The five short buzzes of the call system immediately indicated that something was wrong-it was the prearranged signal used in the nursing home to alert nursing staff to an emergency. The nurse in charge quickly went to trace the source of difficulty. Upon entering the client's room, she found the nurse aide leaning over Mr. Smith, who was slumped in his bed. He was completely dressed except for his shoes, and he appeared to have been sitting on the edge of his bed dressing for breakfast when he fell back unconscious. His pulse was weak and irregular, and he showed no response when his name was called. Death appeared imminent unless treatment was initiated promptly.
What should be the next action? Should he be treated aggressively? The rescue squad or ambulance could be called to take him quickly to the hospital for treatment. Or should he be kept in the nursing home? In the home the nurse could treat him with comfort measures but he would probably die without the life-support equipment that would be available to him in the hospital.
Nurses who care for the elderly and chronically ill in nursing homes frequently are confronted with situations similar to that described. A client has a cardiac arrest or sudden loss of consciousness. A decision must be made quickly. There is no time to confer with family members or the physician unless by chance they happen to be present; frequently in the nursing home there is no other professional nurse with whom to consult.
Ideally, the client and family members have been consulted soon after admission to discuss what course of ac tion is to be followed should a crisis situation arise. A frank and open atmosphere would help the client to express personal wishes. This information should be shared with other staff members and the physician via nursing reports, care conferences, and nursing care plans. If these steps have not been taken previously, however, the gérontologie nurse is faced with an ethical dilemma-to treat the client aggressively with technology or to allow the client to die. It is a weighty decision to make, and there are no easy answers.
What should guide the nurse's thinking in making this kind of decision in a matter of seconds? I have analyzed this question within an ethical framework, employing theoretical principles, along with the components of the ethical dilemma and the agents involved as defined by Curtin.
Jacques Thireaux, a philosopher, advocated five basic principles that can be used to guide an analysis of the dilemma of "treating or allowing to die." His first principle is the Value-of-Life Principle-a reverence for life and an acceptance of death.
The second is the Principle of Goodness and Rightness. To Thireaux this means that human beings attempt to promote goodness over badness, to cause no harm and to prevent harm.
Thireaux's third consideration, the Principle of Justice or Fairness, advocates that human beings should treat other human beings fairly and justly in distributing goodness among them.
The fourth principle is the Principle of Truth-Telling or Honesty. Thireaux feels that honesty is essential to meaningful communication. Morality depends upon agreements among human beings; the persons involved in the agreements must be confident that the agreements are being made with honesty and truthfulness.
Thireaux's fifth principle is the Principle of Individual Freedom. Persons, being individuals with individual differences, must have the freedom to choose their own ways and means of being moral within the framework of the first four principles. Persons should be allowed to follow the dictates of their own intelligence and conscience as much as possible. However, this freedom to choose is not absolute, so persons must function within the limitations imposed on them by the four other principles.
A gerontological nurse is concerned about whether to treat the client aggressively with all of the technology available or whether to allow the client to die without the use of life-support equipment. Inherent within this issue is another issue-that of the right to decide.
Before the introduction of sophisticated life-support equipment and a variety of life-prolonging drugs, death was accepted as inevitable. The client could progress through the dying process in the familiar environs of home or in the nursing home surrounded by family and friends, or could die in the hospital without the benefit of the respirator, suction apparatus, intravenous feedings, and the like. But our technical knowledge and our utilization of artificial support of circulation, respiration, and other systems has made it possible to prolong the lives of those persons who in the past would have died sooner.3
In our current technologic era this withholding of life-support equipment is sometimes referred to as a form of euthanasia. The word euthanasia is derived from the Greek words for "good death." In our society it commonly has been called "mercy-killing," a term that many people feel is not all consistent with the original meaning. The concept of euthanasia may be divided further into the components of active and passive; passive euthanasia has been described as "letting die"-treatment either is not initiated or the ongoing treatment is stopped, with or without the consent of the client. In contrast, active euthanasia would include one of two things: (1) actions that would provide an individual with the means to commit suicide, or (2) direct actions by others that would bring about a person's death, with or without that person's consent. Active euthanasia may be seen as an act of commission, while passive euthanasia is considered an act of omission and a noninterference with the natural process of dying.4
Those who advocate withholding treatment do so in the interest of "death with dignity" for thé client. They believe that efforts to prolong life for the terminally ill should not be done merely because technology is available to do so. The policy of The Concern for Dying Council, formerly the Euthansia Educational Council, is that the dying individual should not be subjected to unwarranted and unwanted lifesupport measures for the sake of curing. The Council advocates that the dying person and family members value caring as much as curing.5
On the other hand, there is the belief that an individual should not be "allowed to die," but should be sustained with every means available. These means would include life-maintaining machines, organ transplants, experimental drugs, and antibiotics. It has been argued that it is imponible to predict death and that persons have recovered from comas. Furthermore, making judgments to allow death to occur is a sacrilegious act, and the act of death is such an insult and tragedy that any compliance with it is inhumane.3
This act of maintaining a client with life-support equipment then leads to a second dilemma-that of defining death. Definitions have been presented by several sources, including the laws of twelve states. Probably the best-known definition is that of the Ad Hoc Committee of the Harvard Medical School. Reported in 1968, it has since become known as the "Harvard Criteria" and includes these conditions: (1) unreceptivity and unresponsivity in which even an intensely painful stimulus evokes no vocal or other responses; (2) no movements or breathing observed during a period of at least one hour; absence of spontaneous breathing may be established by turning off the respirator for three minutes and observing for any effort to breathe spontaneously; (3) absence of reflexes; and (4) a flat electroencephalogram recorded for a minimum of ten minutes and recorded again at least twenty-four hours later with no change.4 All of the definitions of death, including the Harvard Criteria, help to provide guidelines, but many questions are still being raised about their preciseness.
Curtin defines "ethical agents" as all of those persons who would be involved in making the decision about whether to treat or allow to die.1 These persons would be the client, family, the physician, the nurse, and other members of the health-care team who have worked closely with the client. In some situations, the courts also may be involved.
What is the role of the client in this situation? Does the client have the right to determine what will happen? Most writers argue that the client should remain in the center of the decision-making. Veatch maintains that it is both morally and legally sound to emphasize the role of the client as decision-maker when legally competent.6 The American Hospital Association Statement on the Patient's Bill of Rights asserts that the client has the right to receive information about treatment and the risks involved; furthermore the client has the right to refuse this treatment to the extent permitted by law.4
Hoyt, in a textbook on health law. states that every human being of adult years and sound mind has the right to determine what shall be done with his own body, and that the person may choose whethef to be treated or not, and to what extent. '
Some clients speak frequently with family, friends, and healthcare personnel about their wishes. Others have signed*a Living. Will. The Living Will is a document requesting that in those situations where the client is physically incapable of making a decision, the physician would avoid the use of extreme measures to prolong the client's life. In 1976 the California Legislature passed the Natural Death Act, recognizing the legality of such a signed document under certain conditions. Other states since have followed California's example.4
What input should be received from families? Because family members are "significant others" who are emotionally involved with the client, can they be expected to make decisions guided by rational thinking? Will their decisions be influenced by feelings of guilt or old family conflicts? Can they be expected to consider what is best for the client, or will they be thinking of themselves? The American Medical Association, in a statement adopted by its House of Delegates in 1973, advocated that the decision to cease using extraordinary means should be up to the client and/or the immediate family. It is a commonly held belief that the family should be involved in making this decision, unless circumstances make this impossible.4
What should be the responsibility of the physician in making the decision to treat or allow to die? Some feel that the physician should have all of the responsibility, as evidenced in a recent national public opinion poll in which persons were asked about a client dying in a hospital, with no hope of cure. Seven percent of the respondents felt that the physician alone should decide. Others argue against this viewpoint, saying that the physician may be so dedicated to fighting the disease that the person is forgotten, or the physician may have a duty to preserve life as long as possible without considering the consequences to the client.1
A prevalent view is that the physician should be consulted even though the final decision may rest with the client or family. The American Medical Association House of Delegates Statement emphasizes that the advice and judgment of the physician should be available freely to the client and family when they are deciding on a course of action.4 And, in the national public opinion poll mentioned earlier, more than 50% of the respondents felt that the decision to treat or allow to die should be made by family members or by the physician along with family members.4
What should be the nurse's role? Epstein maintains that nurses are probably in the best position to know whether the remaining life is worth the suffering to the client. Not only do nurses spend more time with the client than does the physician, and frequently more time than family members, but the nurse's concerns with the sociologie and psychologic basis of illness and health, and skills of communication, allow a broader understanding of the client.8
In a case study of nurse's feelings about euthanasia at the University of Washington Hospital and Swedish Hospital Medical Center, it was found that nurses received requests for euthansia from terminally ill clients and their families more frequently than did physicians, leading to the conclusion that the nurse has more interaction with the client and family than does the physician.4 Based on both Epstein's viewpoint and the study done at the University of Washington Hospital, one might argue that the nurse potentially is in a highly informed position regarding the client's and family's wishes. However, a contrasting viewpoint is that the nurse is under obligation to follow the decision of the physician.4
Application to the Dilemma
The following narrative indicates how the ethical framework of Thireaux' five principles could be applied to a hypothetical situation. In the case of Mr. Smith, introduced at the beginning of this article, the nurse has not previously discussed with either the client or his family the options to follow in the event of a crisis.
Mr. Smith was a 94-year-old man who had lived in the nursing home for eight years. His wife had moved there at the saine time he did; she had now been dead for five years.
Mr. Smith was a respected professional man, known and loved by many people. His children lived at a distance, so their visits were infrequent, but he had many friends among the nursing home residents and made a point of greeting eac h one ix'rsonally every day. Although he had had episodes of angina for several years, he believed in being as ac tive as possible within his health limitations.
Mr. Smith was heard frequently to say, "I've had a good life and I'm ready to die when my time comes." If he had signed a Living Will he did not say so, nor was there any indication of it on his chart.
At the time of Mr. Smith's crisis, his physician could not be reached. The physician's answering service would attempt to reach him and have him call as quickly as possible.
What now should be the decision-to treat or allow to die? Who should make the decision? The client was unresponsive, the physician unavailable, the family a long distance away. The responsibility for this decision would fall upon the nurse.
An analysis of the situation based on the five principles advocated by Thireaux might lead to the resolution of this dilemma.
The Value-of-Life Principle
Mr. Smith had demonstrated a strong reverence for the value of life. His life had been great in quantity and it also had quality. He lived life to the fullest within the limitations of his physical condition; he made a point of going outside for exercise daily regardless of the weather; he maintained friendships both in and out of the nursing home. At the same time, however, he had an acceptance of death. He spoke frequently of being ready to die; he also talked of his wife's death and looked forward to seeing her again in the afterlife in which he believed so strongly. Based on what the nurse perceived to be his reverence for life and acceptance of death, she might feel that he would choose to die quietly rather than to be maintained on life-support equipment.
Principle of Goodness
Would there be good in preserving Mr. Smith's life if he were to require life-support equipment to maintain it? Would Mr. Smith be satisfied with that kind of life? Assuming he lived through this crisis but was an invalid and confined to his room or to his bed- would he see this as being good? Would his family view this as good? Since Mr. Smith valued activities with his family and friends, he probably would not perceive this as good.
Principle of Justice
Would it be fair to Mr. Smith to keep him alive with technology? Would it be fair to him or to his family emotionally? Intellectually? Financially? He had been a professional person but had limited financial means. He enjoyed life- he enjoyed the warmth of interpersonal relationships; he enjoyed the intellectual discussions, reading, and lectures because of the mental stimulation they provided. Although the nurse could never know for certain, she could perhaps judge that Mr. Smith would indeed find life-prolonging devices unjust if their use meant that he would not be able to continue his previous lifestyle.
Principle of Truth-Telling
Mr. Smith was known as a very honest man. He was straightforward and honest in his relationships with his family, the other residents, and the nurses. His physicians had always kept him informed of his physical condition. If Mr. Smith had had feelings about wanting his life prolonged with lifesupport equipment, he probably would not have made statements about "being ready to die." One could perhaps assume that he had expressed these same feelings to his family.
Principle of Individual Freedom
The Principle of Individual Freedom implies that Mr. Smith should have the right to decide for himself, and that this right should be respected. Since Mr. Smith was not responsive, thus could not communicate a decision to the nurse, the nurse would have to make a judgment based on his previous comments. If his statements about being "ready to die" were interpreted as his decision that he be allowed to die, then the nurse should respect that wish.
Based on these considerations, the decision could be made to keep Mr. Smith in his own room in the nursing home, and to provide comfort measures like positioning with pillows to facilitate his breathing. Thus, he would be surrounded by the staff persons and the room environment familiar to him.
Although Thireaux believes that the Principle of Individual Freedom is limited by the other four principles, the author feels that it should receive primary consideration in an elderly client. The competent elderly person should be kept informed of his or her health status and should be given the right to decide personally whether to be allowed to die or treated aggressively. If the client chooses u> be sustained with life-support equipment in the hope of recovery, that wish should be respected. On the other hand, if the client elects to die with dignity in a familiar environment, without the aid of technology but provided with comfort measures, that option should be available. Health care workers, including physicians and nurses, should defer to the elderly person's choice.
The professional nurse who practices in a nursing home or other long-term care facility is in a unique position, with the ability to establish close relationships with clients, and in some cases their families, over a period of time. There is also an opportunity to develop a good understanding of the elderly person's beliefs and desires in regard to health and treatment. Whenever possible, the nurse should seek opportunities to discuss these beliefs and desires openly with the client. The nurse will then be in a position to keep both family members and physician apprised of the client's wishes, and can make an informed decision should a crisis situation arise.
Because every situation is unique,» the nurse may be asked to assist in resolving other questions. Sometimes the client and family members disagree. The client may feel strongly about being allowed to die while family members, out of their feelings for the loved one and a sense of hope, may wish to do all that is humanly possible by using aggressive treatment. How can the nurse facilitate the resolution of this conflict? Or what happens when the family is aware of an unconscious person's wishes but does not choose to respect those wishes? What role can the nurse then play? When the decision becomes primarily the nurse's alone, as in the hypothetical situation discussed above, can she be depended upon to make a decision in the best interest of an unconscious client?
These questions are difficult ones to answer. However, by using an ethical framework such as Thireaux' five principles, defining the dilemma precisely, and examining both the components and agents involved, the nurse will have some structured guidelines to aid her in analyzing each situation she faces.
- 1. Curtin !.. A proposed model for critical ethical analysis. Nurs Forum 1978; 17:12-17.
- 2. Thireaux ]. Ethics. Encino, Glenco, 1977: 81-9.'
- 3. Butler R, Lewis iVI. Aging and Mental Health, 2nd ed. St. Louis, C.V. Mosby, 197.1:259.
- 1. Davis A. Aroskar iVI. Ethical Dilemmas and Nursing Practice. New York, Appleton-Cenlury-Crofts, 1978.
- 5. Concern for Dying Council: Statement of Beliefs, Purpose. Program. New York, 1978.
- 6. Veatch R. Choosing not to prolong dying. In: Beauchamp T, Walthers I. (eds). Contemporary Issues in Bioethics. 1st ed. Encino, Dickenson, 1978:303.
- 7. Hoyl C, Hoyt J. Law of Hospital, Physicians and Patient. Berwyn, 111., Physicians Record Co., 1972:479.
- 8. Epstein C. Learning to Care for the Aged. Res ton, Reston, 1977:202.