Advanced decisions in end of life planning

go finishs in curio of liveness planningThe advance(a) guardianship planning (ACP)process is concerned with ensuring the persevering has expressed their wishes should their condition knock off, leave them with bulge mental competency or unable to communicate their termination.(REF LCP)Part of this process is resulting the long-suffering to create travel decisions with regards to refusing treatment (Joseph, 2010). As decision of sprightliness-time planning is such(prenominal) a vast topic this essay each(prenominal)ow searingly evaluate the key beliefs of locomote decisions with regards to cardiorespiratory Resuscitation ( mouth-to-mouth resuscitation). cardiac resuscitation is an issue in many health kick settings including hospitals, primary care, day hospitals and care for homes. The honest debate and the associated problems with in advance(p) decisions are becoming ever much apparent due to the ever increasing number of elderly people in nursing and residential homes. (DH, 2000, 2010). Previous evidence ground research has looked at jockstraping elderly people and their families with decision making in end of career planning (references) as well as Patients requesting Do non Resuscitate (DNR) baffles against the advice of others (REF). There appears to be a gap in the publications concerning the complexity of the tensions associated between the defend, the castigates of the patient and family (or independent advocate) when the patient has specifically pass along resuscitation in the compositors case of a cardiac arrest against the advice of the multidisciplinary team. This jobion is base on an issue experient within my practice and plunder reach many ethical and lesson debates for the nursing cater. The familiarity gained from this reflection provide inform my future practice on how patients rights are back up or challenged and the subsequent roles of the draw.Gibbs (1988) developed his model of reflection in order to reflect on events, critically evaluate fundamental concepts and influence future practice. The number 1 element of this model is based on experience and a description of events. Mr metalworker is an elderly gentleman in his late 80s currently life history in a nursing home. He has one daughter and a word of honor in law who he is close to and his wife and son passed remote a few years ago. Mr smiths health has been deteriorating over a period of time and the staff nanny-goats and his daughter want to begin the advanced care planning process. For the purpose of this reflection, names and personal data has been changed in line with the NMCs (2008) policy on confidentiality.It is a sizeable deal difficult to establish when a person is reaching the final stages of life (Ellershaw Wilkinson, 2003), however factors ware been place in the Liverpool maintenance pass in order to allow patients to be assessed, including reduced performance status (Karnovsky, 1949) increased dependence in activities of periodic living (Barthel, 1965) weight loss and overall carnal decline (McNicholl, 2006).Mr Smith had lost a significant amount of weight over the preliminary 6 months, was requiring more help with various tasks, including personal hygiene and often required the go for of a wheelchair as he was becoming more unstable on his feet. It was due to this that it was mat up the ACP process was necessary.Effective nursing practice relies upon the ability to develop therapeutic relationships with the patient and family (Peplau, 1952). The qualities of the relationship imply good listening skills, a build up of trust and empathy ( Watt-Watson, Garfinkel, Gallop, Stevens, 2002). It is alpha for relatives to be included in controvertions concerning end of life planning as it allows everyone involved to understand and come to terms with the decision (McDermott 2002).A contact was arranged with Mr smith and his daughter (after consent was gained) t o disuss his care wishes in the event of his condition deteriorating. Mr Smith understood that his condition was getting worse scarce was adamant that he wanted every effort to keep him alive. Therefore, if he went under cardiac arrest Mr Smith would wish the restrain to contract cardiac resuscitation.Cardiopulmonary Resuscitiation (CPR) is a complicated ethical decision comprising of many legal, ethical and emotional decisions for that of the hold up, patient and family (Jeven, 1999).The principle role of the prevail is to assist the patient in restoring or maintaining the best level of health possible (NMC, 2004). Cardiopulmonary resuscitation (CPR) is a procedure that aims to prolong the life of an individual who goes under a cardiac arrest by attempting to restore breathing and increase oxygenated logical argument flow to the brain and heart. The decision to carry out this procedure should be based on any probable risks or benefits to the patient and should not be carrie d out with no regard to the tonus or life expectancy of the patient (BMA, Royal College of breast feeding the Resuscitation Council, 2007).These discussions led to a severalize in attitudes as it was felt by the majority that a do not resuscitate (DNR) order would be the most sensible and true to life(predicate) option. A DNR order is often implemented when a person is passing ill and death is imminent (British aesculapian Association, 2007). Furthermore, if the patient has other degenerative illnesses, which will reduce the quality or length of life, CPR has the potential to prolong suffering and do more equipment casualty than good and so would not be deemed beneficial (BMA, Royal College of treat the Resuscitation Council, 2007).However, Mr Smith did not agree with this and felt angry and conf utilize as to why his family would level that a DNR would be appropriate. He was willing to accept the associated risks of CPR and well-kept that his age should not prevent him being entitled to treatment. This statement is supported by equal rights for the elderly, in which people cannot be denied CPR on the nose because of age (DH, 2001).This decision appeared somewhat irrational as he had give tongue to for some time that it was his time to go and he was fed up of suffering and his mental capacity was called into question.The Mental Capacity Act (2005) states that an advanced decision (formerly known as an advanced directive) gives a person over the age of 18, who is deemed to experience mental capacity, the ability to consent to or reject a specific treatment if they contract in a side where they lack capacity or are unable to state their decision. A person is considered to have capacity if they are able to understand and admit information in order to make an informed decision be able to understand the consequences of any interventions and be able to communicate their decision (GMC, 2008). Current English law states that individuals are presumed to have mental capacity unless it can be proven otherwise and this does not take out the allowance for seemingly irrational and risky decisions to be made (NMC, 2004, BMA 2009, DOH, 2001, MCA, 2005)Mr Smith was deemed to have full mental capacity as he fulfill the criteria outlined by the MCA (2005) and a second opinion doctor was alike called to ensure that this was the case. If the patient lacked capacity to make their own decisions, nursing staff must act in line with the patients best wishes (Dimond, 2006). In such percentage members of the multidisciplinary team must be able to provide watch justification (Hutchinson, 2005). Had it been the case that Mr Smith lacked capacity it would have been reasonable for the encourage to justify not performing CPR, however, failure to comply with his wishes could potentially collar to legal and professional consequences as the NMC (2004) states that patients autonomy must be consider even where this may result in harm.However, the ACP is not legally fertilisation as clinical judgement takes priority (REF LCP). This can put the nurse into a moral dilemma because following professional and legal responsibilities would abjure the patient their rights.Beauchamp and Childress (1994) devised an ethical framework based on 4 moral principles to provide guidance on the conflict between the role of the nurse and the rights of the patient. Beneficence, suggests that any decision to be made must be in the best interests of the specific patient as well as advisement up potential benefit and risks (Beauchamp Childress, 2008). In this case it could be suggested that the risks off the beaten track(predicate) outweigh any potential benefits and to do CPR would not be the greater good but this would affect the principle of autonomy. Autonomy is the patients right to accept or refuse any medical treatment. It follows deontological theories (Mill, 1982) which deem an operation to be right, if it accords with a moral duty or code, regardless of the solvent (Noble-Adams 1999). This approach would justify the nurse performing CPR because they would be following their legal and professional code of conduct in that a patients wishes must be respected and carried out (NMC, 2008). However going against the patients wishes could also be deemed as morally right as part of the nurses role is to allow the patient to go with arrogance (King,1996). Howver, this could be suggested as following the tralatitious notion of paternalism, which is not compatible with modern day ethics (Rumbold, 1999). all(prenominal) of these issues cause a moral dilemma for the nurse and impact upon the patients rights as it has been suggested that CPR can deny a patients right to die with dignity by prolonging the dying process (McDermott 2002) and so could be suggested that the greatest good in the situation would be achieved by not performing CPR.The principle of non-maleficence is based on doing no harm (Edwards, 1996). Many people have unrealistic expectations of the success rates of CPR due to media representations (Dean 2001). Patients who survive cardiac arrests following resuscitation is as low as 20% and not all of these inidivudals get to the position of being well enough to be execute from hospital (Cardozo, 2005). These rates of success are reduced even save when patients have underlying problems and poor health (Schultz 1997). However, it could be argued that the ultimate harm would be to do nothing resulting in death which would also be against Mr smiths wishes. The fact that Mr smith was already considered emaciated and having deteriorating health increases the risk of physical damage during chest compressions but as Mr Smith had already written an advanced directive stating he wished to receive CPR then this should be carried out (Pennels, 2001). This puts the nurse in a serious dilemma as patients and their families taking legal action is becoming increasingly common (Oxtoby, 2005) and the nurse is bound by the legalities of their professional code, which would claim that failing to carry out CPR would be considered negligent (Jevon, 1999) and as nurses are professionally accountable for their actions this could put their career in jepoardy(NMC, 2004).The final ethical principle of rightness is concerned with fairness and equality maintaining that every individual has the right to life (Human Rights Act, 1998) and therefore, the patient has a right for the nurse to carry out CPR (even if they have not previously stated this) especially if they have an advanced descision stating that they wish to be bring to in the event of cardiac arrest. (Costello, 2002). by and by all this has been taken into consideration, the rights of the patient, including those who have an advanced decision can calm down be overruled as before the decision can be employ there must be reasonable evidence to suggest that the decision is still valid and applicable (BMA, 2007). Mr Smith ap peared not to be playing in line with his advanced decisions as he was refusing to eat or drink and appeared withdrawn in his personality, not wanting to participate in his activities of living (Roper, Logan and Tierney, 2000).It has been suggested that many health care professionals do not discuss goals of care as they have inadequate communication skills or that there is often conflicting ideas between the patient and professional about what is in their best interests (H attendet et al, 1998)As this has often found to be the case, one of the registered nurses contumacious to have a further chat with Mr Smith as it was felt that his needs were not being appropriately addressed. It transpired that Mr Smith did wish to die a smooth death but was scared of what might rule and if he said he did not wish to be resuscitated then he could be left suffering alone in great pain in his last few minutes.The Liverpool Care Pathway suggests that the role of the nurse in the last few days of life shifts to a holistic approach of care to promote comfort and moves away from the idea of active care which includes any invasive or unneeded procedures that could be avoided (REFERENCE).The Gold Standards Framework provides an holistic estimation plan to aid communication between the nurse and the patient, including how physical, emotional, social, spiritual and communicational needs came be met (Thomas, 2009)The nurse stated that medications can be arranged for end of life care to alleviate any pain and suffering.Discuss syringe drivers, end of life medication and controversyDuring the final stages of life a congenital physiological process causes the swallowing reflex not to work and so the use of oral medication is limited (Thorns Gerrard, 2003). A common palliative care practice is to use a syringe driver to administer drugs (ODoherty et al, 2001), which allows convenient parenteral treatment of pain, nausea and breathlessness (GrassbyHutchings, 1997). In most circumst ances this form of medication administration comes without controversy (Woods, 2004), however, the double effect of sedatives and opiates will reduce anxiety and pain but have also been claimed to supress respiratory function, which has the potential to speed up the dying process (BNF, 2007). The most weighty aspect of this double effect is that it is permissible so long as death is not intended and is tops as a byproduct of an objective carried out for the patients best interests (Fohr, 1998). Furthermore, it has been stated that there is a lack of falsifiable evidence to support this claim (Kaldjian et al, 2004) and research has suggested that repiratory depression does not occur with patients receiving opiods for pain in end of life treatment (Walsh, 1982).The role of the nurse is, therefore to allow the patient to die peacefully. However, health professionals are accountable for their actions and must be able to provide justifications if any problems arise (Dimond, 2004)An a ssessment using the Abbey pain scale(INCLUDE MORE DETAILS) was carried out to analyse levels of pain experienced by Mr Smith and the appropriate drugs were administered via the syringe driver.Mr Smith continued to deteriorate and died peacefully with his favourite classical music on, his daughter holding his hired man and a picture of his wife by his bed.She also clarified that the advanced decision he would have made was only concerned with CPR and did not have to decline all treatment just because he declined one.The nurse asked him if it was clear the end was near what the staff and his family could do to help his transition into death. Mr Smith stated he did not want to be alone and wished to have his family with him to reassure him and comfort him in his last moments. The point of this discussion was not to overrule Mr Smiths advanced decision but to prolong its applicability and validity to his current circumstances. Details of these discussions were recorded in his care pla n records in line with relevant policies (REFERENCE)WHAT WAS GOOD/ large(p) closely EXPERIENCE?GOOD THAT IT WAS REALISED BEFORE IT WAS TOO LATEBAD COMMUNICATIONAnalysis what sense can you make of the situationOn reflection of the situation the complexities of the tensions between the rights of the patient and the role of the nurse become alarmingly apparent. Nurses are expected to use evidence based knowledge to inform their practice centred on the NMC professional code of conduct. This practice can often involve moral dilemmas on life and death matters for which the nurse can be held professionally accountable. The nurses role is ever more dispute when the patient is entitled to make their own decisions, often deemed unwise or not in their best interests. This reflection informs my practice as it highlights the impressiveness of not only allowing the patient to make an informed decision based on knowledge and evidence but also to explore their feelings poop the decision to be made. In this case it wasnt that Mr Smith wanted CPR in the event of a cardiac arrest because he felt like it was the best option and would extend his life or the quality of it but because he was scared of dying and unsure of what would happen. As the nurse discussed his fears and anxieties and suggested ways in which these could be dealt with Mr Smith agreed that a DNR order would be the most effective way to ensure a peaceful and dignified death without prolonging any pain or suffering for him or his family. This experience has taught me that each situation is unique and there can never be any absolute right or wrong in nursing. Patients well-being depends on many factors including anxiety or unmet physical or emotional needs (Dewing, 2002). Communication with patients, their relatives or an advocate is of utmost richness when identifying individual needs as well as understanding the rationale fuck decision making. Furthermore, communication between the multidisplinary team is i mperative in order to promote best practice (Bridges and Wilkinson, 2011).The insight I have gained from this experience will inform my future practice to understand the feelings and attitudes behind the patients actions and behaviours.Conclusion what else could you have doneAction plan, if it rose again what would you doDiscussionGeneral checkup Council. (2008). patient and doctor making decisions together. uncommitted http//www.gmc-uk.org/static/documents/content/Consent_0510.pdf. Last accessed 23 April 2011.Abbey Pain Scale Abbey, J De Bellis, A Piller, N Esterman, A Giles, L Parker, D and Lowcay, B. Funded by the JH JD Gunn Medical search Foundation 1998-2002.10. Bedell SE, Pelle D, Maher PL, et al. Do-not-resuscitateorders for critically ill patients in the hospital. How arethey used and what is their impact? JAMA 1986 256233-237.13. Haidet P, Hamel MB, Davis RB, et al. Outcomes,preferences for resuscitation and physicianpatientcommunication among patients with metastaticco lon cancer. SUPPORT Investigators. Study to find Prognoses and Preferences for Outcomesand Risks of Treatments. Am J Med 1998 105222-229.19. Deep KS, Grif?th CH, Wilson JF. Discussingpreferences for cardiopulmonary resuscitation whatdo resident physicians and their hospitalized patientsthink was decided? Patient Educ Couns 2008 7220-25.Gallagher A, Wainwright P (2007) lowest drugging promoting ethical nursing practice.Nursing Standard. 21, 34, 42-46. Date of sufferance January 4 2007.Fohr SA (1998) The double effect of painmedication separating myth from reality. daybook of Palliative Medicine. 1, 4,315-328British National pharmacopeia (2007)British National Formulary No. 53. BritishMedical Association and the RoyalPharmaceutical company of Great Britain,London.Dimond B (2004) Legal Aspects ofNursing. Fourth edition. Longman, Harlow.Woods S (2004) storehouse sedation anursing perspective. In Tnnsj T (Ed)Terminal Sedation Euthanasia inDisguise? Kluwer Academic Publishers,Dordrech t, 43-56.Kaldjian LC, Jekel JF, Bernene JL,Rosenthal GE, Vaughan-Sarrazin M,Duffy TP (2004) Internists attitudestowards terminal sedation in end of lifecare. Journal of Medical ethical motive. 30, 5,499-503.Bridges j, Wilkinson C (2011) achieving dignity for senior(a) people with dementia in hospital. Nursing Standard. 25, 29, 42-47. January 11 2011.Tschudin, Verena (2003). morals in Nursing the caring relationship (3rd ed.). Edinburgh Butterworth-HeinemannRumbold, G (1999). Ethics in Nursing Practice. Balliere Tindall. ISBN0-7020-2312-4.Baskett P, Steen P, Bossaert L(2006) The ethics of resuscitationand end of life decisions. In BaskettP, Nolan J (Eds) A Pocket Book ofthe European Resuscitation CouncilGuidelines for Resuscitation 2005.Mosby Elsevier, Edinburgh, 194-210.Beauchamp T, Childress J (2001)Principles of biomedical Ethics. Fifthedition. Oxford University Press,Oxford.Biegler P (2003) Should patientconsent be required to redeem a donot resuscitate order? Journal ofMedica l Ethics. 29, 6, 359-363.Cardozo M (2005) What is a gooddeath? Issues to examine in criticalcare. British Journal of Nursing. 14,20, 1056-1060.Costello J (2002) Do notresuscitate orders and older peoplefindings from an ethnographic studyof hospital wards for older people.Journal of ripe(p) Nursing. 39, 5,491-499.Dean J (2001) The resuscitationstatus of a patient a unendingdilemma. British Journal of Nursing.10, 8, 537-543.Department of health (2001a)Consent What you have a Right toExpect. A Guide for Adults. TheStationery Office, London.Department of Health (2001b) quest Consent Working with OlderPeople. The Stationery Office, London.Department of Health (2001c)The adept Patient A NewApproach to Chronic Disease wariness for the 21st Century.The Stationery Office, London.Dimond B (2006) Mental capacityand professional advice in a patientwith dysphagia. British Journal ofNursing. 15, 10, 574-575.Driscoll J, Teh B (2001) Thepotential of contemplative practice todevelop individual o rthopaedicnurse practitioners and theirpractice. Journal of orthopedicalNursing. 5, 2, 95-103.Edwards S (1996) Nursing EthicsA Principle-Based Approach.Macmillan, Basingstoke.Gibbs G (1988) Learning by DoingA Guide to Teaching and LearningMethods. Further Education Unit,London.Hek G, Judd M, Moule P (2002)Making Sense of Research AnIntroduction for Health and SocialCare Practitioners. Second edition.Sage, London.Hendrick J (2000) Law and Ethicsin Nursing and Health Care. StanleyThornes, Cheltenham.Hutchinson C (2005) Addressingissues related to adult patients wholack the capacity to give consent.Nursing Standard. 19, 23, 47-53.Jevon P (1999) Do not resuscitateorders the issues. NursingStandard. 13, 40, 45-46.Jevon P, Raby M (2002)Resuscitation in primary care.Nursing Standard. 17, 7, 33-35.McDermott A (2002) Involvingpatients in discussions ofdo-not-resuscitate orders.Professional Nurse. 17, 8, 465-468.Noble-Adams R (1999) Ethics andnursing research 1 development,theories and princ iples. BritishJournal of Nursing. 8, 13, 888-892.Nursing and midwifery Council(2004) The NMC Code ofProfessional Conduct Standards forConduct, Performance and Ethics.NMC, London.Oxtoby K (2005) Consentobtaining permission to care.Nursing Times. 101, 1, 23.Payne S, Hardey M, Coleman P(2000) Interactions between nursesduring handovers in elderly care.Journal of Advanced Nursing. 32, 2,277-285.Pennels C (2001) Resuscitationthe legal and ethical implications.Professional Nurse. 16, 11, 1476-1477.Polit D, Beck C (2006) Essentialsof Nursing Research Methods,Appraisal and Utilization. Sixthedition. Lippincott, Williams andWilkins, Philadelphia PA.Resuscitation Council (UK)(2001) Decisions Relating toCardiopulmonary Resuscitation AJoint Statement from the BritishMedical Association, theResuscitation Council (UK) and theRoyal College of Nursing. RC (UK),London.Royal College of Nursing (1997)Ethical Dilemmas Issues in Nursingand Health 43. RCN, London.Rundell S, Rundell L (1992) Thenursing contribution to theresuscitation debate. Journal ofClinical Nursing. 1, 2, 195-198.Schultz L (1997) Not forresuscitation two decades ofchallenge for nursing ethics and practice.Nursing Ethics. 4, 3, 227-238.Sletteboe A (1997) Dilemma aconcept analysis. Journal ofAdvanced Nursing. 26, 4, 449-454.Thompson I, Melia K, Boyd K,Horsburgh D (2006) NursingEthics. Fifth edition. ChurchillLivingstone, Edinburgh.Tschudin V (1992) Ethics inNursing The pity Relationship.Second edition. Butterworth-Heinemann, Oxford.UK Clinical Ethics Network(2006) The Four Principles.www.ethics-network.org.uk/framework/framework.htm (Lastaccessed June 25 2007.)