Question

You are a nurse caring for a hospice, bedridden, terminal cancer patient in a nursing home. Every time you move the patient, he screams in pain and has tears in his eyes. The patient's daughter has never heard her dad yell in all 60 years of her life. She has also never seen him cry. The daughter requests that the nursing staff do not turn her dad. She states, "he is going to die soon. Just leave him to die peacefully."

How do you as the nurse, form your ethical thoughts regarding this decision?

Would all nurses be comfortable not turning the patient? How would you decide?

Explain and give an example of each:

Beneficence

Nonmaleficence

Autonomy

Justice

Accountability

Answer 1

Ethical thoughts regarding the decision:

Hospice refers to the provision of Palliative care for terminally ill patients, either at a specialised facility or at a residence , and support for the family , typically refraining from taking extraordinary measures to prolong life . Palliative care is a specialised area of health care that focuses on relieving and preventing the the suffering of patients. The nurse repositon or turn the patient , usually every two hourly to prevent bed sore or pressure sores.  

As the patient yells due to pain while turning, and the daughters' request of not to turn the patient, the nurse has to rethink about turning every 2 hourly. As the ' turning' causes more pain and suffering for the patient, the nurse has to think and decide on it base in ethical principles. Aim of Palliative care , especially at the end stage of life , to reduce patient suffering and provide comfort as far as possible and fullfill the wishes of family members and the patient. So the request has to be considered and omit the ' frequent turning ' of patient as it causes more pain in him.

All the nurse will not be comfortable with the decision ' not to turn the patient ' . It is due to the knowledge that frequent repositioning can help to prevent the pressure sore in elderly patients and also it prevents pneumonia from accumulating the lung secretions at  one place in the lungs. Frequent turning can increase blood supply to the pressure areas, there by preventing the pressure sore in bedridden patient.  

( I ) will decide that not to turn the patient frequently. The decision is based on following facts:

Beneficience : It is the ethical principle of ' Doing good ' for the patient. Turning causes pain and suffering in this case.

Nonmaleficence : Ethical principle of ' no harm ' to patient. At the end life patient wants to be free from pain. Turning can harm the patient comfort.  

Autonomy : nurse has to respect patient's autonomy. His wish is not to turn and it is expressed by his daughter.  

Justice : Justice or fair treatment to patient. The nurse has to show the kind treatment to the patient, while adhering to the progessional standards .

Accountability: Nurse should be accountable to her profession and to the patient care.

She can consult with seniors , if she has some confusions over ethical dilemma between the professional accountability of turning the patient to prevent bed sore or add comfort to the patient by refraining from turning the patient.  

Research show that Repositioning the elderly , who is near to death, every two hourly is of no much use when comparing the result. A research conducted in Australia , among elderly at their end stage of life. Even though frequent repositioning done every two hour , most of the elderly developed bed sore at the final week of their life. Moreover frequent turning may interrupt sleep and rest that again can worsen the condition of patient. During their end of life let them sleep peacefully . The research recommended the use of Alternating Pressure Air Mattress ( APAM) to prevent bed sore rather than turning the patient frequently.