Ethical Principles (13 Nov)

Question 1

What is the aim of palliative care?

Answer 1

Pall care does not aim to hasten death but to enhance quality of life for both patients and their loved ones.

Question 2

What are the common ethical issues confronted by nurses in pall context?

Answer 2

• Disclosure of disease to patient/family members
• Treatment to alleviate symptoms
• End-of-life care decisions
• Withholding or withdrawing of artificial hydration and nutrition

Question 3

What are the nurses responsibilities in pall care?

Answer 3

1. Provide appropriate care
2. Be honest
3. Maintain confidentiality
4. Maintain good relationship with patient and family
5. Maintain trust by managing potential conflict of interest/values

Question 4

Which are the ethical principles in pall care?

Answer 4

1. Autonomy
2. Beneficence
3. Nonmaleficence
4. Justice

Question 5

What is autonomy?

Answer 5

The ability of an adult of sound mind to make decision concerning their own life.

Question 6

What are the relevant issues in pall care regarding autonomy?

Answer 6

Respecting a person’s choice and dignity
Informed consent
Communication, honesty and truthfulness

Question 7

John is a 45-year-old man has been diagnosed with prostate
cancer. A surgery is planned and it is expected to be successful.
John has learning disability and lives in a sheltered home. He has
limited understanding about his condition. He does not wish to
undergo the operation although he understands that it will save
his life.
Should John’s wish be respected?

What should we consider when trying to make a decision?

Answer 7

His capacity in relation to his condition
Elicit the reasons why John doe snot with to undergo the surgery.
What are the alternatives?
Any decision must be discussed thoroughly (interdisciplinary meeting/faily conference)

Question 8

What are the 5 statutory principles of mental capacity act?

Answer 8

1. Assume a person has capacity unless the opposite is proven
2. Take all practicable steps to help a person make their own decision.
3. A person has the right to make an unwise decision.
4. Always act in the person’s best interest.
5. Choose the less restrictive option.

Question 9

What are beneficence and nonmaleficence?

Answer 9

Beneficence - do good
Nonmaleficence - do no harm

Question 10

What are the relevant issues for beneficence and nonmaleficence?

Answer 10

Moral engagement
Evaluation of benefit and harm
Treatment options
Provision of appropriate education

Question 11

Mr. Dave, a 65-year-old retired principal, was diagnosed with Chronic Obstructive
Pulmonary Disease and Prostate Cancer for 10 years. He was sent to Emergency
Department because of Pneumonia and Cardiac Failure. He was intubated and admitted
to Intensive Care Unit (ICU) for ventilator support and antibiotic therapy. The doctor
failed to wean him from ventilator for three weeks.

Mr. Dave highlighted to the doctor that he could no longer bear the treatment. He wished
to be removed from the ventilator and not to resuscitate him if he collapsed.

The doctor discussed with Mr. Dave’s wife of his wish and that he was unlikely to achieve
functional recovery because of multi organs dysfunction. Mrs Dave felt extremely sad
and refused to accede to Mr. Dave’s request because she was afraid to lose him.

Mr Dave told his wife that the cancer caused him pain and he had difficulty breathing
whilst taking sedation medications. He also shared he feared experiencing distress in
breathing and would prefer simply to die in his sleep. His wife said nothing but held his
hands and began to cry.

What are the considerations when making the decision?

Answer 11

His capacity in relation to his condition
What are the alternatives?
Treatment provided should be in the best interest of the patient.
Any decision must be discussed thoroughly (
interdisciplinary meeting/family conference).

Question 12

What is justice?

Answer 12

Fairness in treatment of individuals to equitable allocation of healthcare resources or budget.

Question 13

What are the relevant issues for justice?

Answer 13

Distribution of resources
Respect for people’s rights
Respect for morally respectable laws

Question 14

Susan, a 80-year-old resident from a nursing home has end-stage
heart failure. She has been having chest infection for 2 weeks and
treated with antibiotics. Susan is very frail and will imminently die.
Should the medication or treatment be continued?

What should we consider?

Answer 14

Manage each patient based on their clinical needs with support
of family or caregiver.

As healthcare professionals, we need to be careful of not
imposing our own personal or professional opinions to judge on
others.

Any decision must be discussed thoroughly (
interdisciplinary meeting/family conference).

Question 15

What is an ACP?

Answer 15

NOT a legal document.

A process to discuss and document your care preferences with your loved ones with regard to future healthcare options in a medical crisis where you can no longer speak for yourself.

It guides the medical decision towards your preferences and helps to ease the burden of decision-making for loved ones.

Question 16

What is an AMD?

Answer 16

A legal document that you complete, stating that you do not with to receive extraordinary life-sustaining treatment to artificially prolong life in the event of terminal illness, where death is inevitable and impending.

Only effective when the patient is terminally ill.

Question 17

What is an LPA?

Answer 17

A legal document where the patient (donor) gives another person (donee) the authority to make decisions on their behalf.

2 types:
Personal Welfare LPA: for decisions relating to personal welfare which could include healthcare decisions if the donor specifically states so
Property and Affairs LPA: covers financial and property matters

Question 18

What is artificial nutrition/hydration?

Answer 18

Defined as the nutritional and
hydration support of an invasive nature requiring the placement of a tube
into the alimentary tract or parenterally via intravenous or subcutaneous
means.

Decisions on artificial nutrition and hydration must be made on an
individual basis. Communications with patient and family is an important
component of this decision.

Question 19

What are the advantages of artificial hydration?

Answer 19

Some evidence suggests that artificial hydration for patients with intestinal obstruction or delirium secondary to opoid toxicity may be useful.

Question 20

What are the disadvantages of artificial hydration?

Answer 20

Artificial hydration can cause fluid overload, throat/respiratory secretions and
peripheral oedema. There is a need for IV/SC cannula to deliver hydration.

Question 21

What if patients feel thirsty?

Answer 21

Most of the thirst sensation results from dry oral mucosa and lips. Patients with
good oral care are less likely to feel thirsty.
Studies have shown that artificial hydration does not affect thirst sensation in
terminally ill patients.

Question 22

Will patients die hungry?

Answer 22

Patient towards the end of life have decreased oral intake and poor appetite. This is
part of the natural process of dying and patients do not feel hungry at this stage. In
fact, force feeding them may result in vomiting.

Question 23

Management for artificial nutrition and hydration

Answer 23

• Monitor drug dosages and consider reducing doses as patient takes less fluid progressively.
• “Pleasure feeding” if patient is alert enough to consume orally.
• Use of time limited trial of hydration may be useful in some cases. Have clear goals about intended outcomes and consider stopping if these goals are not achieved after a stated period of time or when burdens outweigh benefits
• Oral care

Question 24

What is At-Own-RIsk (AOR) feeding?

Answer 24

The decision for oral feeding despite compromised swallowing safety.

For patients who are not keen for non-oral feeding and understand and accept the risk of aspiration and possible complications.