The ethics of refusing care

[mattcastens]

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.

[aimeee, BSN, RN]

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.

[NRSKarenRN, BSN, RN]

ana position statement: withholding/withdrawing tx

http://www.nursingworld.org/readroom/position/ethics/eteuth.htm

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.

discussion

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

http://www.springnet.com/ce/m910a.htm

withholding and withdrawing life-sustaining treatment

october 1, 2000 - american family physician

http://www.aafp.org/afp/20001001/1555.html

includes patient handouts on artificial nutrition and hydration http://www.aafp.org/afp/20001001/1562ph.html

and cardio pulmonary resuscitation

http://www.aafp.org/afp/20001001/1564ph.html

withholding & withdrawing life prolonging medical treatment: guidance for decision making. british medical assoc.

http://www.bmjpg.com/withwith/chapters/intro.htm

hospice ethics and issues : multiple links

http://www.hospicene.org/links/ethics.html

end of life decisions: bibliography

http://www.nursingworld.org/ethics/eendbib.htm

[hoolahan, ASN, RN]

I don't think I would refuse to care for the pt, and I don't think I would be allowed to. I think that unless every nurse on the unit refused to care for the pt, a coworker would offer to care for the pt instead if it is that distressing to a particular nurse. (Hopefully)

I don't think you should even think about refusing the assignment, until there is an ethics commitee meeting first. If it is a family issue, you cannot know what it is like to be in their shoes. Yes, maybe they are guilty, but they have to deal with things they way they need to. We can only educate them and support them. We can also be sure the pt is kept comfortable and pain free even if on a vent. There is no reason for anyone to suffer with all the emphasis and education on pain management .

As for the doctors not being truthful or behaving unethically, well they stick together. I had a pt who was morbidly obese, severe PVD, renal insufficiency, and was hemiplegic from a prior stroke, sent to the OR for CABG. I had her several days post op, oh yeah, 86 years old. Her quality of life was not good before the surgery! In my eyes, this woman should have never been accepted for surgery. The surgeon should have said to her, loose 50 pounds, come back and we'll think about it. This is not to punish her, but for her own benefit, not just from a surgical standpoint, but to lower BP and improve her overall health. The surgeon poo-poo'd a concern I had, so I said, WHY did you even do this lady in the first place if you feel that way. He said, the truth? Money. Now that is a sad state of affairs. I honestly don't know what to say about that. I have seen countless surgeons lie to pt's. Not that long ago there were some magical statitics that were held against a surgeon if the pt dies within 30 days of surgery. I heard surgeons threaten residents "This pt better be here when I get back on Monday (This with a pressure of 60 sys with pressors full speed!) They would make pt's a DNR on day 32 so as not to be conspicuous. It is one of the reasons I no longer enjoy critical care so much. After 17 years in critical care, I have seen more suffering than I care to. It isn't the routine pt's I remember, but the ones who suffered, it takes its toll on you. I am now doing home health, though I still do a shift or two with an agency in my former CT ICU, but I am loving HH, b/c I can make such a difference. I feel like I am improving quality of life and I can watch people improve as a direct result of my pt education. And see symptom relief when I have suggested a med adjustment. The pt's in the inner city are so grateful to have us, and it feel really good after all these years, even though work is still work and politics still suck.

[mattcastens]

Great responses so far, thanks!

Let me clarify my position, which I should have done in my original post....

I, personally, believe that if a family member or patient were to request a procedure or treatment that either has no hope, or greatly unlikely chance of success (not including palliative care, of course), or likely to create a worse situation, it is entirely ethical for a physician to say, "It is your choice to procede, but for the reasons I have stated, I do not wish to participate in this course of action. However, here is a list of physicians I can recommend that may be able to help you in your continued treatment." By doing this, a doctor may remove themself from the situation without removing possible treatment from the patient's options.

By the same token, why couldn't a nurse say, "It is your choice to procede, but due to personal beliefs I can no longer be a part of the care team?" After all, there are other nurses involved, and a simple change of assignment (usually) isn't a problem. It would be even easier to say at the start of the shift, "I don't believe that this course of action is ethical, and I am requesting to no longer be given this patient as an assignment."

Certainly, if no other nurse is qualified or available to care for someone, there is a moral obligatoin to care for the patient.

Thoughts?

[rjlrn95]

Instead of saying "it is an ethical issue w/me" I would just simply ask not to be assigned to Jane Doe for personal reasons. shouldn't be a problem unless you have a control freak for a chg nurse or manager. Should it? We are supposed to have that choice, as long as we don't abuse it.

And thanks to NRSKarenRN for all the references and good info, going to print some of it out and carry w/me, as I do agency

nursing.

[hoolahan, ASN, RN]

Matt, ITA with what you say, but if even one nurse opts out, then it is cause for an ethics committee to meet. Especially if it the same doc involved, or a recurring issue.

We have had ethics meetings in HH too. One reason nurses call these meetings is b/c we do not want to be involved in a case where a pt lives alone, is unsafe, but the pt is not willing to enter a long-term care facility. Ex., a bedbound pt, who cannot turn him or herself, cannot get out of their own home if there were to be a fire, or pt's who are totally non-compliant. We explain our feelings about it to the pt. We have a meeting, and the bottom line is always this...pt's have a right to live their life the way they choose, and we go on the record as officially saying we have discussed alternatives with them, and we will not be held liable for their unsafe choices. We also do this for non-compliant pt's. We have discharged pt's for verabl abuse or lewd behavior by pt and/or family members. In those cases 2 nurses or one nurse and an escort or other personnel hand deliver a letter stating the same, to the home and have someone sign that they recieved the letter, if they won't sign, we have a witness.

As for docs saying that? I wish I could hear that one every once in a while. In my former place of employment, I did hear of surgeon's turning pt's down for surgery. but more often it is the pt's who have been turned down everywhere else that I have seen. The sad part is, someone will always do it for a buck.

[mustangsheba]

Ethics is not only a professional thing, it is also personal. (For that reason, I do not administer chemotherapy and I do not work ICU.) These are just my personal biases. I refuse to administer care that merely prolongs suffering. I'm usually asked what I can do when I report to a new facility, and I just tell them that I don't do those two things but I can do anything else. Most managers respect our individual principles and try to accommodate us in staffing if a particular case is inconsistent with our value systems. I admit, I have gone head to head with physicians when they are ignoring or misleading family. I encourage you to be up front with your managers with what you find unhealthy for you in giving care. This is not abandonment. This is good self care. There is always someone else who has a different comfort level who can step in, someone for whom you can take over in a different situation.

[NRSKarenRN, BSN, RN]

Matt:

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.

Sincerely,

Gladys

Gladys B. White, Ph.D., R.N.

Director

Center for Ethics and Human Rights

American Nurses Association

600 Maryland Avenue, SW

Suite 100 West

Washington, D.C., 20024-2571

E-MAIL: [email protected]

TEL: [phone]

FAX: [phone]