Some of the issues that need to be addressed in these advanced directives include specific treatments to be refused or desired; the time the directive needs to take effect; specific hospitals and physicians to be used; what lawyer, it any, should be consulted; and any other consultations, such as family or a religious figure (Butts & Rich, 2013, p. 255). These advanced receives will be utilized it the patient loses their decision-making capacity and has been rendered incompetent due to their symptom’s.
The problem arises when the patient does not have this advanced directive. When the patient can no longer make competent decisions, the family might experience difficulty in trying to determine a progressive right course of action. When a patient loses their autonomous decision-making capacity, the decision making falls to a surrogate. A surrogate decision marker is an individual, usually a family member, who acts on behalf of the patient to make decisions about the patient’s treatment options Butts & Rich, 2013, p. 257).
Decisions about treatment options can be complex. The surrogate, in absence Of an advanced directive, must consult the attending physician, other family members, and other healthcare providers in order to make the best decision for the patient. Fortunately for surrogates there are ethical principles that can govern their decisions. One of them in particular can be Of comfort to the surrogate. Withholding and Withdrawing treatment from a terminally ill or permanently unconscious patient allows a natural dying process to take its course.
It does not constitute killing or assisted suicide (Butts & Rich, 013, p. 2571 Medical futility can influence the decision to withhold or withdraw treatment. Medical futility is an unacceptably low chance of achieving a therapeutic benefit for the patient (Butts & Rich, 2013, p. 259). Healthcare professionals have accepted and ethically justified withholding and withdrawing treatments deemed futile or extraordinary. Most Other people have also accepted this concept. However, it is not universally accepted. In the 1995 case Of Giggling u.
Massachusetts General Hospital, the family Of the patient wanted the attending physician to order CPRM to be provided to the dying patient. The patient, Ms. Giggling, was comatose and dying With multiple organ-system failure. The court supported the physician’s claim that CPRM was medically futile (Butts & Rich, 2013, p. 261). A permanent vegetative state (PAS) is a state in which a person with severe brain damage has enough autonomic function to survive with constant medical intervention but does not exhibit any awareness or higher brain function (Butts & Rich, 2013, p. 52). PAS has played a major role in court cases related to withholding and withdrawing treatment. The case 1976 of Karen Ann Quintal was the first landmark case involving withholding and withdrawing treatment. In 1975, Karen was at a party, mixed alcohol with Valid, lapsed into a coma, and placed on a ventilator. Her parents sued to have her removed from the ventilator. They kept getting denied by the courts. Finally after many legal battles, the Nevus Jersey Supreme Court granted her parents the right to remove her from a ventilator.
Previously, physicians would not remove her from a ventilator because they could not establish brain death, Once Karen was taken off the ventilator, she continued to breathe on her own for ten years (“The big sleep,” ND. )_ Because of this case, the definition of and criteria for PAS as established. It also set precedence for parents to have the right to choose withholding and Withdrawing treatment for their child. It also aided in the creation and implementation of the advanced directive.
The 1990 case of Nancy Curran also dealt With the issue Of parents trying to Withhold and Withdraw treatment for their child who was in a PAS. In 1983, Nancy was in an automobile accident and sustained injuries that led to complete loss Of consciousness with significant oxygen deprivation and then to a PAS with continuous artificial nutrition and hydration. After almost eight years of litigation, the Supreme Court f Missouri finally granted the wishes of her parents for the discontinuance of her feeding tube.
She died three days after the court’s decision (“The case of,” n. D. ), Because of this case, conditions for withholding and withdrawing treatment were established. The 2005 case of Terra Shiva highlighted the issue of surrogate decision-making in regards to withholding and withdrawing treatment. In 1990, Terra was found unresponsive by her husband, Michael. She had suffered an acute cardiac arrest with prolonged cerebral hypoxia, She was diagnosed with a PAS and had a tending tube in place. Her husband wanted the deeding tube removed, but her parents objected.
The feeding tube was removed twice and then replaced because of the legal battle between the husband and the parents, By Florida law, the husband, as spouse and guardian, had a legal right to serve as the surrogate decision maker for Terra. Her parents thought otherwise. A total of twenty-one lawsuits and appeals were filed. After the court finally established that there was clear and convincing evidence that Terra had previously stated that she did not want to live in a condition where she would be a burden to anyone else, the court ordered that the feeding tube be removed or a third and final time.
Terra died thirteen days after (Hunter, n_d. N Because of this case, substituted judgment became the ethical and legal standard, with guardianship as the focal point regarding decision making for the withholding and withdrawing of treatment. All of these cases highlight the importance of having an advanced directive and the multitude Of legal complications associated with not having one. The main ethical issue regarding the withholding and Withdrawing Of treatment is Who is the appropriate surrogate decision maker for an incompetent person?
As demonstrated in the previous legal cases, if there re no documented preferences, then there is a good chance for a legal dispute between the parties involved who think that they have the right to make that decision. The biggest challenge for a surrogate decision maker is for them to be able to make an unbiased substituted decision based on an understanding of what the patients would decide for themselves, and not the values of the surrogate.
To assist the surrogate with making the proper decision, physicians should provide all relevant medical information and explain that decisions regarding withholding or withdrawing life-sustaining treatment should be based hat substituted judgment when there is evidence to the patient’s preferences and values. In making a substituted judgment, surrogate decision makers may consider the patient’s advance directive, if any; the patient’s values about life and the way it should be lived; and the patient’s attitudes towards sickness, suffering, medical procedures, and death.
If there is not adequate evidence of the incompetent patient’s preferences and values, then the decision should be based on the best interests of the patient including what outcome would most likely promote the patient’s well-being (“Opinion 2. 20,” n. D. )_ Because Of the Renville of autonomy the physician should almost always accept the surrogate’s decision for the incompetent patient. However, there are situations that may require either institutional or judicial review and/or intervention in the decision- making process.
These include: there is no available family member willing to be the patient’s surrogate decision maker, there is a dispute among family members and there is no surrogate decision maker designated in an advanced directive, the physician believes that the family’s decision is clearly not what the patient would have decided if competent, and the physician believes that the session is not a decision that could reasonably be judged to be in the patient’s best interests.
When there are disputes among family members or between family and health care providers, the use of ethics committees specifically designed to facilitate sound decision making is recommended before resorting to the courts (“Opinion 2. 20,” n. D. ), No matter what decision the physician or the surrogate decision maker determines as the best course of action regarding the withholding and withdrawing of treatment, nurses need to give compassionate, excellent care to the patient. The family members need to feel a sense of inference that the nurses will maintain moral sensitivity with a course of right action.
In fact, the American Nurses Association (ANA) in their Code of Ethics for Nurses with Interpretive Statements emphasizes that nurses must ethically support the provision of compassionate and dignified end-of-life care as long as nurses do not have the sole intention of ending a person’s life (Butts & Rich, 2013, p. 268). This course of right action includes the promotion of comfort, the relief of pain, and support of the family when the decision has been made to withhold or withdrawn treatment. The decision to withhold or withdraw treatment is an incredibly complex ethical issue.