6.6: Spotlight Application
A True Story of a New Nurse’s Introduction to Ethical Dilemmas
A new nurse graduate meets Mary, a 70-year-old woman who was living alone at home with Amyotrophic Lateral Sclerosis (ALS or also referred to as “Lou Gehrig’s disease”). Mary’s husband died many years ago and they did not have children. She had a small support system including relatives who lived out of state and friends with whom she had lost touch since her diagnosis. Mary was fiercely independent and maintained her nutrition and hydration through a gastrostomy tube to avoid aspiration.
As Mary’s disease progressed, the new nurse discussed several safety issues related to Mary living alone. As the new nurse shared several alternative options related to skilled nursing care with Mary, Mary shared her own plan. Mary said her plan included a combination of opioids, benzodiazepines, and a plastic bag to suffocate herself and be found by a nurse during a scheduled visit. In addition to safety issues and possible suicide ideation, the new nurse recognized she was in the midst of an ethical dilemma in terms of the treatment plan, her values and what she felt was best for Mary, and Mary’s preferences.
Applying the MORAL Ethical Decision-Making Model to Mary’s Case
| Massage the Dilemma |
Data:
Mary lives alone and does not want to go to a nursing home. She lacks social support. She has a progressive and incurable disease that affects her ability to swallow, talk, walk, and eventually breathe. She has made statements to staff indicating she prefers to die rather than leave her home to receive total care in a long-term care setting.
Ethical Conflicts: According to the deontological theory, suicide is always wrong. According to the consequentialism ethical theory, an action’s morality depends on the consequences of that action. Mary has a progressive, incurable illness that requires total care that will force her to leave the home. She wishes to stay in her home until she dies. Ethical Goals: To honor Mary’s dignity and respect her autonomy in making treatment decisions. For Mary to experience a “good” death as she defines it, and neither hasten nor prolong her dying process through illegal or amoral interventions. |
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| Outline the Options |
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| Review Criteria and Resolve |
Mary was assessed to be rational and capable of decision-making by a psychiatrist. Mary defined a “good” death as one occurring in her home and not in a hospital or long-term care setting. Mary did not want her life to be prolonged through the use of technology such as a ventilator.
Resolution: Mary elected to discontinue tube feeding and limit hydration to only that necessary for medication to provide comfort care and symptom management. |
| Affirm Position and Act |
Although some health care members did not personally believe in discontinuing food and fluids through the g-tube based on their interpretation of the deontological ethical theory, Mary’s decision was acceptable both legally and ethically, based on the consequentialism ethical theory that the decision best supported Mary’s goals and respected her autonomy.
Daily visits were scheduled with hospice staff, including the nurse, nursing assistant, social worker, chaplain, and volunteers. Hired caregivers supplemented visits and in the last couple of days were scheduled around the clock. Mary died comfortably in her bed seven days after implementation of the agreed-upon plan. |
| Look Back | The health care team evaluated what happened during Mary’s situation and what could be learned from this ethical dilemma and applied to future patient-care scenarios. |