End-of-Life Issues: Patient Autonomy and External Decision-Making, Article Review Example

Article and Summary

In “Legal Aspects of End-of-Life Care,”  Claire McGowan explores the variety of significant aspects to nursing of end-of-life scenarios, with an emphasis on legal implications and impacts.  Beginning with a basic assertion of the importance of the subject to the critical care nurse, who is invariably involved in these circumstances as they occur in hospital settings, McGowan then proceeds to note just how influential court rulings and legal determinations have been in recent decades in regard to treatment as ongoing or to be terminated.  She cites the notorious Quinlan case as an example of how end-of-life issues may be so complex and conflicted that they are relegated to judicial decision-making.  Equally importantly, McGowan affirms how this landmark case, subsequent rulings and public debate notwithstanding, set the stage for the right to ongoing care in extreme cases to be denied when the patient, the family, and/or medical opinion deems it to be no benefit to the patient.  This allows the author to then note how state interests are typically not permitted to override decisions made by those directly involved in the cases, and/or as when a patient has in advance provided directives.

From here, McGowan discusses the critical factor of competency.  On one level, the patient has the ultimate authority in making end-of-life care decisions: “A competent patient has the right to refuse or discontinue lifesustaining treatments, even if that desire conflicts with the desires of the patient’s family” (McGowan, 2011, p.  65).  The difficulty, not unexpectedly, arises when the patient’s ability to make a cognitive, informed decision is questionable.  This in turn leads to a further conundrum;  while capacity does not require a legal determination, it is nonetheless an issue invariably taken to the courts.  Competence is, in pain terms, the core of the issue of end-of-life scenarios, as the patient is the object of the issue.  This being the case, McGowan emphasize the vital role of the critical care nurse in terms of actual assessment.  Virtually no other party is as acquainted with the patient’s state of being at this juncture, so the nurse is poised to best comprehend and note the patient’s ability to decide, as well as their wishes in the matter.  The author then discusses the appointing of surrogate decision-makes by the courts, and she cites interesting research not affirming the patient’s family as most capable of performing this role.  For example, 16 studies report that family members incorrectly interpret the end-of-life treatment goals in a third of cases (p. 66).  McGowan then asserts that the critical care nurse may be invaluable here, not in acting as the surrogate, but in guiding them to informed decisions most reflective of the patient’s desires.

McGowan concludes by offering a list of strategies which incorporates the knowledge of the nurse, the responsibility of the facility, and the lack of a defining structure regarding the main issue.  Multiple points are offered, but each consistently reflects an obligation on the parts of those involved to engage in cooperative decision-making, as each agent is empowered to provide a valuable perspective.  Medical futility, or the pointlessness of continued interventions is some end-of-life cases, both inherently generates debate and is not addressed by the ANA’s Code of Ethics.  While McGowan ends by reinforcing the need for the critical care nurse to be an essential partner in such decision-making, she closes by stating only that, as dispute may nonetheless ensue, the best solution in some cases is the transfer of the patient to a different facility, indicating an intent to both acknowledge the limits of the nurse’s authority and to protect their integrity in such volatile circumstances.

Implications

As McGowan notes and as is widely understood, advances in medical technology are reshaping the entire framework of how end-of-life care is actually defined.  Quality of life is a consideration of unprecedented import and, certainly, it is correct that the critical care nurse plays a significant role in decision-making when competence is at issue.  This reality, however, carries with it a responsibility equally unprecedented, and one with no “guidebook.”  Essentially, it is simply more crucial than ever before that the nurse fully comprehend both the core ethics of the profession and the legal limitations of it.  Regarding the former, and likely in opposition to other external parties, the nurse must focus on what they understand to be the patient’s best interests.  As challenging as this is, the nurse is nonetheless equipped to do so as others cannot, for they are professionally committed to this core concern at all times, and not subject to extraneous influences.  In a very real sense, then, the primary implication of McGowan’s report is a necessary reinforcement of fundamental nursing ethics.

As to the legal aspect, it is an unfortunate reality that even the most ethically-motivated and committed nurse must concede an absence of actual authority in these cases.  What McGowan fails to note, and tellingly, is that there is no structure mandating nurse input when end-of-life decision-making is in place, and this emphasizes that the nurse in ancillary to the process.  In plain terms, the nurse may never exceed their authority here, no matter the greater degree of patient knowledge, and this is important.  Just as the nurse must be committed to the patient’s best interest, so too may they never lose sight of their inability to actually determine choices.  This translates to the point indirectly made by McGowan, which is that the nurse is as obligated to protect their own standing as they are to attend to the patient, and offer what knowledge they possess.

References

McGowan, C. M.  (2011).  “Legal Aspects of End-of-Life Care.” Critical Care Nurse, 31  (5), 64-69.