Introduction: This assignment illuminates the use of ethical decision making model in taking decisions while managing patients in their best interest. Ethical decision making is very challenging for the health care professionals while working for the benefits and the interests of the patients.
While caring for the dying or the terminally ill patients, health care providers address various issues of pain and suffering in relation to the psychological, spiritual, mental and physical complexities of the person having the terminal illness.
The ethical decision making models act as guide to make decisions in different complex situations addressing various issues which includes ethical principles, person’s own values and beliefs, institutional policies, legal considerations and social values
Nurses can improve results of ethical decisions by:
• preferring client wishes.
• encouraging the importance of ethical issues in care of patient.
• obtaining necessary consultation on ethical concerns
• becoming involved in the development of policy on ethical issues
• advocating for safe and competent nursing care within Alberta communities
• encouraging and facilitating cooperation and collaboration between professionals and
between agencies to effect improvements within health care
• participating in the development of practice standards, issues statements and position
papers on professional issues
• working with colleagues to identify crucial ethical issues for the profession,
− the implementation of evidence-based practice
− shaping the direction of health-care reform
• linking of resource allocation decisions to client outcomes
In this assignment i am going to use STORCH Model for ethical decision making.
This model was developed by Jan Storch for use in health policy decision making, but later it was adapted for use in ethical decision making.
Dr. Storch suggested the use of this circular model as a way of reminding us that it is important to return to each consideration as we move towards decision making. This model involves three major steps:
Information and identification
Clarification and evaluation.
Ethical principles— Autonomy
Social expectations and Legal requirements
Range of actions/ anticipated consequences
Professional code of ethics
One’s values’ beliefs, values of others and value conflict
3. Actions and Review.
Case study: Eighty four years old Mr. Adam, was admitted to the ICU. He has been suffering from throat malignancy for 18 months. Now his disease condition has become worsen. His life expectancy is about 3 months. He has difficulty in breathing, difficulty in swallowing and cries with pain. He is on mechanical support and has nasogastric tube in place. He lives with his 82 years old wife.
He was a active social worker. His wife tells that he believes in living life in a productive way. He used to drive cancer patients to the rehabilitation centre voluntarily. He has two daughters who live in Ontario, but now they are here to visit their father. He requested the nurse to remove the nasogastric tube and mechanical ventilation as he does not want to live life in this way. His wife agreed to his decision as she does not want to see him suffering anymore. She want him to die peacefully and painlessly.
According to Storch Model of ethical decision making, in this case scenario,
Information and identification: Nurse Need to gather all the information regarding Mr. Adam.
Nurse can arrange a family conference including his wife and the daughters also the family physician can be involved. She should listen to the views and concerns of all the family members related to the request of the patient.
Nurse should consider the medical condition of the patient, Mr. Adam is terminally ill and now as his condition has become worsen he has become totally dependent on life support system. He has severe pain which he cannot tolerate.
His life expectancy is very short and the prognosis is really poor.
Mr. Adam is suffering from throat cancer and is on the last stage but his decision making capacity can be intact, so nurse should assess the reason for his decision. Nurse should assess if there is depression, as it may effect the decision of the patient.
Mr. Adam is staying alone with his wife, so the financial resources may be limited to bear his stay in hospital.
He was an active social worker. Mr. Adam used to drive cancer patients to the rehabilitation centre. He may have strong social connections and a positive quality of life.
Mr. Adam believes in active living of life not in this dependent manner and he spends his life living for others and helping others in their time of need. He had very positive attitude towards life. He believes in life worth living rather living.
Nurse should assess the expectations of his family regarding the condition of the patient. Mr. Adam’s wife and daughter should be asked about their expectations for Mr. Adam’s health status and prognosis. His daughters live far away from him so they may not have as much familiar with his condition as Mrs. Adam do.
Nurse can consult the doctor regarding the condition of the patient and also about the outcome of the decision.
Identify the surrogate decision makers for Mr. Adam.
According to the second step:
Clarification and evaluation: nurse should assess the different values associated with Mr. Adam.
Mr. Adam’s personal values regarding life are worth living life. He believes in living life in a productive and positive way.
Nurse should assess the cultural values of the patient, what role cultural values play in his life. What his culture says about life and death.
Nurse should also keep in view the religious values of the patient. What role does his religion play in his life? If the religion allows for hastening the death process.
Professional values play an important role in ethical decision making. Nurse should consider the professional values associated with the removal of life support system.
Nurse should assess the values of the family members regarding the decision of hastening death of their family member.
Mr. Adam’s wife is in favor of his decision to remove life support as she does not want to see him suffering. She wants him to die peacefully and painlessly.
Consider the ethical principles.
Principle of Autonomy: According to this principle patient has the right to decide for himself, here in this case Mr. Adam is autonomous and deciding removal of life support system. He tells the nurse that he does not want to live life like this.
Nurse should respect his autonomy towards the life and should consider his decision and wish while taking actions.
Principle of non maleficence: According to this principle nurse should do no harm to the patient. In the above case scenario,
patient want to stop the life support and continuing the treatment may go against the principle as it is against his wish.
Principle of beneficence: According to this principle, nurse should do good for the patient. Here patient is asking for stopping life support system but it does not provide any benefit towards his condition at the same time it works in favor of his wish to die.
Principle of justice: According to this principle, all persons should be equally provided with health care services. In this case patient is provided with required health care needs.
Consider the social expectations and legal requirements:
Nurse should look for any similar history in the hospital. Identify any previous similar case in the institution, so that she/he can look for the policies and steps that can be taken.
Nurse should check the hospital policies regarding the hastening of death of the patient. She should assess that what steps can be taken according to the policies.
Nurse should ask for any legal documentation of client’s decision making authorities. She can ask for any legal will or advance directives.
While considering the different aspects of model nurse should assess that what possible range of actions can de done.
Considering the information provided, Mr. Adam is a strong social human being, he spent life doing productive, now as he is chronically sick and dependent which for him is not worth living. He is old and the life expectancy is poor also it gives him severe pain. His wife want him die peacefully. And also the financial sources may be limited to continue life support.
The ethical principles gives him the right to decide for himself.
According to Canadian Nurses association code of ethics for registered nurses, there are seven primary nursing values:
1. Providing safe, compassionate, competent and ethical care
2. Promoting health and well-being
3. Promoting and respecting informed decision-making
4. Preserving dignity
5. Maintaining privacy and confidentiality
6. Promoting justice
7. Being accountable
( CNA code of ethics for registered nurse)
Nurse should consider the professional code of ethics while making decision for the patient that whether she is going according to provided professional guidelines.
In this case nurse should follow the professional code of ethics while caring
And deciding for Mr. Adam.
Nurse can consider her own values and beliefs regarding life and death in empathizing and understanding the needs of the patient and family.
Nurse should understand the values and beliefs of the persons involved in the decision making for the patient. How the stopping of life support system effect the family members? What they believe about death process?
Mr, Adam’s wife believes in his peaceful death.
Nurse should assess if there is any conflict between the values of patient, family members , profession, culture, religion.
Action and review: in this case scenario action must be decided according to the various perspectives proposed by the model.
Nurse can check what she can provide to the patient, whether the request to hasten dying is made under depression or really in relevant means to patient.
If it is due to depression, what nurse can do to promote and facilitate calm and peace to mind of patient.
How she can provide compassionate care and peaceful death to the patient.
If patient really wants to die, nurse should t check what she can do while regulating the hospital policies.
All the perspectives given by the model should be reviewed before taking any actions.
Conclusion: In the nutshell, I can say that Storch Model is the best suited model to the above case scenario as it covers all the issues and perspectives related to the decision. The ethical decision making skill can achieved by reading literature and with the practice experience. These decisions play important role in the lives of patients and nurses as well. There is need of ethical relationship between patient and nurse. There should be better understanding of nurses own values, beliefs, patient and his values and beliefs, professional values , institutional policies.