Report: Bioetics

Topics: Practice Issues Related to Technology

Prepared by: Tiffany Anne A. Buenaventura
MSNI-C

PRACTICE ISSUES RELATED TO TECHNOLOGY

Nursing care is inextricably intertwined with ever-expanding advances of scientific

knowledge and technology. Few would deny the benefit of medical advances, often
referred to in terms such as wonders of miracles. However, the many benefits
brought to the health care arena by technology are often accompanied by serious
dilemmas for both practitioner and patients.

Impact of technology on nursing and health care

Current technology makes it possible to restart hearts, use machines to breathe for
people, correct deformities, assist the body in dealing with disease through use of
medications and other interventions, eliminate diseased parts through surgery, and
even to replace malfunctioning or diseased vital organs.

Benefit and Challenges of Technology

Current technology includes advances in medications, surgical techniques,

machines and equipment, diagnostic procedures, specialized treatments, expanded
understanding of the causes of and progression of disease, gene diagnosis and
therapy, and greater insight into what is required for people to stay healthy.

Benefit- new interventions have saved lives, improved quality of life, alleviate
suffering, and significantly decreased the incidence of some disease.

Challenges- dilemma relates to questions of quality of life, and whether physical

existence is synonymous with living. Another issue relates to whether the
availability of certain technologies means they should always be used.

Understanding Quality of Life

• Is a subjective appraisal of factors that make life worth living and contribute
to a positive experience of living, means different things to different people.

• Is a personal perspective that is determined by each individual.

 • Recognizing this, we should not judge the quality of another’s life based on
our values.

“ Some people believes that biological life must be preserved, regardless of

the effect on the person whose body is being kept alive. A frequently asked
question is whether a person is truly alive in situations where there is merely
physiological functioning, without awareness of oneself or others.”

Principles of Beneficence and Nonmaleficence

• When dealing with technology, the principles of beneficence and

nonmaleficence may be in conflict.

• A particular technology, with may be implemented with the intention of doing

good (beneficence) may result in much suffering for the patient.

• In circumstances in which there is little or no expectation of recovery or

improved functioning, the essential question is whether the harm exposed by
technology outweighs the good intended by its use.

CURRENT TECHNOLOGY: Issues and Dilemmas

One of the nursing’s primary responsibilities is to help patients and families

deal with the purposes, benefits, and limitations of the specific technologies.
This section focuses primarily on the issue of withdrawing or withholding
treatment as a prime example of a dilemma related to technology.

Treating Patients: When to Intervene and What End

One of the most controversial bioethical topics recent years centers around
withholding or withdrawing life-sustaining treatments when they are deemed to
have poor outcomes or offer no benefits. Decisions about withholding or
withdrawing medical treatment are generally made by physicians in consultation
with patients and family members.

Issues of Life, Death and Dying

• When does life begin?

• When does life end?

• How can we be sure that someone has died?

 • Who decides?

• What happened if conception cannot occur “naturally”, and artificial

processes are employed either in vivo or in vitro? Is the laboratory embryo is
a life?

CASE PRESENTATION

A CHILD WITH LEUKEMIA

Lucia, a twelve-year-old child with leukemia, has relapsed in spite of routine

chemotherapeutic interventions. This child has suffered the side effects of the
treatment, including nausea, hair loss, and frequent hospitalizations with infections,
and is deteriorating physically. She says she feels as if she is being tortured with all
the needles, spinal taps, and bone marrow samples; that she has no friends; and
that this kind of life is not worth living. A bone marrow transplant (the only hope for
a cure at this point) would mean subjecting her to an intensive chemotherapy, total
body irradiation, and weeks in isolation following the transplant. The family is told
that there is a 40 percent chance that the transplant will be effective. The
procedure is very expensive, and the family has already had to obtain a second
mortgage for their home because their insurance has not covered many of the
expensive to date.

Factors influencing Choices Regarding Medical Technology

• What factors do you think to be considered in making the decision about

having the bone marrow transplant?

• How do percentages of risk and benefit affect your decision making?

• In this situation, do you think a 40 percent chance of success is enough to go

ahead with the transplant? What if it were 60 percent? What about 20
percent?

• How can you help patients and families use statistical information in thinking
about their decisions? What other factors would you help them to consider?

• Who should be involved in making this decision?

Medical Futility
 Medical futility refers to situations in which interventions are judged to have very
little or no

medical benefit, or in which the chance for success is low.

Quantitative definition

- interventions that have no pathophysiologic rationale, have already failed in the

patient, will not achieve the goal of care, and situations where maximal treatment is
failing.

-objective data and the clinical expertise of the physician are the basis of
determining futility in these situation.

Qualitative definition

-situation in which the likelihood of success is very small; no worthwhile goals of

care can be achieved; patient quality of life is unacceptable; and prospective
benefit is not worth the resources required.

- In these situation, the meaning of futility must consider perceptions of the patient
and family and judgments of the health care team.

CASE PRESENTATION

Mr. Mason and His Son

Mr. Mason is a seventy-eight-year-old retired, widowed ironworker. He has

been estranged from his adult son, an only child, for many years. He was
recently diagnosed with advanced lung cancer. He recognized that he needed to
make some plans for his immediate future, so he contacted his son and allowed
him power of attorney. Mr. Mason is admitted to your unit in severe pain. He is
somewhat confused, and you are unable to elicit information from him about his
wishes regarding life sustaining measures. You carefully begin discussing this
difficult subject with his son, as it is your hospital’s policy that everyone
admitted to you oncology unit be informed about advance directives. Following
are three possible twists this case could take, each of which is based on a real-
life situation.

Ending 1. Mr. Mason’s son begins to sob uncontrollably, saying, “I was never a
very good son. I left home when I was barely nineteen and didn’t even write or
call for many years. I am just getting to know my dad, and now this happens. I
want as much time with him as possible. He told me a few days ago that he was
ready to die and didn’t want to be kept alive on machines. But it is so unfair to
me. I want him alive and more time with him. Please, do everything you can to
keep him alive. I need some more time with him. I need for him to forgive me.”

Ending 2. Mr. Mason’s son seems impatient, continually looking at his watch as
you talk to him. Finally, seeming exasperated, he says, “Look, he’s going to die
anyway, right? Two things: First, I’m a busy man, and the quicker we get this
over with the better; second, I have an appointment in 20 minutes with a real
estate agent, and later with Dad’s stockbroker. I’d really like to start arranging to
sell his house and cash some of his stocks. My son starts college in two months,
and we could use the money. I suppose you think this is cruel, but realistically,
would Dad rather we spend the money he worked so hard for on keeping him
alive, when he’s bound to die anyway, or on his grandson’s education? It’s pretty
clear to me. I say, just let Dad go, that would be the best for everyone
concerned.”

Ending 3. The son quickly acknowledges that he understand the question.

Without hesitation he says, “Do all you can to keep him alive. The tyrant was
mean to me all my life. I hate him. I want him to suffer as long as possible.”

Family Reaction to Medical Futile Situations

• What is your response to the son’s statement in each of these scenarios?

Include both your thinking response and your feeling response.

• How would your feelings lead you to advise one option over another?

• How do you think the nurse should react to each response?

• What values and dilemmas are evident in each scenario?

• Identify your personal and professional values related to each scenario.

• Who should make the decision? Do you feel conflicting loyalties?

 • How would you respond to the son’s decision?

Do Not Resuscitate Orders

Principles to be considered:

• Autonomy

• Self-determination

• Nonmaleficence

• Respect for persons

CPR must be initiated, unless;

• It would clearly be futile to do so

• The practitioner has specific instructions not to do so

DNR orders:

• Written directives

• Documented immediately

• Noting the reason the order was written

• Who gave consent and who was involved in the discussion

• Is the patient competent to give consent or who was authorized to do so

• Time frame for the DNR order

CASE PRESESNTATION

Mistaken Resuscitation

Jacob has had a chronic lung condition for the past ten of his thirty-two
years. The condition causes some restrictions on his life, but he has kept up
with a regular job and is very involved in his church. He is currently
hospitalized with a severe respiratory infection. Although his condition did not
seem to be that serious, when he was admitted he made sure that there was
a DNR order in his chart, noting that he has a firm religious conviction that
the Creator, and not the doctor, is to decide when it is time for him to die.
Because of a staff shortage, Lashanda, a registered nurse who usually works
on another unit, has been assigned to Jacob’s unit. Although she has been
working on the other side of the unit, she is presently covering the whole unit
while other staffs are at lunch. As she answers a call light from Jacob’s
roommate, she notices that Jacob is not breathing and has no pulse. Since
she is unfamiliar with Jacob’s DNR request, she immediately calls a “code”
and initiates CPR, figuring that there will be no question that this would be
the appropriate action for someone this age. Although Jacob is successfully
resuscitated, he is intensely angry, saying that it was an interference in the
Creator’s plan.

Decisions Regarding Resuscitation

• What do you think about Jacob’s request for a DNR order? What ethical
principles are involved in his choice?

• What do you think about Lashanda’s response in the situation? Do you

think she acted appropriately under the circumstances?

• How do you think you might respond in a similar situation? What

principles would guide your actions?

• Describe potential legal ramifications in this situation.

• What guidelines would your state’s laws regarding DNR status offer to
Lashanda? Would they support her actions?