Nursing Made Incredibly Easy!:
Department: Ask an Expert
Davis, Charlotte BSN, RN, CCRN; Stone, Andrea M. BSN, RN
CCU/CVICU Direct Care Nurse • Heritage Medical Center • Shelbyville, Tenn.
Direct Care Nurse/Charge Nurse • Alvin C. York VA Medical Center • Murfreesboro, Tenn.
MICU Direct Care Nurse • VA Medical Center • Nashville, Tenn.
The authors have disclosed that they have no financial relationships related to this article.
A: One of the greatest ethical dilemmas a nurse can encounter is when a patient refuses life-sustaining treatment—any procedure, medication, intervention, or use of medical technology that can postpone death. As healthcare providers, we're instilled with the primary objective to save lives. However, when treatment options are aimed at prolonging the patient's life, and no acceptable curative treatment option is available, patients may opt to cease medical treatment.
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Even when curative options are available, patients may not be willing to undergo the physical trauma, time involved, or associated emotional distress. As patient advocates, we're torn between the need to save the patient's life and ensuring that his or her psychosocial needs are met and decisions honored.
Common examples of life-sustaining treatment include dialysis, mechanical ventilation, CPR, tube feeding, parenteral nutrition, I.V. fluids, antibiotics, chemotherapy, blood transfusions, extensive burn debridement, painful surgical interventions, and organ transplantation.
Patients who've been deemed competent to make healthcare decisions can refuse to seek or accept a specific treatment, or all medical treatment, from healthcare practitioners. The term competent means the patient understands that refusing to accept treatment will result in eventual death. Some patients may elect to refuse specific medical treatments, such as blood transfusions, because of religious beliefs, but will accept synthetic blood plasma expanders that aren't made of donor blood.
When a patient refuses initial life-sustaining treatment, respectfully explore the underlying reason for the refusal. This allows the healthcare team to identify alternative options that may be equally medically effective and also acceptable to the patient. In the end, the patient has the right to accept or refuse life-sustaining medical treatment.
After a competent patient chooses to forego a life-sustaining treatment or procedure, the healthcare team is faced with only one option: We must support the wishes of the patient that will ultimately result in his or her death. Forcing treatment on a patient without his or her informed consent is illegal. Ensure that the risks and benefits of all treatment options are discussed with the patient so that he or she can make an informed decision that reflects his or her values and beliefs.
In acute care settings, the decision to remove or withhold life-sustaining treatment can be very traumatic for families. It's imperative that the healthcare team conveys information to the patient and family as soon as a prognosis is known. This allows the patient and family to develop realistic expectations. After the decision has been made to refuse life-sustaining treatment, ensure the patient and family have access to ancillary services that can make their transition easier.
Providing care for patients who refuse life-sustaining treatment can cause you to experience many different emotions. If you feel uncomfortable withholding artificial food, fluids, or medications, consult with your management team to see if a temporary alternative assignment can be arranged. Often, just discussing your concerns may help you understand the patient's decision.
Medical technology can potentially allow the prolonging of a patient's life. However, these treatments carry risks and may also cause the patient physical, spiritual, or emotional pain. Many patients state that they would prefer their remaining life to be filled with family, friends, and enjoyable activities.
Be consciously aware not to impose your values or beliefs onto your patient who refuses life-sustaining treatment. Allow the patient to make the end-of-life care choices that reflect his or her values and beliefs so that quality of life can be optimized. As nurses, our goal is not only to promote our patients' health, but also enhance the remaining time that our critically and terminally ill patients have with their family and loved ones.
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Learn more about it
Cleveland Clinic. Policy on patient refusal of life-sustaining treatment. http://www.clevelandclinic.org/bioethics/policies/patientrefusal.html
Magauran BG Jr.Risk management for the emergency physician: competency and decision-making capacity, informed consent, and refusal of care against medical advice. Emerg Med Clin North Am. 2009;27(4):605–614, viii.
Pope TM.Legal briefing: medical futility and assisted suicide. J Clin Ethics. 2009;20(3):274–286.
Withers E, Sklar DP, Crandall CS.Impairment and severity: how ED physicians decide to override an impaired patient's refusal. Am J Emerg Med. 2008;26(7):803–807.
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