Abstract and Introduction
Abstract
Nurses encounter ethical dilemmas in their clinical practice especially those associated with palliative and end-of-life care. The Hospice and Palliative Nurses Association (HPNA) members were asked to participate in an ethics survey. The survey aimed to identify ethical issues experienced by hospice and palliative nurses, identify resources available to them and barriers if any to their use, and to identify how HPNA can be of support to hospice and palliative nurses. One hundred twenty-nine (n = 129) HPNA members completed the online survey. The information from each of the surveys was carefully reviewed, and responses were collapsed into 6 themes. The ethical dilemmas included inadequate communication, provision of nonbeneficial care, patient autonomy usurped/threatened, issues with symptom management and the use of opioids, issues related to decision making, and issues related to discontinuing life-prolonging therapies. Approximately two-thirds of the nurses used resources in an attempt to resolve the ethical issues, including a formal ethics consultation, involvement of the palliative/hospice team, consulting with other professionals, and use of educational resources. One-third of the nurses said there were institutional or personal barriers that prevented the ethical dilemma from being resolved. Participants suggested ways that HPNA could help them to effectively manage ethical dilemmas.
Introduction
Nurses frequently confront ethical dilemmas in their clinical practice especially those associated with end-of-life (EOL) care. These dilemmas have become more common in the face of advances in science and medical technology. Health care providers now have the means to prolong life and in some cases prolong the dying process. Implicit is a responsibility to provide care that is clinically and ethically appropriate. Many nurses, who are in the frontline of providing compassionate and skilled EOL care, feel ill prepared to address ethical issues when they occur, and yet the nurse is more likely to be involved in EOL care and be present at the time of death than are any other health professionals. Nurses are uniquely positioned to have conversations with patients and families about present and future health care interventions and how they align with their values, beliefs, and goals. The American Nurses Association's position statement, Registered Nurses' Roles and Responsibilities in Providing Expert Care and Counseling at the End of Life, supports nursing in advocating on behalf of patients regarding identification of health care preferences. The position statement asserts that it is nurses' responsibility to facilitate the process of informed health care decision making for patients. The close relationship between hospice and palliative nurses with their patients and families provides a natural setting for these conversations to occur. In acknowledgment of this reality, the Institute of Medicine's report, The Future of Nursing: Leading Change Advancing Health Care, states that although physicians have traditionally been responsible for these difficult EOL conversations, nurses are now taking the lead.