In the final instalment of this 3 part series, I want to focus on the legal, ethical and moral aspects that have shaped and moulded my philosophy of palliative care nursing. If you haven’t already, have a look at Part 1 and Part 2
The legal aspect of any nursing is quite simply and straight forward. The law is the law. I can proudly say that I have never knowingly broken any aspect with regards to palliative nursing care that I have provided. Ignorance of the law is no excuse, so I have made myself very aware of my boundaries by understanding the scopes of practice and workplace policy and procedures which underpin what I can and cannot do. Smarter people than me have already done the hard work of sifting through legislation, so I am confident that as long as I stay within my defined boundaries, by default, I won’t break the law.
The tricky part for me is deciding on what my morals and ethics are? Are they set in stone? No. Do they change in accordance with the situation I find my self in? Absolutely Yes! Does this make me a hypocrite? Maybe, I’ll leave that up to you to decide.
Ethics is generally understood to be the recognized rules of conduct and actions in respect to how a particular group or a culture defines them. For example, a group may decide to ethically and passionately refuse the use of blood as a part of their health care model. This same group may have less conviction on accepting individual components of blood. Does that make them hypocrites? Maybe, but I don’t see that I need to judge that.
The refusal to accept blood / product is not a core ethical belief of mine. For me, if the use of blood or blood products is a valid treatment after all pros and cons have been considered, then hook ’em up. However, I am prepared to suspend (or is this change?) my ethical point of view to meet my patients,even if their ethical decision may lead to an unnecessary and preventable outcome. In this case, I will be their ethical advocate.
Morals are a bit different. Not concerned with group or culture, it is an individual thing. A set of ideals or principles if you like, based on what is right or wrong conduct (but who’s?). For me, my morals are a part of my ongoing developmental journey through life. Shaped by my experiences and up bringing, some have altered and changed as have I also changed over the years. In my palliative care role, my moral compass is quite flexible and can change according to the situation that I find myself in. Let me give you a variable scenario to help explain this.
Imagine that you are a nurse working in a palliative care ward and as you walk past “Bill’s” door, you glance in and notice that he appears very still. Bill is an old man and in the final stages of aggressive pancreatic cancer. The doctor suspects death could be only a day or so away. Five minutes ago, you were with Bill, his pain was under control and he was excited as his son, who he hadn’t seen in over 25 years, was due to arrive in 10 minutes. Bill Jnr. and his Father have been estranged, neither now could remember the reason, but both had decided that they wanted to patch things up while they still could.
Bill is not breathing. He has no pulse. There is no NFR order in place. Do you start CPR knowing full well that Bill wants to see his son and that he wants to be resuscitated. This has to be assumed since no NFR order is in place. Doesn’t it? But the Doctor thinks death is only days away. Is there really any point?
You have two immediate options. Walk quietly back out the door, go to the staff room and make yourself a cup of tea or … commence CPR. What do you do? Would you react differently if Bill had no son? What if you knew he had a son, but didn’t know about his impending arrival and their back story? Would your actions / thought processes be different if Bill had been unconscious, but you still knew all the variables? Potentially, with your training and the multitude of equipment that is available, maybe you can bring him back from the light. Do you? Did I…
What if instead of one or two days, the doctor had best guessed that Bill had a month to live or two or three. Does that change your enthusiasm to get in there and start jumping on a chest, cracking ribs. Where is that magic marker, that moment in time when palliative care reaches that tipping point where CPR is not a viable or preferred option. Could it be argued that it’s from the moment no active or curative treatment will make a difference to the life expectancy of the patient? But what if the prognosis was 2 years to live.
What if “Bill” instead of being an old man was a 25 year old with a young family who also has incurable pancreatic cancer? Do you perform CPR? Or instead it’s a 49 yr old Mother who just wants to get to the weekend to see her daughter walk down the isle, or it’s a 9 year old little girl who desperately want to see one more Christmas.
At what point do you let nature take it’s course?
Everyone you nurse has a back story, your part is written in the final chapters. What is says is up to you. Working as a Palliative Care nurse can be the most beautiful rewading experience one minute and the next you hate it with a passion and curse the injustices of God. Make no mistake your Ethics, Morals and Value Systems WILL be judged by others. It’s a part of the Gig so get used to it. But no one will judge you as harshly as you do yourself
For me, what differentiates the good from the great palliative care nurse is flexibility in morals and an understanding that everyone have a different ethical perspective that must be respected. All of this starts with Critical Thinking! With out this flexibility, a dogma of opinion, thought and action will develop and this is not in the patients best interest. Every nurse, palliative care or otherwise needs to approach every situation with a “what if” or “it depends”.This flexibility will ensure that the best possible care is provided based on the here and now and not just on theoretical rhetoric.
I welcome any discussion