Ethical and Legal

Responsibilities in End of
Life Care

Professional Dilemmas

Four ethical issues that arise from Nursing

Practice include:

1)
2)
3)
4)

Consent/autonomy
Resource allocation
End-of-life care
Truth telling

Copyright 2013 by Nelson Education

Ltd.

Professional Dilemmas
Consentinformed consent & voluntary choices
important
Autonomyneed the information about the
choices & freedom to make choices
Nurses roles include building trust relationships
with clients, providing current & complete
information & respecting clients wishes
Resource Allocation
Macro-allocation (made by governments at all levels)
Meso-allocation (made at the institutional level)
Micro-allocation (made at the bedside, regarding
individual clients)

Copyright 2013 by Nelson Education

Ltd.

End of Life Issues

End-of-life Issues

Nurses often key professionals who

provide care throughout the dying process
Three types of ethical dilemmas include
1) Possible interventions by professionals
2) Possible interventions by those close to
client
3) Possible interventions by client

Copyright 2013 by Nelson Education

Ltd.

Professional Dilemmas
Quality of Life becomes issue with end-of-life
Resuscitation with Cardiopulmonary resuscitation
(CPR), medication & ventilation as ways to prolong
life versus do-not resuscitate orders
CNA Joint Statement on Resuscitative
Interventions (1995) noted 4 categories when
considering CPR

Those will definitely benefit, those

whom we are uncertain will benefit,
those whom will likely not benefit,
those who will not benefit
Copyright 2013 by Nelson Education
Ltd.

CNA: Advance directives

https://www.cna-aiic.ca/~/media/cna/page
-content/pdf-en/ethics_pract_advance_dir
ectives_may_1998_e.pdf?la=en

Slide 6

Professional Dilemmas
Advance Directives: are the means used to
document and communicate a person preferences
regarding life-sustaining treatment in the event
that they become incapable of expressing those
wishes for themselves (CNA, 1998)

First, their existence aims to ensure that the

wishes of a person, previously competent,
are carried out when that person is no longer
able to speak for him or herself.
Second, an advance directive allows for the
appointment of a specific person, a
substitute decision-maker, who can help to
carry out those wishes and ensure that they
are followed.
Copyright 2013 by Nelson Education
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Ltd.

Professional Dilemmas
Advance Directives are commonly expressed
in two ways:
a. An instruction directive or living will, which
identifies what life-sustaining treatment a
person wants in certain situations
b. A proxy directive, which explains who is to
make health care decisions if the person
becomes incompetent. Often referred to as
Power of Attorney (POA) for personal care.
Advanced directives come into effect should a
person become incompetent or incapacitated.
They provide instructions regarding decisions
about care to their substitute decision maker
Copyright 2013 by Nelson Education
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2014 Pearson Canada Inc.

(contin
ued)

49-9

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2014 Pearson Canada Inc.

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Euthanasia
Euthanasia
is defined as a deliberate act undertaken by one
person with the intention of ending the life of
another person to relieve that persons suffering
where the act is the cause of death
deliberate, painless termination of life of a
person afflicted with incurable and progressive
disease
Passive euthanasia, in which treatment may be
ceased or withheld
Active euthanasia, in which body processes
necessary to sustain life are actively interfered
with or interrupted
Assisted suicide is defined as the act of
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intentionally killing oneself with the assistance of

Professional Dilemmas
Euthanasia (Assisted Suicide): An act that brings about
the immediate death of a terminally ill patient
A means to end suffering and allow death with
dignity
Legal in the Netherlands, with due process
the illness must be terminal, with no hope for
recovery
the request must be voluntary and well
considered
the patient must be suffering unbearable pain
a second physician must be consulted
CNA Code of Ethics states that nurses have an
obligation to assist people to achieve their optimal
level of well-being in all states: health, illness,
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injury, or in the dying process

Withdrawal of Treatment
Life-sustaining treatment is withdrawn
Previously labelled as passive euthanasia
Difficulty arises when patient or family views
contrast with that of the health care team
Individuals who argue against euthanasia is
basing on their reasoning on the principle of
the sanctity of life and traditional rules
Others who support euthanasia believe that
sanctity of life is not an absolute principle
and can be overridden with respect for individual
autonomy and dignity of human life.
10

Slippery Slope Argument

Once permitted, euthanasia will become an
accepted practice for the chronically ill, very old,
person with dementia
Can be prevented by limiting the choice to
competent patients
What if a patient is coerced, or does not wish to
be a burden?

13

Professional Dilemmas
CNA position statement on providing
nursing care at the end-of-life articulates
the roles of the nurse at the end of life as
advocacy and promotion of a dignified
and peaceful death
These roles are carried out by ensuring that
clients have access to and understanding of
current treatments, alternatives, and
options, and by facilitating informed choice
and the expression of clients needs, wishes,
and beliefs regarding the dying process
CNA link
https://www.cna-aiic.ca/~/media/cna/page-content
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Ltd.
/pdf-fr/fs08_palliative_care_nov_2000_e.pdf?la=e

Ethical Models
A Framework for Ethical Decision Making (2001)
1) Identify the problem and collect as much information
as you can
2) Specify potentially feasible alternatives
3) Use your own ethical resources to help decide what is
morally relevant for each alternative
4) Propose and test possible resolutions
5) Finally, make your choice

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Ltd.

16

Ethical Models
An Ethical Decision-Making Model for Critical
Care Nursing
1) Gather background information
2) Identify whether the problem is an ethical
issue
3) Identify key stakeholders
4) Identify possible courses of action
5) Reconcile the facts of the case with relevant
principles
6) Resolution

Copyright 2013 by Nelson Education

Ltd.

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Copyright

2014 Pearson Canada Inc.

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End-of-Life Care
It is the nurses role at the end of life to:
communicate treatment to ensure that patients are well
informed of choices and identify how patient want EOL
issues to be addressed

care for and comfort the patient and family

alleviate fear of the unknown (They dont know what to

expect. Give them examples, scenarios, tell the truth.)

preserve the patients dignity and support the family (painfree, no aggressive
End-of-Life
Issues treatment (tube feeds), involve them in
decision making ( autonomy))
respect the rolechallenges
of culture and religion
Communication
Advanced directives (living wills)
Ethical issues related to resuscitation
2
Copyright 2010 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Caring for Older Adults

Issues include:

loss of dignity and respect

abandonment by families
clients not wanting to burden their families
clients finding it hard to rely on others

not condoning practices which are insulting or

demeaning

advocating for independence whenever possible

listening respectfully

Nurses can help by

Artificial Nutrition and Hydration

Artificial Nutrition and Hydration (ANH) non oral
means of administering nutrition to a patient
Common but controversial issues at the end of life

Issues arise when patients with progressive, life

limiting illness refuse or cannot take oral
nourishment and fluids
Deciding whether or not to initiate ANH is an important
conversation to have with patients and their families
Families often believe that their loved ones will suffer
without nutrition

Nurses:
important to help family members understand that loss of
appetite is an integral part of dying process.

Slide 21

Artificial Nutrition and Hydration

CNA (2008) position statement: Stresses the
importance of the health care team working
together to determine whether food and fluid are
beneficial or harmful to a client.
Questions that may help health care professionals
about goals of care:
1. Will clients well-being be enhanced by artificial
nutrition?
2. Are there symptoms that could be relieved or
aggravated?
3. Could hydration enhance clients mental status
or level of consciousness?
4. Will it temporarily prolong clients life?
Slide 22
5. Is that what the client and family want?

Artificial Nutrition and Hydration

When food and hydration are administered for a
prolong period to a client who is not expected to
improve, some nurses will view this care as
extraordinary or heroic, whereas others will see it
as humane
Nurses to stress to families that dying individuals
who are not receiving artificial nutrition or
hydration will still be provided with adequate care.

Slide 23

Do not resuscitate orders

Cardiopulmonary resuscitation (CPR) has become a
standard intervention because of its potential benefits if
implemented immediately

Nurses may experience moral distress due to the

knowledge that patient itll have little benefit

Each health care institutions have a policy for obtaining a

DNR order.
Ethical approach of nurses includes:
- clarifying patient and family goals of care
- balancing potential burden benefit of treatment plan
5

Cultural Considerations
Familiarity with cultural traditions, or a willingness
to learn, will facilitate respect while supporting
patients and families
In some culture, they prefer peaceful death at
home rather than the hospital
Some may requests not to reveal the prognosis
to dying patients believing patients last days
should be free of worry and pain
Examples of specific cultural considerations
regarding death and dying:

Islamic traditions include families preparing the body

for burial and burial without delay

Buddhist traditions include chanting to assist the spirit

to leave the body

Culture: Preparation of the body, Organ

Donation, Autopsy, and Cremation
Recorded consideration
staff must document and request of all suitable patients
Nurses to be knowledgeable about client death-related
rituals such as last rites.
Nurses need to ask family members about preferences
Autopsy: may be prohibited, opposed, or discouraged by
Eastern Orthodox religions, Muslims, Jehovahs Witnesses,
and Orthodox Jews.
Organ: some religions prohibit the removal of any body parts.
It varies among faith
Cremation: prohibited, opposed, or discouraged by Mormon,
Eastern Orthodox, Islamic, and Jewish Orthodox faiths
Hindus prefers cremation and cast the ashes in a holy river
Buddhists may permit euthanasia in hopeless illness
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Culture: Preparation of the body, Organ

Donation, Autopsy, and Cremation
Christian science: unlike to use medical means to prolong life
Jewish faith: opposes prolonging life after irreversible brain
damage
Last rites
Chanting at the bedside
Administration of Holy Communion
Special proceedings for washing, dressing, positioning
Muslims customarily turn the body toward Mecca

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Legislation Relevant to
Nursing Practice and End-of-Life Care
The following are some of the major features of the
legislation:
a) Under the Health Care Consent Act, 1996, resuscitation is
considered to be a treatment.
There is no legal requirement to obtain a physicians written,
telephone or verbal DNR order.
b) The Health Care Consent Act, 1996 and Substitute
Decisions Act, 1992 enable a capable person to create an
advance directive:
the person can indicate the kinds of treatment he or she would
like to be accepted or rejected in the event that the person
becomes incapable.
Slide 28
Copyright 2010 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Legislation Relevant to
Nursing Practice and End-of-Life Care
c) Under the Health Care Consent Act, 1996, a clients wishes
about treatment may be expressed in:
a power of attorney for personal care; any written form; a
verbal form; or any other manner (such as sign language)
In addition, a clients wishes about treatment:
can be changed at any time (nurses must respect the most
current wishes and ensure the client has given informed
consent for the treatment choice); and
are to be interpreted by the clients substitute decisionmaker if the client is found to be incapable; and the wishes do
not constitute consent or refusal of consent.
Copyrig
ht
2010
Elsevier
Canada,
Slide 29
a
division

CNO LINK new

CNO website. Medical Assistance in Dying
http://www.cno.org/en/trending-topics/medical-assistance-indying/medical-assistance-in-dying--additional-resources-andreferences/

Slide 30

Consent for DNR order

My client has expressed that he doesnt
want to be resuscitated. Do I need to get a
Do Not Resuscitate (DNR) order?
CNO:
Consent is required for all plans of care, including
treatments or refusal of treatment.
In a situation where a client has stated that they
do not wish to be resuscitated, their consent, or
that of their substitute decision-maker, is what is
required.
Nurses must be aware of the policy related to DNR
orders within the organization where they work.
Slide 31

Who can certify death

Im an RN who works with clients in the community.
My employer has requested that I sign certificates of
death for clients where death is expected. Can an RN
sign a certificate of death?
CNO:
Only physicians and NPs can sign certificates of
death; and NPs only have the authority to certify
death when specific conditions exist.
Even when a physician or NP has already filled out
the certificate, an RN or RPN cannot date or time the
form because that would constitute certifying death.
Slide 32