the dying patient

THE DYING PATIENT’S ETHICAL CHOICE 2

During one of my clinical placements on the Medical Floor at the hospital, I had the opportunity

to provide care to an end of life patient whom was diagnosed with terminally ill cancer. At the time, he

was waiting to be placed on the Hospice Unit which specialized in nursing end of life patients at St

Joseph’s Care Group for further treatment. “Hospice care is designed to support families and caregivers,

as well as patients, yet there are few options available to assist caregivers with their daily responsibilities

of patient care.” (Emperio et al) (2011).

During my conversations with my patient, he had voiced his concern numerous times that he did

not want to die in the hospital or to be transferred to the hospice care unit. His choice was to die in his

home with his family by his side. “A patient’s place of care may become her place of death. For some

patients this is a strong preference and a significant reason for wanting to be cared for at home.”

(Wheatley et al) (2007).

As the days went on, I could see a significant physical and psychological change in my patient

while caring for him in the hospital in that his appetite had declined, and that he was getting further into

engaging in a depressive state of mind. All he kept on saying was that “I want to go home!” I felt for him

in that I reassured and supported him for his reasons as to why he wanted to go home. I talked with my

preceptor and we had discussed his choice and she had informed me that there was going to be a family

meeting set up with the health care team in regards to possibly discharging the patient to his home;

however, there were some physical barriers to overcome in the meantime. During my interactions with

my patient while providing care for him, I realized that he was confiding in me and felt like he could trust

me in which it almost seemed like there was a therapeutic nurse client relationship occurring. “There are

five components to the nurse-client relationship: trust, respect, professional intimacy, empathy and


power. Regardless of the context, length of interaction and whether a nurse is the primary or secondary

care provider, these components are always present.” (Therapeutic Nurse-Client Relationship, Revised)

(www.CNO.ORG)(2009).

The next week, prior to starting my clinical, I was informed by my preceptor that the family

meeting had taken place and that my patient was in the process of returning home on a trial basis to see

how the outcome would be while caring for him in his home. Throughout the day while caring for the

patient, I observed him to be in relatively good spirits. He was smiling and very talkative with me and

had consumed majority of his meals during the shift. He then informed me that he was going home soon

to be with his friends and family by his side. He was able to make his choice about his final time of life

and that he wanted to enjoy and spend it with family and friends. I had admired and respected his

autonomy for him to make that choice. “Autonomy is the capacity to make and express (and perhaps act

on) choices. It is characteristic of (some) persons.” (Wheatley et al) (2007). He asked me if I knew the

date that he was going home. I replied to him and said that I would check with his primary nurse. I had

spoken with my preceptor in regards to what my patient had asked of me and she had said that they are

uncertain of what exactly the date that he will be going to his home as the family have voiced concerns

in that they will have to share the care between the patient’s son and daughter’s schedules in order to

accommodate their father’s care. She had also mentioned to me that the son and daughter have been

experiencing stress during this time and feel that their father should be transferred to the hospice unit

where he could receive nursing care. “Caregiver Stress” creates physical and psychological strain over

extended periods of time, is accompanied by high levels of unpredictability and uncontrollability, has the

http://www.CNO.ORG)(2009)


capacity to create secondary stress in multiple life domains such as work and family relationships and

frequently requires high levels of vigilance.” (Schulz et al)(2008). They both realize that their father’s

wish is to die at home; however, they feel that they will not be able to provide care due to their hectic

lifestyles and would add more stress. I personally feel that the nurse in this situation is caught in the

middle while trying to advocate for the patient and at the same time trying to reason with the patient’s

family. “A client wants to die at home in peace and comfort. The family knows that the presence of the

client at home will create intolerable stress for the other family members. The nurse is being pressured

by other members of the health care team to talk the family into taking the client home.” (CNO Practice

Standard Ethics)(www.CNO.ORG)(2009).

As a student nurse, I found it frustrating at times, due to having a lack of knowledge and

experience in this situation. In both circumstances I am trying to understand how the patient feels and in

the other way, knowing that the family is concerned. “Being able to relate to their patients often means

that nurses are better able to assess their patient’s needs. However, nursing students are considered

novices who do not yet possess clinical knowledge, and their relational knowledge is sometimes

overlooked. This is distressing for many students who find themselves confronted by difficult ethical

situations.” (Beckett et al)(2005). I know that the patient is cognitively aware and is able to make a

sound choice as to where he wants to spend the remainder of his life which is very little at the present

time, however, his family feel that added stress would add a hindrance to the situation and they feel

that their father deserves better care even though this is his choice. I have acknowledged that it is the



nurse’s role and responsibility to provide the best care to the patient while respecting his wishes in a

professional manner. “Much of the discussion of patient advocacy is rooted in the recognition and

valuing of patient rights and the role of nurses as advocates for the interests and rights of individuals.”

(MacDonald)(2006). Advocacy is vital role in which nurses participate with their patients. Nurses are

constantly promoting health to their patients in a caring and compassionate manner and therefore are

advocating for the patient to whom they provide care to. My patient is self-determined that he wants to

spend his final days at his home and I am aware that as a nurse it is her responsibility to advocate and

support him so that he make the best possible decision for himself. I understand that this is an uneasy

situation; however, nurses as professional health care providers must face the dilemma and act

accordingly for their patient’s best interest. To make the right decision for the patient, I experienced it

to be uncomfortable at times as this is fairly new to me; however I believe that the nurse will gain more

confidence over a period of time with having more exposure in dealing with it. “Kohnke (1982) suggests

that advocacy is a form of caring and compassion on the part of the nurse and that it is a learned

activity. She believes that advocacy is a skill that nurses develop through various experiences, particularly

if advocacy is prized as worthwhile. Kohnke (1990) explains that the task of advocacy is focused on

ensuring patient self-determination over decision-making. She describes advocacy as “the act of

informing and supporting a person so that he can make the best decisions possible for himself.”

(MacDonald)(2006).


In the days to follow, I had the opportunity to attend an interdisciplinary team case conference

with my patient, his family, my preceptor, the physician, social worker, pharmacist, clergy, dietician, and

psychologist to discuss the future plan of care for my patient. The main focus was what the patient

wanted and how can health care providers support him and fulfill his needs during this time of his life.

“Quality end-of-life care is best provided through the collaborative practice of an interdisciplinary team

to meet the physical, emotional, social, and spiritual needs of the person and their family. Nurses as

members of the interprofessional team, collaborate with the person, the person’s family and all those

involved in providing care (such as physicians, other health-care professionals and volunteers) to support

a holistic approach; incorporate the person’s priorities, values and choices in all aspects of care; and

address any specific concerns that may arise.” (www.cna-aiic.ca)(2008). It was interesting to hear what

my patient had to say in regards to what his needs are and that his main goal was to die at his home

peacefully with his loved ones surrounding him. He had stated to the health care team during the

meeting that he wanted all health care professionals whom were involved with his care to continue on

treating him while he was living at home. He is spiritual and values his religion in which he practices on a

regular basis. His family supports and value him in regards to his choice; however, there are some

concerns they have in regards to whom would be caring for him when they are not able to be there. I

can understand why they are concerned and that they do not want to have to worry if their father is left

alone. “CNA recognizes a person’s right to make informed choices about his or her plan of care for the

end of life that reflect his or her personal, culture, and religious values. When assisting an individual in

http://www.cna-aiic.ca)(2008)


this planning, nurses should consider the individual as a person in relationship with others, including his

or her family.” (www.cna-aiic.ca)(2008).

During the case conference in which the patient, his family and other health care providers had

attended, other options had been discussed such as having home care services put into place while the

patient was living at his home. These home care services involved nursing services, personal support,

and homemaking as an option if the family was not able to be at home during that time. In regards to

advocating for my patient, I elaborated more to my preceptor in that home care would be an ideal plan

of care for my patient and also the patient’s family in that he would be able to have his wish in that he

can die at home and also his family would feel more at ease in that knowing that their father can be

cared for by health care professionals and support while providing care to him in his home. I had further

discussed with my patient’s physician, and with my preceptor that I have observed a significant change

with my patient since my last clinical which was the previous week in that my patient had voiced various

times that he wants to return to his home and leave the hospital. I had also commented to both of them

that his health has declined in that he was getting depressed, and his appetite had decreased. His

cognitive status is intact and he is able to make his own decision as to where he wants to spend the

remainder of his life. I believe that he should be able to make this decision based on his cognitive mental

status and that he has every right as a human being to choose where he wants to die. At present, many

ill individuals want to remain in their home as the hospitals and institutions are lacking the facilities to

accommodate them while they are waiting to be placed to other places such as long term care, and

other facilities. There are many home care providers which included professional nurses, personal

support workers, and homemakers to provide care and support to patients and their families. In this

http://www.cna-aiic.ca)(2008)


case, I do not see why my patient cannot have a community health nurse visit him and provide the care

and support needed.

In regards to accessing ethical knowledge to determine my decision making and action, I

accessed the CNA Code of Ethics, CNO Standards of Practice which I found various articles involving the

Nurse-Client Therapeutic Relationship, and Standards of Practice.

I enlisted my embodied knowing by perceiving the situation as very special in that this matter

had influenced me in an emotional, physical and psychological way. I felt compassion and empathy for

my patient in that he should have a choice as to where he wants to spend his final days in life. He is

cognitively aware that he does have little time to spend and he wants it to be right. By using thorough

assessment skills, I could see that he wanted to be at home as numerous times during my shift, he had

commented that he does not like the hospital and wants to go home now. In the physical perspective, I

noticed his health had declined from day to day in that his appetite had decreased which had also

affected his GI system. His skin turgor was losing elasticity, as well as body strength and muscle mass

had deteriorated. Psychologically, he was becoming depressed and not wanting to interact or

communicate with me anymore. He was beginning to isolate himself from everyone. In general, I could

see that his overall health status had declined significantly.

I see myself as a moral agent when caring and providing nursing care to my patient in which I

had formed a therapeutic relationship with him in which he had fully trusted me by interacting with me

in a warm compassionate way. “Nurses need to recognize that they are moral agents in providing care.

This means that they have a responsibility to conduct themselves ethically in what they do and how they

interact with persons receiving care.” (Canadian Nurses Association Code of Ethics for Registered


Nurses)(2008). I in turn, showed empathy for him by advocating for him to return to his home to spend

his final days of life. I wanted him to maintain his quality of life by supporting him in making the best

decision possible while receiving nursing care within his home environment. I felt very emotional at

times while providing care to him as I wanted everything to work out for him and did not want him to

get let down if things did not work out. “Ethics is a deeply personal, embodied process, being and

becoming a moral agent requires the cultivation of a mindful, critical awareness and attunement to

emotion and bodily experience.” (Doane)(2004). At times, I tried to put myself in my patient’s shoes and

reflected to myself the following question, how would I feel and where would I like to spend the final

days of my life. My answer would be the same as my patient in that I would like to spend the remainder

of my life where I am comfortable in my home environment if able. My patient as a human being should

have his right to make the decision as he is cognitively aware what is right for himself with home care

supports in place for him. I felt strong emotions within my body for my patient numerous times while

caring for him and have self-reflected in my mind and body the emotions he was going through while

referring to what the significance of embodied knowing is in correlation to nursing and the moral

agency. “Sound ethical practice in nursing requires embodied knowing. This understanding of how

knowledge comes together in the body has highlighted the significance of embodied moral agency.

Through our bodies, we have an implicit sense of a situation and the intricacy of it. The body not only

acts as an orienting centre of perception and knowledge, but also orients our action. If we pay attention,

we can physically sense our bodies’ implication of the situation and the next steps we should take.”

(Doane)(2004). I directed myself as a moral agent also by listening to my patient in a caring way and also

respecting his decisions under the circumstances which he is experiencing at present with dignity. As a

nursing student, I know that I will be facing many ethical decisions in the role of a professional nurse

while providing care for my patients. The initial step is to form a therapeutic relationship between


the nurse and the patient based on respect, trust, empathy and dignity. Once this has formed, it is much

easier to facilitate direction in communicating, engaging, and interacting with the patient in providing

nursing care based on his needs. By self-reflecting and using critical thinking skills regularly also

enhances the habit of developing embodied knowing which has helped me identify myself as a moral

agent in this situation. Keeping an open mind in relation to my inner bodily experiences has helped me

stay in fine tune with the external environment in which has kept me in balance when caring for my

patient and has made me stronger and increases my self-awareness and wellbeing. “Recognizing and

supporting the development of embodied knowing is not only vital to advancing ethical practice in

nursing, it is essential to promoting the well-being of nurses.” (Doane)(2004). I have acknowledged that

embodied knowledge takes time to develop into the nursing practice and with experience and practice it

will develop overtime within the nurse’s role and responsibilities. Embodied knowledge involves many

concepts of learning within society in which each professional practice. “The development of embodied

knowledge is a sociopolitical issue as much as a philosophical, conceptual, or academic one.” (Doane)

(2004).

Habits of conduct which constrained my embodied knowing and practice was during the time in

which I was in the process of advocating for my patient in which he was waiting to hear when he could

return to his home to spend his final days of life. I had attended the case conferences in which all health

care disciplines, and his family were also present. The goal in which I had hoped to be met was for the

patient to return to his home with home services in place. However, the family had ongoing concerns in

that their wishes to have their father spend his final days on the hospice unit in which he could receive

palliative care. I was informed that many community nurses do specialize in palliative/ End of life care in


Which nursing care is provided on a 24hr basis to the patient while he resides in his home. I was

frustrated at times during the case conferences when I heard the family state that it would be more

realistic if their father would be cared for in an institution versus at his home. In my opinion, after

hearing this from the family, I interpreted that they were neglecting to respect their father’s wish and

only thinking of what their opinion was. It also occurred to me that they were reluctant to trial their

father at home with home care services in place. I did not want to override the family as I had also

respected their decision and knew that they cared for their father and wanted what is best, however, as

an individual entering the health care profession as a student, I felt that I was responsible for providing

respect and dignity to the patient by advocating for him accordingly. “Nurses are often in situations

which challenge their abilities to fulfill their moral responsibility and accountability, and they are too

often overwhelmed by ethical problems; and they experience a great moral distress because of this.”

(Varcoe)(2009). During the case conferences with other health care disciplines and the patient’s family, I

had practised ethical nursing in which I took on an advocacy role on behalf of the patient by promoting

the values and wellbeing of my patient. I voiced numerous of times that it would be worth the time and

effort to try having him at home with support services in place to see if it would be in the best interest

and outcome for the patient. I had along with my preceptor voiced concern that my patient’s health had

declined as he wanted to go home soon. He was not in happy spirits while staying in the hospital as he

had voiced many of times that he wants to go home. “Ethical nursing care means promoting the values

of client well-being, respecting client choice, assuring privacy and confidentiality, respecting the sanctity

and quality of life, maintaining commitments, respecting truthfulness and ensuring fairness in the use of

resources. It also includes acting with integrity, honesty and professionalism in all dealings with the client

and other health care team members.” (www.CNO.ORG)(2009).



There are many contextual forces which shaped my action, the situation and my experience in

that by collaborating with other health care disciplines and hearing what they had to contribute to the

care of the patient is very informative in that we all agree that we all provide patient centered care to

the patient and that the main concern is what is best for the patient while enhancing quality care. Each

health care professional provides a specialized expertise and I had learnt a great deal of information

which contributed to the wellbeing of the patient at hand. Learning from the experiences of other

nurses whom have had previous experiences with this type of action contributed to the situation and to

the meaning. By listening to them, I had learnt a great deal in regards to engaging my personal

knowledge and applying it within the social context or organization to give it meaning. “As well as being

narratively and dialogically derived, the nurses’ identities appeared to emerge through layers of

negotiations with self, with others, and within a context of social organization.” (Doane)(2004). Many of

the nurses had informed me that it takes many years of experience and by building on it, many

circumstances in the past have similar consequences in regards to the same interventions or goals of

each patient. Whatever the goal or outcome is, it all has meaning and each nurse builds on that meaning

when they are faced with this dilemma again. “Confronted with many different events and situations in

their practice, the nurses selected and organized their experiences of those events into a set of workable

meanings. These workable meanings shaped how they identified themselves within the situations and

how their professional identity blended with their personal identity.” (Doane)(2004).

In conclusion, my patient’s wish had come true for him as he was able to return home and

spend his final years of life. Home supports such as nursing, personal support workers, and homemakers

were provided to him. Sadly to say, he had passed away one month later in his sleep with his family by

his side.


References

Beckett et al (2007) (p. 30). Doing the Right Thing: Nursing Students, Relational Practice, and MoralAgency. Journal of Nursing Education, 46(1), 28-32.

Canadian Nurses Association (2008). Code of Ethics for Registered Nurses 2008 Centennial Edition.Ottawa.

Canadian Nurses Association (2008). Position Statement: Providing Nursing Care At The End OfLife. www.cna-aiic.ca.

College of Nurses of Ontario (2009) Practice Standard: Ethics. (p. 3-23). www.cno.org.

College of Nurses of Ontario. (2009) Practice Standard: Professional Standards, Revised 2002.(p. 3-13). www.cno.org.

College of Nurses of Ontario (2009) Practice Standard: Therapeutic Nurse-Client Relationship, Revised2006. (p. 3-16). www.cno.org.

Doane, G. (2004)(pp . 433-446). Being an Ethical Practitioner: The Embodiment of Mind, Emotion, andAction. Chapter twenty-one. Toronto: Pearson Prentice Hall.

Empeno et al (2011) The Hospice Caregiver Support Project: Providing Support to Reduce CaregiverStress. Journal of Palliative Medicine Volume 14, November 5, 2011. San Diego, California.

MacDonald, H, (2006) Relational ethics and advocacy in nursing: literature review. Journal of AdvancedNursing 57, 119-126. Health Sciences University of the Fraser Valley, Chilliwack, British Columbia, Canada.

Schultz et al (2008) Physical And Mental Health Effects Of Family Caregiving. National Institute Of Health. American Journal Nursing. University of Pittsburgh.

Varcoe et al (2009). Constrained Agency: The Social Structure Of Nurses’ Work. Health, illness, and Health care in Canada (4th ed. pp. 122-140).

Wheatley et al (2007). Palliative Care. “Please, I want to go home”: ethical issues raised when Considering choice of place of care in palliative care. Postgrad Med Journal; 83: 643-648.Doi: 10.1136/pgmj.2007.058487.

http://www.cno.org/

http://www.cno.org/

http://www.cno.org/

http://www.cna-aiic.ca/

Running Head: The Dying Patient’s Ethical Choice 1

Individual Ethics Essay

“The Dying Patient’s Ethical choice”

Donna Lagergren

Student Number 0278613

Karen Poole

Lakehead University

N 4600

December 3, 2013

I declare that this paper is my original work. Excepting where I have cited my own previous work, thisPaper in its entirety, or any portion thereof, has not been submitted to meet the requirements of anyOther credit course.

Student Signature Donna Lagergren

Date: December 3, 2013

the dying patient

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