be made for patient care. The nurse is obliged to provide for the patient's safety, to avoid patient abandonment, and to withdraw only when assured that
alternative sources of nursing care are available to the patient."
I hope that this helps and thanks for your inquiry.
Gladys B. White, Ph.D., R.N.
Center for Ethics and Human Rights
American Nurses Association
600 Maryland Avenue, SW
Suite 100 West
Washington, D.C., 20024-2571
TEL: (202) 651-7054
FAX: (202) 651-7001
Last edit by NRSKarenRN on Oct 8, '01