Flashcards in Lecture #10 - Ethical Challenges in Palliative Care Deck (40):
Moral distress def?
Environment/professional requirement impedes on nurses desired action in relation with her own ethical standards. "Nurse cannot do the right thing."
Moral distress en indicators of environment vs nurse weakness?
Moral agency def?
A nurse capacity to engage in actions that morally relevant (right). IN both the hospital/caring setting and in a socio-political settings.
Brazil four construct of moral distress?
1. negation of nurses role as pt advocate
2. Lack of competency in work team
3. Disrespect of pt autonomy
4. Therapeutic obstinancy
Strategies to address moral distress?
1. Listening to nurses
2. Teaching articulation/advocacy for resolution of moral distress in universities to nurses.
3. Communication channel in workplace to address these challenges
4. Orders should provides guidance to there members.
Chan and al. findings?
-Palliative pt not a priority (task-oriented priority), causing distress in nurses.
- Palliative care requests deamed too early/pt too sick/no place on floor
- Its hard to let go when you don't have a Dx/you don't understand what is going on.
- Prognostic is hard and thus when to demand pall. care is harder.
- Perception that pal. and acute care don't happen simultaneously
- Yet no accepted standard of pall. care delivery.
Primary goal of palliative approach?
Ensure pt is comfortable and maintains a level of functioning.
What is suffering (Carnevale)?
Suffering is not pain. Pain refers to nociception (Eg. Giving birth gives pain, but not suffering). Depression results in suffering, not pain.
1. Only properly understood by how it is subjectively experienced by a person. Cannot be correlated with severity of illness (Cassell).
2. The intactness of the person must be threatened (Cassell).
Suffering should be viewed as an emotion.
Can one's suffering be assessed by another (Carnevale)?
NO, suffering is subjective, not objective except in term of own sympathetic response. Even is it has distinctive features, it cannot be correlated with intensity.
What is the moral significance of suffering (Carnevale)?
Eliminating suffering is a primary obligation of modern medicine. Thus making suffering bad, and its relief, good. This help to justify the limits of life-sustaining therapies (better off dead than alive and suffering).
Principle of double-effect?
1. Action must be morally good.
2. Bad effect must not be the means by which the good effect is achieved.
3. Motive is good effect only.
4. Good effect at least equivalent to bad effect.
Fundamental moral dilemma?
High responsibility with low level of control.
Autonomy: Right to self-determination
Beneficence: do good
Nonmalefiscience: Dont do bad
1. Substituted Judgment Standard
2. Pure Autonomy Standard
3. Best interest standard
1. Once-competent, done by family
2. Formerly autonomous and then expressed desires toward future situations, now-incompetent (Mandate).
3. Pt preference not known. Proportionality (benefits>burden)
4. Free/enlightened consent.
Legal vs Factual competence?
you are or arent.
Ability to make decisions (complex, risk involved)
CNA informed decision making standards?
1. Provide info
2. Respect wishes of capable person
3. Respect each person decision-making process
4. NUrsing provided with the person informed consent.
5. Nurses sensitive to power differentials between HCP and pt
6. Advocate for pt
7. Assist family in understanding person decision making.
8. Respect informed decision-making of capable persons
9. Assist person in decision-making
10. Respect law on consent
Autonomous decision based on?
1. BAsed in understanding
2. Is intentional
3. Is Voluntary
Controversial Exceptions to override pt autonomy or fail to inform?
1. Therapeutic privilege: refers to an uncommon situation whereby a physician may be excused from revealing information to a patient when disclosing it would pose a serious psychological threat, so serious a threat as to be medically contraindicated.
2. Therapeutic use of placebos.
3. Withholding info from research subjects.
Seeking a child acceptance of care based on their developmentally adapted understanding of situation/treatments.
Is withholding artificial nutrition/hydration in children legal?
YES, both legal and ethically OK.
Does pediatric pall. care = end-of-life care?
No. Pall care begin when illness is Dx.
Should we use "Do-not-resuscitate" term?
Maturity and moral reasoning?
Preschool: NO decision-making
Primary: NO full capacity but should be involved
Ado: Can have capacity, but must be assessed individually.
Are children incompetent?
NO, commonly underestimate. We need child. to assent to treatments
Are newborns children too?
YES, but sometimes not treated equally.
Noninitiation of resuscitation in delivery room is acceptable when?
< 23 weeks
< 400g birth weight
- Confirmed trisomy 14
Resuscitation always indicated in delivery room when?
>25 weeks older
- most congenital malformation
Does initiation of rescu. in delivery room mandate continued support?
Noninitiation of resuscitation in delivery room and later withdrawal are considered..... ethically.
Culture = Ethnicity?
NO, b/c culture = a system of meaning shared by a group of people learned and passed on from one generation to the next. And culture groups are not homogeneous.
Does epistemological relativism entail Moral relativism?
Act of bridging/mediation between groups/persons of different cultural background to reduce conflict.
Culturally sensitive care (FORTIN 2015) continuum.
-Explanatory Phenomenon: Culture is reified (making something abstract more concrete)
- Humanist view: Contextualized, complex understanding, cultural humility
- Universalist approach: Otherness is overshadowed by sameness =>we are all humans
Pt perception of a good death?
- pain relief
- close to loved ones
- having support of family and friends
- feeling free to talk
- reflecting on life
- trusting relationships with HCP
- Finding meaning in life
Is palliative sedation (and analgesia) = euthanasia?
NO. Its OK to administer sedation that may shorten life with principle of double-effect.
Disability = a life not worth living?
NO, Dickinson child with cerebral-palsy reported happy life (Cross-sectional studies)
Bill 52 (QC): An act respecting end-of-life, key features?
- Explicitly recognizes right to "end-of-life care": no Ped. exception
- Explicitly recognize the "legality" of palliative sedation: NO peds exceptions
- "Legalizes" advance medical directives: Only >18
- Legalize medical aid in dying: Only >18
Indication for pall. sedation?
- Acute delirium
- Respiratory distress
- Uncontrolled SOB
- Refractory seizures
- Unrelieved intolerable pain
- Abundant refractory bronchial secretions
- UNtreatable N/V
Bill 52 medical aid for dying criteria's (need to meet all)?
- Full age and capable of consent
- Be at the end of life
- Suffer from serious/incurable illness
- Advanced state of irreversible decline in capability
- Experience constant/unbearable physical/psychological pain