Nurb End of LIfe Cultural and Legal issues Flashcards
family meeting, include the patient if able
a. Establish consensus on withdrawal among the medical team members
b. identify the appropriate decision maker, patient, or surrogate: and establish consensus on proceeding among patient/family.
c. document the decision as well as the plan in the medical record
Guidelines for withdrawal of life supporting interventions
1. Clarify the decision:
- Clarify the decision:
- Identify patient/family goals
- Review the process with family and patient if awake
- Create a calm environment
- Principles of symptoms management in withdraw
- orchestrating withdrawal of therapies
- Removal of mechanic ventilation
- After death care
Guidelines for withdrawal of life supporting interventions
A. Ensuring comfort
B. visiting loved ones
- Identify patient/family goals
a. Emphasize comfort consistent with patient goals
b. describe plan
c. reassure to treat signs of distress: adequate analgesia and sedation
d. Address length of survival
- Review the process with family and patient if awake
- provide a private room
- liberalize visiting hours
- remove lines, tubes, turn monitors off, disable alarms
- have one iv line I place for administration of sedatives and analgesics
Create a calm environment
a. presence of attending physician
b. medications must be immediately available at the bedside
c. administration of medication should be guided by anticipatory dosing
d. medication should be titrate to effect
e. continuous infusion is preferable to bolus dosing
- Principles of symptoms management in withdraw
gradual not hasten or prolong
a. any medical treatment that is not essential to the comfort of the dying patient may be withheld or withdrawn,
b. not to prolong dying unnecessarily or act to hasten it
c. reason for th gradual withdrawal of therapies over days is to relate distance between the removal of the medical intervention and the patient’s death
- orchestrating withdrawal of therapies-
-maintain pt comfort
. Removal of mechanic ventilation
a. physician should acknowledge and confirm to the family when the patient has died
b. offer reassurance to the family that the decision was appropriate and correct
c. multidisciplinary team should debrief
. After death care
- is a clinical term, is assessed by clinicians in a healthcare setting and applies to one’s ability to make health decisions
. Decision making
A. Capacity
- is a legal term that is decided by the courts, persons may also be declared relevant in area (such as violence) and is not just related to issues of their healthcare
decision making
B. competence
-note that oral statements made by the pt prior to listing capacity can be used in decision making, especially if they were documented
Advanced directives
Living wills-
Durable power of attorney of health care
- treatment directives
- appointment directives, health care proxy to represent the pt in decision making
Advanced directives
Living wills-
Durable power of attorney of health care
- there is no ethical or legal distinction between a therapy. However many families and heath care providers find it much more difficult withdraw/ discontinue a therapy than to withhold it to begin with
- both of these are based on the right of self-determinism. One must balance the benefit vs. burden in the decision making process
withhold or withdrawing of life sustaining therapies
: not starting a treatment or therapy
withholding
: a treatment or therapy was started and now is to be stopped
withdrawing
: artificial feedings, hydration, ventilation, and dialysis
- life-sustaining therapies
- should not be viewed any differently than withdrawal of other life-sustaining therapies.
- However because the discontinuation of support usually result in death more quickly than the withdrawal of other therapies it can be very upsetting of all involved
withdrawal of mechanical ventilation
if a therapy is to be initiative it can be done with the understanding that it is a ___, with a specific time frame stating when is should be d/c if unsuccessful. This can serve two purpose 1. Decreases the pts risk of being held hostage if the family and or healthcare providers (HCP) are later reluctant to withdraw the intervention and 2. May help to alleviate guilt of the HCp or family when the time comes to make the decision to withdraw the interventions
one option is a trial intervention:
particularly as it pertains to the administration of medically proved nutrition and hydration hcp have often been hesitant to withdraw these therapies, fearing that it may be illegal or the same as participating in assisted suicide/euthanasia, it is not the same. Ana code of ethics and position statement reaffirm this
withhold or withdrawing of life sustaining therapies
- only meant that hcp is not to attempt cpr if the pt has a cardiac or respiratory arrest
- general successful attempts at cpr in individuals who are dying is
Resuscitation and DNRs
DNR
- conflict arise regarding the benefit of treatment (conflicts of values, disproportionate burden)
- these often involve communication failures between all parties involved (pt, family, hcp)
Medical futility
- such request often signify crisis, such as unrelieved suffering and a plea for help
- nurses should assess why request has been made
- often it is due to feeling of no other option
- Ana prohibits nurses acting to end life. Allows nurse to say to the pt “This view is supported by my profession.”
request for assisted suicide/euthanasia
- scope of practice and standards of care
- codes of ethical conduct
- guidance for responsible end-of-life/ palliative practice
Standard of Professional Nursing Practice
