Ethical Presentation

N362
Cibyl Chan, Reid Kaneko, Kelsey Nguyen, David Schoen,
& Zac Yamashita

Synopsis
Patient is involved in a traumatic accident, that leaves him/her cognitively
impaired and unable to communicate. The patient will likely recover from any
life-threatening injuries, however they are such that the patient will unable to
consume food orally. Patient has advanced directives for full support (specifies
artificial nutrition), and so tube feeding is started. The family of the patient
does not want to prolong the patients life because the patient is not expected to
regain cognitive function or independent mobility, and will require long-term
care in a skilled nursing facility or 24-hour home care. Since the patient has
advanced directives, however, they must be respected.

What is the dilemma for

nurses?
-

Quality of life for the patient.

Going against familys strong objection, whom know the patient best.
Questioning if this is truly what the patient intended when they created
their advanced directives.
Long-term emotional costs to the family.
Legal requirement to uphold advanced directive.

Pros
-

Provision 1.4, The Rights to Self-Determination:

- The nurse should provide interventions to relieve pain and other
symptoms in the dying patient consistent with palliative care practice
standards and may not act with the sole intent to end life. (ANA Code
of Ethics, 2015)
- Since the patient is not dying of another cause, discontinuing the
feeding tube would imply a desire to cause the patients death.
(Dunlop, 2006)

Provision 2.1, Primacy of the Patients Interest:

- When the patients interests are in conflict with those of others,
nurses help to resolve the conflict. Where conflict persists, the nurses
commitment remains to the identified patient. (ANA Code of Ethics,
2015)

Pros
-

[Certain groups of people]... do not consider the lives of the severely

disabled meaningless. (Dunlop, 2006)

Consistent with ANA expressed values and goals in the Code of Ethics of
Nurses (2001), the acceptance or refusal of food and fluids, whether
delivered by normal or artificial means, must be respected. (ANA, 2011)

President Barack Obama requested federal rulemaking to reinforce

existing regulations - 42 CFR 482.13 and 42 CFR 489.102(a) - that all
patients advance directives, such as durable powers of attorney and health
care proxies, are respected in all hospitals receiving Medicare or Medicaid
funding. (ANA, 2011)

Cons
-

Provision 1.3, The Nature of Health:

- ...assuring the responsible and appropriate use of interventions in
order to optimize the health and well-being of those in their care. This
includes acting to minimize unwarranted, unwanted, or unnecessary
medical treatment and patient suffering. (ANA Code of ethics, 2015)
Provision 1.4, The Rights to Self-Determination:
- ... to be given accurate, complete, and understandable information in
a manner that facilitates an informed decision; and to be assisted with
weighing the benefits, burdens, and available options in their
treatment... (ANA Code of Ethics, 2015) All too frequently, however,
a statement is made in very categorical terms whether or not to use a
feeding tube. (Dunlop, 2006)

Cons
-

Provision 5.4, Preservation of Integrity

- Nurses have a duty to remain consistent with both their personal &
professional values
- compromise that doesnt jeopardize the dignity or well-being of the
nurse or others
American Academy of Hospice & Palliative Medicine:
- Position Statement: Artificial hydration is potentially harmful and
may provide little or no benefit to the patient making(ing) the period
of dying more UNCOMFORTABLE of the patient and family (Amelia,
Lawrence, & Gresle, 2005)
ANA recognizes that providing food and fluids is not the same as artificial
nutrition and hydration.
- To do one is to offer comfort, yet to do the other is to potentially
cause harm. (Amelia, Lawrence, & Gresle, 2005)

References
Amelia, E.J., Lawrence, J.F., & Gresle, S.O. (2005). Tube feeding: prolonging life or death in vulnerable populations.
Mortality 10(1), 69-81.
American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive Statements. Nursesbooks.org.
Retrieved from http://www.nursingworld.org/MainMenuCategories/EthicsStandards/
CodeofEthicsforNurses/Code-of-Ethics-For-Nurses.html
American Nurses Association. (2011). Forgoing Nutrition and Hydration. Nursingworld.org. Retrieved from
http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/Positions-and-Resolutions/ANA
PositionStatements/Position-Statements-Alphabetically/prtetnutr14451.pdf
Dunlop, John T. (2006). The Feeding Tube Dilemma: Key Questions. Retrieved from
https://cbhd.org/content/feeding-tube-dilemma-key-questions.
Epstein, E. G., & Delgado, S. (2010). Understanding and Addressing Moral Distress. OJIN: The Online Journal of
Issues in Nursing, 15(3). Retrieved from http://www.nursingworld.org/MainMenuCategories/
EthicsStandards/Courage-and-Distress/Understanding-Moral-Distress.html.