Ethical Dilemma: Honoring Patient Wishes

For patients, the aging process often involves a variety of health problems which can quickly become burdensome for family members. Even when a patient's health problems are not severe, family members may still have a difficult time adequately meeting the patient's needs. Consequently, subsidized nursing care is often necessary, especially for patients who lose control of their mental and physical faculties.

Commonly diagnosed in elderly patients, incontinence and dementia often tests the caretakers' patience, but may not be a valid enough reason for placing an elderly patient in a nursing home. As a result, some family members may be tempted to exaggerate the health condition of an elderly patient in order to be eligible for nursing assistance. For example, family members may feel inclined to overstate an elderly patient's dementia because they are frustrated with and incapable of dealing with the associated trials of the urinary or fecal incontinence of their loved one.

In situations where family members attempt to justify the need for wrongful placement of their loved one in a nursing home, ethical dilemmas may arise for the elderly patient, the patient's family members, and members of the healthcare team such as the nurse. The underlying cause of the ethical dilemma lies in deciding whose wishes should take precedence. The purpose of this paper is to discuss issues involved with supporting a patient's wishes, the wishes of a patient's family, and the legal implications of placing a patient with incontinence and dementia in a nursing home.

Discussion

Patient Wishes

Incontinence is a serious health issue for the elderly living at home as it leads to restricted activities of daily living, and increased care from the family (Shimanouchi, Kamei, & Hayashi, 2000). As the elder becomes more incontinent and a loss of independence follows, the patient is left frustrated and in some situations, even combative with caregivers. Family members share in the patient's frustration, especially as they have to make adjustments in their own lives to accommodate the never-ending needs of a loved one. The patient's loss of control over body and mind is difficult to accept, and the elder tries compensate for this loss by trying to maintain a sense of dignity. An elder in this state of being may continue to try to use a bathroom despite being incontinent, resulting in frequent accidents their family is left to clean up. The family in this situation becomes desperate for a solution, and so determines to admit the patient to the hospital. The hospitalized elder may confide in the nurse the fear of losing independence and the desire to go home. The elder may agree to comply with home health aides and family members in order to leave. The family, however, may feel the elder would be better off living in a long-term care facility because they may view the patient as mentally incompetent to care for them self. The nurse may strongly disagree with this plan of action, thinking of the patient's wishes and needs. The ethical principle of autonomy applies to an elder found in this situation. Autonomy is the patient's right to make their own choices (Lassetter, 2006a). If the elder cannot be found incompetent to make decisions, the patient still possesses the right to make choices according to what they want or need. The elder in this situation is concerned with losing independence and wants to continue to have access to a bathroom. The patient's combativeness with the home health care aids may reflect the nagging fear of losing control over the elder's life.

The theory of Liberal Individualism (LI) also applies to protecting the patient's interests over all others. The LI theory involves the idea that people have certain rights that must be protected and are based off of legal, moral, or institutional rules (Lassetter, 2006b). The elder in this ethical dilemma has the moral and legal right to decide what is to be done with the rest of their life. The family's desire to institutionalize the elder because of frustration with the patient's accidents does not override the elder's right to decide the plan of care. The family has a right to protect their own interests as well, but this cannot be accomplished by taking away the rights of the elder under this theory. The best outcome for this situation would be for a compromise to be reached where the elder could retain as much independence as possible without the family feeling frustrated. Compromise might be achieved by allowing the patient to live at home as desired, while promising to be cooperative with health care aids and to let the family know when the bathroom is needed so they can assist the patient. If the family and the patient could come to this compromise, the nurse could feel good about honoring the patient's wishes, and knowing the family was at ease with the situation.

Family Wishes

Contrary to the patient's wishes the family may feel the patient's exercise of autonomy is difficult to manage, as it can result in frequent accidents, and increased care on their part. The family's feelings need to be dealt with as well. While promoting the patient's autonomy is important, the caregivers need to feel they can handle all that the patient's choices entail. The family should be able to strike a balance between their wishes to lighten the load of care giving and the patient's wish to remain at home. The family has an excellent source of relief in the home health aids that take care of the elder. If the family is willing to pay more to have the patient put in a nursing home, they might consider paying the home health aids a higher wage to come in more often. This approach would result in less care and worry on the family's part, while allowing the elder to remain at home.

Another ethical principle to be considered in this case is that of fidelity. Fidelity means to give precedence to the patient's wishes over the interests of others and self-interest (Lassetter, 2006a). If declared incompetent, the elder will face living in a long-term care facility. The family's desire to have the patient put in a home may compel them to have a psychiatrist declare their loved one mentally unstable, in order to fulfill their wishes. Despite the family's wishes, both the psychiatrist and the nurse involved have the responsibility of fidelity to the patient. Even though the family may be declaring the patient incapable of living at home, it is up to the nurse and the psychiatrist to make an in-depth evaluation of the situation, without making it the family's decision.

The family's feelings still should be taken into consideration when planning the elder's care, because the patient may not have a strong support system if they return home, when their family wanted them put into a facility. The nurse and psychiatrist have the responsibility of advocating for the patient's interests over the family's, while at the same time making sure the elder has a safe and caring environment to return home to.

Legal Implications

Incontinence alone is not enough to commit an elder to a nursing home; there must be evidence of mental incompetence as well. In order to put the family at ease with honoring the elder's wishes, it would be very helpful for the healthcare team to differentiate between competence and decision making capacity. Mental competence is not determined by members of the healthcare team, but rather by a judge. What the healthcare team can determine is the decision-making capacity of the patient. Once this status is declared, if the patient is deemed able to make their own medical choices, it does not matter if they are incompetent to care for themselves in other aspects of their life such as finances or employment (Moran, Pouya 2004). Legally the patient has the right to make health care decisions if they have the capacity to do so. Even if the elder in this situation may be slightly cognitively impaired, their ability to make decisions and to understand information may still be intact, and this is what counts when it comes to honoring the patient's wishes. If the elder is found to be unable to make medical decisions on their own, the patient could appoint a loving friend or family member as a durable power of attorney (DPA) to make health care decisions for them. The patient could use this DPA as an advocate for their wishes. The friend or family member advocating for the patient would be an asset to the nurse's duty of patient advocacy. The outcome of the ethical dilemma would be easier to arrive at because there would be two people standing up for the patient's autonomy, one of them being part of the elder's family. A durable power of attorney would increase the elder's autonomy because they act as spokesmen for the patient. The DPA would be a very good option for the patient with slight cognitive impairment because the elder could still speak out in areas where they were still competent. In areas where cognitive impairment was present, a DPA could act as the patient's advocate and communicate the patient's best interests. The elder could be allowed to go home and live based off of their decision making capacity, or by what the DPA said even if the family did not agree with the elder's wishes.

Implications for Clinical Practice

The ethical dilemma of the elder is one that hits close to home. Many people are faced with losing their independence and control over their lives as they get older. My personal belief is that autonomy is vital to individual well-being. The feeling of independence gives people a sense of inner strength and dignity, especially as the aging process continues.

If I was the nurse in this ethical dilemma, knowing that the patient was afraid of losing autonomy would make me work to find a way where the patient could stay at home. If the psychiatrist tried to declare the elder incompetent, I would confront him or her on the grounds of fidelity to the patient. As a nurse I would try to recognize the family's feelings of frustration and the burden of care giving. I would sit down with the family and explain that the elder's autonomy must be protected as the patient's legal right. I would try to come to a compromise with the family as to how both the patient's and family's needs could be met. I am sure I will come across many situations in my practice where patient and family wishes collide. I will try to be empathetic to both parties, realizing that in advocating for my patient, I must consider the family's needs and requests as well.

Conclusion

Facing ethical dilemmas in any situation is not easy, especially when dealing with healthcare. It is imperative that nurses analyze the situation, taking into account the patient's wishes, the family's wishes, and the legal implications involved. Only after applying ethics to patient care and recognizing the needs of all parties can the outcome of a dilemma be what is right and best. Applying ethics to nursing will result in better patient care and will aid nurses in their quest to honor the wishes of the patient.

References

Lassetter, J. (2006a).

Summary of ethical principles. Unpublished manuscript, Brigham Young University, Provo, UT.

Lassetter, J. (2006b).

Summary of ethical theories. Unpublished manuscript, Brigham Young University, Provo, UT.

Moran, D., Pouya, P. (2004). Caring for the frail elderly: Ethical considerations.

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