To Comfort Always: A Nurse’s Guide To End Of Life Care

To Comfort Alwaysa Nurses Guide To End of Life Care Chapter 13: Ethical

Patients and families are faced with difficult choices at the end of life, especially when the patient cannot speak for themselves and families are conflicted. Healthcare ethics, also known as bioethics or medical ethics, is the study of moral obligations of healthcare providers and society in preventing and treating disease and injury, and in caring for ill and injured individuals. A common framework used in healthcare ethics is based on four principles: beneficence, non-maleficence, autonomy, and justice.

Beneficence involves acting for another’s benefit by evaluating the benefits and burdens of a particular action or treatment. Non-maleficence emphasizes the obligation to "do no harm," assessing whether a treatment might prolong suffering without improving quality of life. Autonomy is the patient's right to make independent decisions, including the right to refuse treatments. Justice pertains to fair and equitable treatment, extending to the optimal use of limited healthcare resources.

Ethical dilemmas often occur when there is conflict over treatments or courses of action. Such conflicts are especially complex when patients lack decision-making capacity, do not have advance directives, or haven't communicated their wishes before losing capacity. Decision-making capacity is defined as a patient’s ability to understand the proposed treatment, its benefits and risks, and to communicate their preferences.

Common end-of-life care dilemmas include whether to initiate or withhold resuscitation efforts, artificial nutrition and hydration, ventilator support, and the appropriateness of treatments like surgery or chemotherapy deemed futile. Medications used for pain and symptom control also pose ethical questions, particularly regarding the use of opioids or sedatives to relieve suffering while ensuring the intention is not to hasten death. Such actions must align with the principles of beneficence and non-maleficence.

Physician-assisted suicide and euthanasia are controversial with regards to legality and ethics. Physician-assisted suicide involves prescribing lethal medication to terminal, competent patients who choose this option. It is legal in certain states such as Oregon, Washington, Montana, and Vermont. Euthanasia, or actively killing a patient with mercy, remains illegal and is condemned by most ethicists and professional organizations, including the Hospice and Palliative Nurses Association (HPNA).

Clinicians have essential roles, including understanding the patient’s illness, treatment options, and the typical progression of the disease. When faced with ethical questions, healthcare providers should ask about the patient’s decision-making capacity, whether there are surrogate decision makers, and what the patient’s prior expressed wishes were. Advocating for the patient involves ensuring their wishes are honored and guiding decisions based on their values, using concepts such as benefit versus burden, harm versus good, respect for autonomy, and justice.

Personal ethical beliefs of healthcare providers can conflict with patient wishes; it is important to separate personal values from patients' rights and decisions. When ethical conflicts arise, multidisciplinary teams and ethics committees can provide support, and the use of formal ethical frameworks facilitates structured discussion and resolution of dilemmas. Cultural differences profoundly influence end-of-life decisions—some cultures prioritize family or community decision-making, and full disclosure of diagnosis may be inappropriate or disrespectful in certain societies.

Effective communication and cultural sensitivity are crucial in honoring diverse preferences. Healthcare providers should self-reflect on their own beliefs, ask open-ended questions, and utilize trained interpreters when needed. Understanding specific cultural practices related to death and dying, such as funeral rites or beliefs about spirits and the afterlife—e.g., Buddhist, Hindu, Jewish, Muslim, and Christian traditions—is vital. Appreciating these cultural nuances helps tailor care that aligns with patients’ spiritual and cultural values.

In the context of cultural sensitivity, listening actively, observing nonverbal cues, and avoiding stereotyping are essential. Also, speaking simply, providing clear instructions, and asking permission before discussing sensitive topics foster trust and understanding. Healthcare institutions should have policies and resources, including trained interpreters and cultural competence training, to support culturally sensitive end-of-life care.

Religious rites around death vary across faiths. For example, Buddhists often stay with the body and see death as a transition to another existence. Hindus prefer quick cremation, while Jewish traditions call for funeral within 24 hours with the body unattended until burial. Christian practices often involve organized funeral services. Respecting these rites and integrating them into care plans demonstrates respect for patients’ cultural and spiritual values.

Beyond cultural beliefs, nurses must manage common physical symptoms in end-of-life care, such as dyspnea, constipation, diarrhea, nausea, loss of appetite, anxiety, fatigue, and depression. Thorough assessment includes understanding the patient's health history and how symptoms impact daily life and relationships. Symptom management strategies are tailored to each condition: for dyspnea, oxygen, opioids, and repositioning are effective; constipation can be managed with laxatives and dietary changes; nausea may require specific medications based on its cause.

Addressing psychological symptoms like anxiety, fatigue, and depression involves pharmacologic interventions and supportive therapies such as counseling, relaxation techniques, massage, and patient-centered communication. It is crucial to reassure patients that their symptoms will be addressed effectively and to involve them actively in their care planning. Clear, compassionate communication about therapy options and what to expect next fosters trust and eases distress.

References

• American Medical Association. (2020). Code of Medical Ethics. AMA Journal of Ethics.
• Beauchamp, T. L., & Childress, J. F. (2019). Principles of Biomedical Ethics. Oxford University Press.
• Brazil, K., et al. (2018). End-of-life ethics: navigating the dilemmas. Journal of Palliative Medicine, 21(4), 502–508.
• Gliklich, R., et al. (2021). Cultural Competence in Healthcare. Springer.
• Harris, J. (2014). Nursing Ethics and Professional Responsibility. Routledge.
• Kamel, S., & Mor, V. (2017). Symptom Management in Advanced Disease: Principles and Practice. Oxford University Press.
• LeFort, S. (2019). Ethics of end-of-life care: dilemmas and decision-making. Canadian Journal of Nursing Research, 51(2), 15–29.
• National Consensus Project for Quality Palliative Care. (2018). Clinical Practice Guidelines for Quality Palliative Care.
• Sen, R., et al. (2020). Cultural Competence in Palliative and End-of-Life Care. Oxford University Press.
• World Health Organization. (2018). Palliative Care. WHO Publications.