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S. Ruppert
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NU02 - Preparing Patients for Treatment (ID 270)
- Event: WCLC 2016
- Type: Nurses Session
- Track: Nurses
- Presentations: 1
- Moderators:D. Borthwick, A. Fraser
- Coordinates: 12/05/2016, 16:00 - 17:30, Schubert 5
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NU02.03 - Ethical Decision Making (ID 6455)
16:00 - 17:30 | Author(s): S. Ruppert
- Abstract
- Presentation
Abstract:
Ethical decision making is very important in the context of treatment of cancer patients. These decisions can lead to withdrawal or withholding of life-sustaining therapy, or change the goal of the therapy from curative to palliative. “Do-not-reanimate” or “allow-natural-death” orders are also part of ethical decision making. Sometimes pain treatment is adapted or palliative sedation is started. It is necessary to make these decisions to ensure dignity at the end-of-life, which is a human right. Ethical decision making is usually done state-of-the-art in the context of Palliative Care, which means dialogue with the patient, the next of kin and other health-care-professionals involved in the treatment. The decision making process is structured, documented and can be replicated for everyone. Most of the time, these decisions are made by physicians only, without a dialogue, especially in Austria in hospitals or nursing homes. Sometimes patients are involved, but more often only their relatives. Physicians rarely ask other health-care-professionals for their opinion. End-of-life-decision-making seldom occurs as a structured well documented process. But the fact, that by law physicians have to take the final decision, does not prevent them from listening to and involving the perspective of the different persons concerned. If the discussion stops with the question “Who is allowed to decide?” then decisions would only be made because of having legal authority and not because of ethical reasons. (Vanlaere & Gastmans, 2008, Arndt, 2007) From an ethical perspective these decisions are often decisions between the autonomy of patients and the care of health care professionals. It is crucial to preserve the dignity of the suffering human being. It is a challenge to make reasonable ethical decisions in a context characterized by strong pressure for efficient and flexible organisational structures on the one side and complex values on the other side. (Gastmans & Vanlaere, 2005). It is not always clear what is right and what is wrong, or what is good and what is bad. Sometimes health care professionals, especially physicians, try to avoid these decisions by not to deciding anything, but avoidance is also a decision. Ethical decision making is much more difficult, if the suffering person cannot express his wishes anymore. Then, physicians and other health care professionals, who are included in the decision-making-process, have to find out the person`s wishes. It is very important that ethical decision making is based on indication for treatment, futility and the wish of patient. (Bundeskanzleramt, 2015) Ethical decision making should include all persons involved – physician, patient, relatives, nurses and also, if appropriate pastor or other religious leader, social workers and other health care professionals. The involvement of patients and – if they wish – their next of kin is necessary. Austrian medical guidelines (Valentin et al. 2004) recommended that nurses and other members of the multidisciplinary team had to be involved in such decisions. The decision making process should be structured, documented and - depending on the context – regularly evaluated. Several models exist for ethical decision making and help to guide and structure the dialogues. Individual ethical case conferences could be part of clinical ethical counseling, which also includes ethical education and providing guidelines. (Zentrale Ethikkommission, 2006). Examples of such decision-making-models are the model of Gastmans and Vanlaere (Vanlaere & Gastmans, 2008) based on the personalism and care-ethic, the Nijmwegener-model of Steinkamp and Gordijn (Steinkamp, 2012) and the model of Arndt (2007). Decision-making-models are not simply checklists. Health care professionals have to use them with empathy in the context of their own experience and values. (Körtner, 2012). General guidelines could deviate from frequently arising problems, but there always would be individual cases, which represent marginal cases because they burst all limits (Körtner, 2012). By using decision-making-models health care professionals have to be alert, not to use those strictly according to the written instructions. The sensitivity for the individual and his special situation has to be preserved. A discussion or counselling, where all persons concerned make a choice together according to their values and principles, is the best guarantee for a well-grounded ethical decision and gives more sense of security for a good result. Nevertheless, there is no guarantee for a right or good action. (Körtner, 2012). Because of the emotional burden of end-of-life-decisions, these models are also helpful to include all important aspects. The participants of these dialogues have to respect the values of the others and to see the situation from their point of view. Using decision-making-models guarantees to involve all relevant individuals. Furthermore, the decision making process becomes repeatable and visible. Finally, it is important to mention that ethical-decision-making can’t be reduced to using decision-making-models. Ethical thinking is a result of dynamic mutual reactions between emotions, intuition, standardization and rational reasoning. (Van der Arend & Gastmans, 2009) The role of nurses in this decision making process and also in the realization of these decisions is rarely recognized. But nurses play an important role in ethical decision making - as national (Ruppert et al., 2012) studies show. Nurses have the closest relationship to the patient compared to all health care professionals. They communicate daily with patients, know their problems, emotions, understand the social context and values. Furthermore, nurses execute the end-of-life-decisions, by, for example, not calling the rescue team. Therefore, it is very important, that nurses reflect and create actively their role in the ethical decision making process. They have to know which end-of-life-decisions are available and legal in the country where they work. Furthermore, they need knowledge in nursing ethics and ethical frame conditions of their organisations. Nurses have to become part of the ethical-decision-making; especially, if discussing ethical problem with the help of decision-making-models becomes routine because this has a vital impact on the daily nursing practise. Then nurses get used to reflect their acts, the values and principles laying behind and to involve the perspectives, values and norms of other individuals. If decision-making is consciously trained, it has a positive impact on situations, where reflection isn’t possible. (Arndt, 2007) Literature: Arndt, Marianne (2007): Ethik denken. Maßstäbe zum Handeln in der Pflege. Stuttgart: Thieme Verlag, 2. Unveränderte Auflage. Bundeskanzleramt (2015): Sterben in Würde. Empfehlungen zur Begleitung und Betreuung von Menschen am Lebensende und damit verbundene Fragestellungen. Stellungnahme der Bioethikkommission. Gastmans, Chris & Vanlaere, Linus (2005): Cirkels van zorg. Ethisch omgaan met ouderen. Leuven: Ten Have. Körtner, Ulrich (2012): Grundkurs Pflegeethik. Wien: Facultas Verlag, 2. Auflage. Ruppert Sabine; Heindl Patrik & Kozon Vlastimil (2012): Rolle der Pflege bei ethischen Entscheidungen. In: Imago Hominis 19 (2), S. 97-105. Steinkamp, Norbert (2012): Methoden ethischer Entscheidungsfindung im Pflegealltag. In: Monteverde Settimio (Hrsg.): Handbuch Pflegeethik. Ethisch denken und handeln in den Praxisfeldern der Pflege. Stuttgart: W. Kohlhammer Verlag, S. 175-192. Valentin, Andreas; Druml, Wilfred & Steltzer, Heinz (2004): Konsensuspapier der Intensivmedizinischen Gesellschaften Österreichs (2004): Empfehlungen zum Thema Therapiebegrenzung und -beendigung an Intensivstationen. In: Wiener Klinische Wochenschrift, 116/21-22: 763-767. Van der Arend, Arie & Gastmans, Chris (2009): Ethisch zorg verlenen. Handboek voor de verpleegkundige beroepen. Baarn: Hbuitgevers, 4. korrigierte Druck, 5. Auflage. Vanlaere, Linus & Gastmans, Chris (2008): Een goed gesprek voor een zo goed mogelijke zorg. Een zorgethische en personalistische overlegmethode. In: Tijdschrift voor Gezondheitdszorg en ethiek 18(2), S. 45-49. Zentrale Ethikkommission bei der Bundesärztekammer (2006): Ethikberatung in der klinischen Medizin. Deutsches Ärzteblatt 103 (24): A1703-1707.
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