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International Journal of Nursing Education. July-September 2015, Vol. 7, No.3 33
Case Study: An Ethical Dilemma in End of Life Care
Rehana Ayyub
MScN Student, Aga Khan University, School of Nursing and Midwifery, Pakistan
ABSTRACT
In any healthcare organization care providers often encounter ethical dilemmas while dealing with
patients. A case study presented ethical dilemma faced by a nurse who was caring for an old female
diagnosis with severe interstitial Lung Disease (ILD). The patient verbally expressed her will not to
give any aggressive treatment and wish a comfort end of life. Her son desired to do all possible
treatment and ultimately the patient died with painful experiences. The ethical dilemma demonstrated
whether to respect the patient’ autonomy or refuse and do aggressive treatment. This paper discusses
a case study and present Volbrecht’s framework of virtue ethics to analyze the ethical dilemma.
Keywords: Ethical Dilemma, Autonomy, End of Life Care, Advanced Directives (AD)
INTRODUCTION
A 75 year old female, admitted with severe
Interstitial Lund Disease (ILD). She was known case
of diabetes, renal failure and coronary artery disease.
She was on continuous oxygen therapy and overnight
application of non-invasive ventilator; Bi-level Positive
Airway Pressure (BIPAP) machine for last 6 months.
During her hospitalization, she expressed her verbal
living will to her family and primary physician that
she would not be given any aggressive treatments and
wished to have comfort end of life. Due to the poor
prognosis, the doctor had put her on (Do Not
Resuscitate) DNR code status after discussing with the
family. She was put on continuous BIPAP as developed
CO2 Narcosis. Later, she went into renal shut down.
Even knowing his mother wish and poor prognosis,
the son expressed his desire to do all possible treatment
other than resuscitation. Hemodialysis was done but
unsuccessful due to severe hypotension. She
developed multiple bedsores, hospital acquired
infection in blood and urine. Concurrently, she became
unresponsive. The son requested to give consultations
to infectious disease (ID), pulmonology, cardiology,
and nephrology. All physicians had recommended
interventions based on patients’ medical problems.
After 20 days her condition got worsen, she was in
pain and suffering. Finally, her son decided to hold
BIPAP; she went into cardiac arrest and expired within
an hour.
Virtue ethics
In this case study I will use Volbrecht’s framework
of virtue ethics to analyze this ethical dilemma. Virtue
ethics believes on the patient’s autonomy and patient’s
choice of decision making. Ethical analysis of virtue
ethics focuses (a) identifying the problem, (b) analyzing
context, (c) exploring options, (d) applying the decision
process, and (e) implementing the plan and evaluating
results (5).
Identifying the problem
This case study presents an ethical dilemma
presented desirable outcome in some respects and
undesirable in others. In this scenario, the patient’
decision to refuse for aggressive treatment had the
desired outcome of allowing her to be remain in
peaceful end of life care. However, her son’s choice
also resulted in a suffering and painful experience and
eventually her death. The ethical dilemma is patient’s
autonomy versus the ethics of care.
Analysis of ethical dilemma
In this case the ethical dilemma is patient’s
autonomy versus the ethics of care. The patient’s
autonomy was neglected and treatments to prolong
life, such as use of non-ventilator machine and dialysis
were implemented. If her son had followed the
recommendations of the doctors, the desirable
outcome would have been possible peace full end of
DOI Number: 10.5958/0974-9357.2015.00129.4
8. Rehana Pak –33–.pmd 6/24/2015, 1:38 PM33
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34 International Journal of Nursing Education. July-September 2015, Vol. 7, No.3
life. On the other hand, the undesired effect would
have had of feeling of guilt of son but that aggressive
treatment would have survived his mother. The
American Nurses Association (ANA) Code for Nurses
(2001) also support that healthcare provider should
respect patients’ wishes and decisions despite their
own personal beliefs (2).
However, it is challenging for loved one to witness
death based on a patient’s decision and such ethical
incidents are thought-provoking. In this scenario to
comprehend the decision-making process, one must
reflect on the ethical principles of respect, compassion,
autonomy, beneficence, non-maleficence, and justice.
These ethical principles may influence individual’s
preference. In his case, the healthcare team explained
the poor prognosis to the son but he did all possible
treatment including hemodialysis and non-invasive
ventilator. Palliative or supportive care may provide
to the patient in order to respect the patient’s
autonomy, while respecting her expressed wishes.
According to Winzelberg, Hanson and Tulsky (2005)
claim that patients are most at risk of receiving care
inconsistent with their preferences when they unable
to participate in decision- making (4).
Applying an ethical decision process
Based on virtue ethics, the healthcare provider and
family did not respect the patient’s autonomy and her
wish to choose peaceful death was neglected.
According to Winzelberg, Hanson and Tulsky (2005)
stated that “efforts to improve end-of-life decision-
making quality have emphasized the principle of
individual autonomy to better ensure that patients
receive care consistent with their preferences” (4).
Patient was competent enough when she declared her
choice before her condition got worsens. The care
providers would have been followed the principle of
beneficence, which focuses on promoting the comfort
of patients. In this scenario the patient comfort was
not receiving aggressive treatment but peaceful end
of life care. The concept of advanced directives
supports the principle of Autonomy, that an individual
has a right to decide for oneself. Advanced directive
is a legal document which provides information to the
care providers about the patient’s wishes regarding
advance treatment options for the future when
decision making would not be possible for the
incompetent patient (3). In many hospitals, there is no
policy for Advanced Directives (AD); through this
policy it would be easier for the health professionals
to plan treatment according to the document of the
patient, with no doubts about the comprehensiveness
of the treatment. “It is an autonomous choice of that
individual. Thus, if one follows instructions spelled
out by an individual, it amounts to respecting an
individual which carries a great moral value. It also
builds up trust between an individual and his treating
physician”(1).
Implementing plan and evaluating results
The hospital where I was working, there was no
policy of advanced directives. However, there was
policy for end of life care. According to Akhter (2011)
stated that “advance directives include living wills,
durable power of attorney and health care proxy” (1).
Further the author states that “it is not necessary to
have a written document, a verbal expression also
receives equal importance”(1). AD is a legal document
which allows care providers to respect the patient’s
wishes regarding advance treatment options for the
future when decision making would not be possible
for the incompetent patient. In my judgment, the
appropriate way to handle this issue could be the
concept of AD. If there would have been the concept
of advanced directives, the ethical dilemma would
have been dealt in a better manner. The patient would
have not suffered and even the loved ones would not
have feeling of guilt. The concept of advanced directive
document appears crucial in such dilemmas. The
introduction of advanced directives can be application
of virtue ethics theory which focuses on respect the
patient’s wishes.
CONCLUSION
In any healthcare industry, patients and families
with diverse background approaches with various
values and beliefs. Care providers need to recognize
ethical dilemmas in their clinical and focus on ethical
principles while dealing with such issues. Nurses
knowledge regarding ethics, their ability to identify
and resolve concerns in such dilemmas are crucial and
challenging. In my opinion, for above stated scenario
AD may helpful to address the dilemma. AD supports
the principle of autonomy, that patient the right to
decide for oneself about treatment plan of care.
Through this concept, healthcare professional may
respect the patient autonomy and prevent the family
feeling of guilt. Healthcare professional can follow and
educate the patients and families about AD and it
would benefit both patients and care providers while
dealing such ethical dilemmas.
8. Rehana Pak –33–.pmd 6/24/2015, 1:38 PM34
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International Journal of Nursing Education. July-September 2015, Vol. 7, No.3 35
Acknowlegment: Nil
Ethical Clearance: Not Required
Source of Funding: Self
Conflict of Interest: Nil
REFERENCES
1. Akhtar, J., (2010) Living Wills in Health care: A
way of empowering individuals. Journal of
Pakistan Medical Association, 60 (3), 240-242.
2. American Nurses Association. (2001). Code of
Ethics for Nurses with Interpretive Statements.
Washington, D.C.
3. Beauchamp,T., & Childress, J.(2001). Principles of
Biomedical Ethics (5th ed.). New York: ‘
Oxford University Press.
4. Winzelberg, G.S., Hanson, L.C., Tulsky, J.A.
(2005). Beyond Autonomy: Diversifying end of-
life decision making approaches to serve patients
and families. Journal of the America G e r i a t r i c s
Society, 53(6), 1046-1050.
5. Volbrecht, R. (2002). Nursing Ethics:
Communities in Dialogue. Upper Saddle, NJ:
Prentice Hall.
8. Rehana Pak –33–.pmd 6/24/2015, 1:38 PM35
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