An ethics request came from nursing staff caring for a patient dying with end-stage throat cancer on acute surgical service. The patient has requested a removal of her tracheotomy and a chance to die as she chooses. She had agreed to try the trach for a while, but is finding it negatively impacts her quality of life too greatly. Her spouse (in his 80s and not physically well) is present and her whole family is agreeable to her request.
The conversation with the patient continued for several days to give her ample time to consider the implications of her decision and allow her to change her mind if she wanted. She remains adamant, has capacity, is well-informed, and has made her decision voluntarily.
Difficulty has arisen because a few staff members on her team see this course as “assisting suicide” and have refused to continue to care for her. Other staff members are uncomfortable and concerned about possible legal repercussions.
When the trach is finally removed, an unexpected crisis develops. The sedation given during the procedure wears off several hours later, such that the patient becomes very short of breath and agitated, which distresses the family and the staff caring for her. Staff felt they were not adequately prepared to handle this sort of crisis and did not have ready/ timely access to palliative care or ENT physician support to deal with it.
The nursing unit manager thinks it would be helpful to have an ethics-focused discussion facilitated by people not connected to this inpatient unit.
- In this scenario there are a number of different ethics concerns affecting the patient and family as well as staff members. What issues would you consider important to include in the discussion with staff who attend the meeting?
- What values may be stake for the various participants in this scenario?
- What steps would you take to prepare for this meeting?
- Does this case have policy implications? If so, what are they?
Some Values and Ethics Issues to Consider
- Capacity
- Respect for patient autonomy
- Informed consent
- Respect for human dignity
- Patient-centered care
- Patient-family relationships
- Moral distress among health care providers
- Medical error
- End-of-life decision-making
