According to Rubulotta & Giorgia (2013), cardiovascular diseases has been a leading cause of death in the population. A relevant code of ethics has been put to guide nursing practice across the world. Though there are minor disparities as one moves from one geographical region to the other, some are universal and acceptable across the geographical divide. According to Epstein & Turner (2015), professional nursing is defined as the ‘protection, promotion, and optimisation of health where the healthcare professional alleviates pain and suffering hence helps in the prevention of disease.’ In Elsie Lee’s case, the nurses were faced with an ethical dilemma considering that she had expressed her wish not to be resuscitated in case need arose. The legal injunction that the family wants to place is founded on the fact that she died while being taken to hospital yet she had made it clear that she did not want to be taken. Nurses are therefore torn between working to satisfy the wish of the patient and working in line with the oath they take while registering to work as nurses. This paper will therefore focus on Elsie Lee’s case study to dissect the ethical dilemma presented and present a number of theories which could be used to determine the line of action.
Ethical and Legal Conflicts
Do Not Attempt Resuscitation (DNAR) orders must be written by licensed physicians in consultation with the patient in question. In some situations, mainly in all situations, a third party is required to be in place to ensure that the patient is in good mental condition when making the decision. While signing the order, the decision is made whether in case of complication, the patient should receive cardiopulmonary resuscitation. In cases such as Elsie Lee’s, verbal orders are not considered formal and hence the chances of holding a case against the institution and the nurses remains minimal. In the situation where the family says that the cause of death was stress while being taken to hospital, a professional pathologist has to ascertain that and stand in place to present the results in court in case a court procedure is called for. According to Levinson & Mills (2014), since the description of cardiopulmonary resuscitation as a lifesaving procedure more than fifty years ago, it has been used as the default treatment for all patients in critical care around Australia unless documentation of no resuscitation order has been recorded in the patient’s file. Therefore, in nursing practice, professional practice is primarily guided by norms where one cannot make verbal orders and adherence be founded upon them.
Despite the fact that healthcare delivery should be focused on ensuring that the patient recovers and pain is alleviated, their opinion should not be used to hinder professional practice. At eighty eight years of age and having suffered from short memory in the past, Elsie’s decisions are subject for cross examination before they are used as basis for a serious decision such as withholding resuscitation. According to Hayes (2012), decisions to withhold cardiopulmonary resuscitation for future cardiac arrest continue to cause problems across the healthcare field considering that there are no standard procedures that are followed by physicians therefore lacking consistency in approaching the issue. In such a case, the nurse should be guided by professional ethics guiding their practice to avoid a scenario where they are in logger heads with the law. In this case, the nurses cannot be held culpable considering that there was no documentation in the patient’s file requiring the she be exempted from cardiopulmonary resuscitation. However, a case can be based on the idea that the nurses should have consulted immediately before her condition deteriorated and ensured that a consultative meeting is made with the relatives.
According to Hayes (2012), in some situations, the decision to withhold cardiopulmonary resuscitation is not clear whether it should be made by the physician or the patient. Butts & Rich (2012), ethics can be defined as a branch of philosophy used to study ideal human behaviour and ideal ways of being (p. 4). When faced by an ethical dilemma, most of the times the nurse is forced to make a decision whether to uphold nursing ethics and work as required to save the life of a patient or work in line with the patient’s orders and see them suffer helplessly. According to Hayes (2012), themes arising while debating on the use of cardiopulmonary resuscitation include the life or death decision needing to be done, good and bad dying and the trust at stake considering that the patient sought healthcare services to help alleviate pain and suffering. In Elsie’s situation, the decision that needs to be taken was a life or death one. Patients in critical situations need cardiopulmonary resuscitation to save their lives. However, in a situation where the patient is against its use, the issue of good and bad dying emerges. The specific concern is on the effort that the family and the healthcare fraternity ought to subject to the patient against their wish.
A policy directive by the Ministry of Health (2014), made it clear that a guideline would be provided in eighteen months addressing how resuscitation plans integrate with other state level programs and projects. The Ministry was also working to evaluate resuscitation plan forms in twenty four months and establish whether they would meet clinical need given rapid changes in End of Life care in Australia. Therefore, the decision to withhold resuscitation can be classified as an end of life care decision. It is a decision when made may invite legal suit with the victim often being absent if they succumb to their suffering. According to Levinson & Mills (2014), the outcome of cardiopulmonary resuscitation in older chronically ill patients is very poor and very few make it to recover and stand to be discharged thereafter. Using such parameters and considerations, subjecting an old and chronically ill patient such as Elsie to the procedure should have been done with the family’s opinion and based on her wish to be exempted from the procedure.
A stakeholder analysis ought to be done when coming up with a decision to use cardiopulmonary resuscitation or not. According to Jabre (2014), offering family members a chance to be present when conducting cardiopulmonary resuscitation have psychological benefits compared to those who are not given a chance. In this case, the stakeholders involved include the family members, the hospital administration, the nurses and the patient. Considering there is no standard procedure in using it, the nurses should have treated it as a life or death case and used the procedure used when the patient with chronic disease wants medication withheld to allow for death. Elsie had a cardiac arrest before dying. The nurses and physicians used the standard measures to handle such a case but unfortunately she succumbed. In such a case, they cannot be held responsible for the death as they were doing what the law provides in relation to healthcare delivery. According to Hayes (2012), the different categories of patients including the ones whose chances of surviving are low (0%-17%), should have different decision-making models used to avoid ethical and legal issues in future.
Ethical theories can be used to explain any ethical decision. However, in some cases, they fail to align to the professional standards or requirements. Utilitarianism theory works towards maximising the benefits that accrue from a given act by an individual. Using its application in healthcare delivery, the decision made in a case such as Elsie’s should satisfy the needs of the majority. According to Sasson et al. (2013), the first step in administering cardiopulmonary resuscitation is realising that the patient needs assistance. This aligns well with ethical theories discussed in this section. However, utilitarianism does not account for legal considerations such as the presence of an order barring the use of cardiopulmonary resuscitation. Kantian ethics tries to develop a situation where individuals embrace the idea of moral deliberation. One should only do what is morally right. In the medical profession, working in the confines of professional practice is key to quality care delivery. According to Keon-Cohen (2013), safeguards must be put in place to protect vulnerable patients and allay concerns and their families of possible neglect, abandonment, exploitation or elderly abuse. Ethical approaches in Kantian ethics and Utilitarianism can be used in such a case to ensure that the individuals work towards the greater benefit of the majority. Their practice should be guided by the law and the oaths taken upon qualification.
The Issue of Human Dignity in Healthcare Setting
The World Health Organization (WHO) recognises the Universal Declaration of Human Rights (UDHR) where patients’ rights are clearly provided. According to WHO (2016), UDHR recognises inherent dignity and unalienable rights which the human family cannot be deprived. Such include right to life. Considering that human beings have the right to life, it is the role of healthcare professionals to ensure that the life of patients is protected and any attempt to save their life made. In situations such as Elsie’s where an order is needed, the law should be consulted to ensure that the decision made does not conflict with professional practice. The notion of human dignity in international law has been subject for debate considering that it has to work with different constitutions and regional laws which have been formulated with a local setting guided by factors such as religion. Considering the Islam dominated countries, the Sharia Law is founded on Muslim teachings and hence international laws have to be compatible with such laws. This explains why the Muslim countries have lagged behind in women representation in social participation. According to Cheng et al. (2015), ‘do not resuscitate’ forms and standard practice is not available in all countries. Therefore, a stardom exists when discussing the issue of human dignity and the prevention of cardiovascular resuscitation which could save the patient.
According to Hayes (2012), involving family members in some decisions is traumatising and may lead to reduced trust with the healthcare delivery. The rationale used in the above argument is that family members bring their sick people to hospital to seek medication and not to be involved in a decision-making process on whether the patient should be subjected to cardiopulmonary resuscitation. Hayes (2012), notes that in some cases, family members tend to be surprised when asked to assent to the order as made by the patient. Especially for elderly patients who are suffering from chronic conditions, relying on their decisions may be less advisable. The discussion on human dignity mandates healthcare givers at the centre of life saving process where every life should be protected. Therefore, before making other considerations on patient wishes, their role as healthcare professions should precede. The general public also play a critical role in care delivery. According to Safar (2012), the Good Samaritan Law protects members of public who act in good faith as they try to save a life as long as they acted in a reasonable manner (p. 249).
In Elsie’s case, the family established that she lost her life due to the stress of being taken to hospital. At the hospital, she had pleaded with the nurse to be left as she was. The nurse however saw it important to take her to hospital. Therefore, legal and ethical issues arising can be addressed focusing on the role of a nurse and the absence of a signed order preventing the physician and nurse from using cardiopulmonary resuscitation and taking her to hospital. Therefore, as much as the family members are seeking legal intervention into Elsie’s death, the absence of a signed order to prevent the activities in her last moments, it would be hard to develop a strong case. Nurses and other healthcare professionals work under strict codes which determine what they can do in life-or-death decision-making situations. In most cases, the decision is based on the benefit of the patient unless an order had been given to bar such care.
Cheng, Y., Wang, J., Huang, S., Kuo, M. & Su, C. (2015). Do-not-resuscitate orders and related actors among family surrogates of patients in the emergency department. Support Care Cancer. Doi: 10.1007/s00520-015-2971-7
Hayes, B. (2012). Clinical model for ethical cardiopulmonary resuscitation decision-making. Internal Medicine Journal. Australian College of Physicians.
Jabre, P., Tazarourte, K., Azoulay, E. et al. (2014). Offering the opportunity for family to be present during cardiopulmonary resuscitation: 1-year assessment. Intensive care medicine 40 (7): 981-987.
Keon-Cohen, Z. (2013). End of life care. Leadership and quality in end of life care in Australia. University of Monash.
Levinson, M. & Mills, A. (2014). Cardiopulmonary resuscitation-time for a change in the paradigm. The Medical Journal of Australia, 201(3), 152-154. Doi:
Rubulotta, F., & Rubulotta, G. (2013). Cardiopulmonary resuscitation and ethics. Revista Brasileira de Terapia Intensiva, 25(4), 265–269.
Safar, P. (2012). Advances in cardiopulmonary resuscitation: The Wolf Creek Conference on Cardiopulmonary Resuscitation, October 30, 31, 1975. London: Springer Science & Business Media. pp. 249.
Sasson, C., Meischke, H., Abella, S. B. et al. (2013). Increasing cardiopulmonary resuscitation provision in communities with low bystander cardiopulmonary resuscitation rates. A science advisory from the American Heart Association for Healthcare providers, policymakers, public health departments and community leaders. Circulation, 127: 1342- 1350. http://dx.doi.org/10.1161/CIR.0b013e318288b4dd
The Ministry of Health NSW Government. (2014). Using resuscitation plans in the end of life decisions. Policy Directive. 1-27.
World Health Organisation. (2016). Patient’s Rights. Genomic Resource Centre. Retrieved from. http://www.who.int/genomics/public/patientrights/en/
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