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chapter 4 | Questions of Values and Ethics 51 CikguOnline
these health-related ethical dilemmas. It is agent that has demonstrated success in many
important to know who the decision makers are cases. But Elena’s mother emphatically states that
and what their belief systems are. When the she has “had enough” and prefers to spend her
patient is a capable participant, this task is remaining time doing whatever she chooses. Elena
much easier. However, people who are ill are wants her mother to try the drug. To resolve the
often too exhausted to speak for themselves or dilemma, the oncology nurse practitioner and the
to ensure that their voices are heard. When this physician talk with Elena and her mother.
happens, the patient needs an advocate. Family, Everyone reviews the facts and expresses their feel-
friends, spiritual advisers, and nurses often act ings about the situation. Seeing Elena’s distress,
as advocates. A family member may need to be Elena’s mother says, “OK, I will try the Taxol for a
designated as the primary decision maker, a role month. If there is no improvement after this time,
often called the health-care surrogate. I want to stop all treatment and live out the time
The creation of living wills, establishment I have with my daughter and her family.” All
of advance directives, and appointment of a agreed that this was a reasonable decision.
health-care surrogate while a person is still
healthy often ease the burden for the decision The role of the nurse during the implementation
makers during a later crisis. Patients can exer- phase is to ensure that communication does not
cise autonomy through these mechanisms, even break down. Ethical dilemmas are often emotional
though they may no longer be able to commu- issues, filled with guilt, sorrow, anger, and other
nicate their wishes directly. When these strong emotions. These strong feelings can cause
documents are not available, the information communication failures among decision makers.
gathered during the assessment of social factors Remind yourself, “I am here to do what is best for
helps identify those individuals who may be this patient.”
able to act in the patient’s best interest. Keep in mind that an ethical dilemma is not
3. List and rank all the options. Performing this always a choice between two attractive alternatives.
task involves all the decision makers. It is Many are between two unattractive, even unpleas-
sometimes helpful to begin with the least ant, choices. Elena’s mother’s options did not
desired choice and methodically work toward include the choice she really wanted: good health
the preferred treatment choice that is most and a long life.
likely to lead to the desired outcome. Asking Once an agreement is reached, the decision
all participating parties to discuss what they makers must accept it. Sometimes, an agreement is
believe are reasonable outcomes to be attained not reached because the parties cannot reconcile
with the use of available medical treatment their conflicting belief systems or values. At other
often helps in the decision process. By listening times, caregivers are unable to recognize the worth
to others in a controlled situation, family mem- of the patient’s point of view. Occasionally, the
bers and health-care professionals discover that patient or the surrogate may make a request that is
they actually want the same result as the patient not institutionally or legally possible. In some
but had different ideas about how to achieve cases, a different institution or physician may be
their goal. able to honor the request. In other cases, the
patient or surrogate may request information from
Implementation the nurse regarding illegal acts. When this hap-
pens, the nurse should ask the patient and family
During the implementation phase, the patient or
to consider the consequences of their proposed
the surrogate (substitute) decision maker(s) and
actions. It may be necessary to bring other coun-
members of the health-care team reach a mutually
selors into the discussion (with the patient’s
acceptable decision. This occurs through open dis-
permission) to negotiate an agreement.
cussion and sometimes negotiation. An example of
negotiation follows:
Evaluation
Elena’s mother has metastatic ovarian cancer. She As in the nursing process, the purpose of evaluation
and Elena have discussed treatment options. Her in resolving ethical dilemmas is to determine
physician suggested the use of a new chemotherapeutic whether the desired outcomes have occurred. In the