CE2 HOURS Ethical Concerns in End-of-Life Care

CE2Continuing Education

HOURS

Ethical uncertainties and dilemmas arise routinely inpalliative care nursing. Questions about advance dir-ectives, refusal of treatment, and the withdrawal orwithholding of life-sustaining interventions (such asmedically provided nutrition and hydration) can bedifficult to address—especially when intense emo-tions, felt by all involved, cloud decision making.

Such is the case of 88-year-old widow MargaretJoseph, who has been in a nursing home for sevenyears, following a stroke that resulted in left-sidedparesis and dysphagia. Before the stroke, Ms. Josephexhibited symptoms of moderate dementia andcouldn’t make decisions on her own. She has no chil-dren but a niece helps out when needed. Ms. Josephhas urinary incontinence, is immobile, needs totalassistance for activities of daily living, and receivesfeedings through a percutaneous endoscopic gastros-tomy tube. She has been treated occasionally for uri-nary tract infections. Otherwise, her condition hasremained relatively stable over the years.

Recently, however, when Ms. Joseph becamelethargic and developed a fever, she was transferredto an ED for evaluation. Chest X-ray revealed an

infiltrate in both lower lobes; a diagnosis of com-munity-acquired aspiration pneumonia was made,and Ms. Joseph was hospitalized and started onparenteral antibiotics. Blood cultures were taken,and she received supplemental oxygen via mask.After four days, she remained febrile with an ele-vated peripheral white blood cell count. Blood cul-ture results were negative. Her condition continuedto decline. She was transferred to the ICU andplaced on a ventilator, and her antibiotics werechanged. Ms. Joseph showed improvement on thenew antibiotic regimen. Now, efforts to wean herfrom the ventilator have been unsuccessful after aweek, and the health care team is concerned thatshe’ll require prolonged ventilatory support. GivenMs. Joseph’s medical history and the hospitaliza-tion’s toll, the team determines it’s unlikely she’llregain her prior level of functioning.

Although Ms. Joseph’s niece acts as her designatedrepresentative at the nursing home, she hasn’t beenappointed her health care agent. Ms. Joseph has noadvance directives. The team meets with the niece; iflong-term ventilatory support is to be provided, she istold, Ms. Joseph will require a tracheostomy. Hernursing home isn’t equipped to care for patients onventilators, so she’d need to be placed elsewhere.Given her aunt’s poor prognosis, the niece is asked toconsider a do-not-resuscitate (DNR) order. Ms.Joseph’s niece, deeply concerned about her aunt, says

Colleen Scanlon is senior vice president, advocacy, at Catholic HealthInitiatives, Denver, CO. Contact author: Catholic Health Initiatives,1999 Broadway, Suite 2600, Denver, CO 80202. This article is the fifthin a series supported in part by a grant from the Robert Wood JohnsonFoundation. Betty R. Ferrell, PhD, RN, FAAN ([email protected]), andNessa Coyle, MS, NP, FAAN ([email protected]), are the series editors.

By Colleen Scanlon, JD, MS, RN

Ethical Concernsin

End-of-Life Care

When questions about advance directives and the withdrawal of life-sustaining interventions arise, how should decisions be made?

Ethical Concernsin

End-of-Life Care

48 AJN ▼ January 2003 ▼ Vol. 103, No. 1 http://www.nursingcenter.com

she recalls only vague discussions about these issuesand appears uncertain as to how to proceed.

While nurses are familiar with these and otherethical concerns (such as breaches of confidentiality),this doesn’t diminish the distress and tension thatcan complicate such situations. Improving compe-tency with ethical issues helps nurses promote thehighest quality end-of-life care and safeguards pro-fessional integrity.1 This article will outline the vari-ous types of advance care planning, discuss ethicaldecision making at the end of life, and suggest waysin which nurses can become more proficient in thisarea. (A discussion of another issue, assisted suicide,is beyond the scope of this article.)

ETHICAL CONTEXT OF NURSING PRACTICEEven before graduating nurses first recited theFlorence Nightingale Pledge in 1893, promising to“abstain from whatever is deleterious . . . anddevote [themselves] to the welfare of those commit-ted to [their] care,”2 nursing has been based on eth-ical principles. And it has been ongoing; the ANA’sCode of Ethics for Nurses With InterpretiveStatements (http://nursingworld.org/ethics/code/ethicscode150.htm) not only spells out the stan-dards that have guided nurses but also addresses thecomplexities inherent in contemporary health care.3, 4

In fact, the Code of Ethics explicitly addresses thenurse’s role in end-of-life care, stating:

[email protected] AJN ▼ January 2003 ▼ Vol. 103, No. 1 49

Late May, by Deidre Scherer, fabric and thread, 15� � 13�, 1990; photo by Jeff Baird.

Late May is from a seriesentitled The Last Year,which depicts the finalyear of a woman’s life.“While I drew her I real-ized that she was findingcomfort receiving the oxy-gen, as she curled herselfaround the tube in analmost fetal position,” theartist writes.

For more about the artistand her work, go towww.dscherer.com.

The measures nurses take to care for thepatient enable the patient to live with as muchphysical, emotional, social, and spiritual well-being as possible. . . . Nursing care is directedtoward meeting the comprehensive needs ofpatients and their families across the contin-uum of care. This is particularly vital in thecare of patients and their families at the end oflife to prevent and relieve the cascade of symp-toms and suffering that are commonly associ-ated with dying. Nurses are leaders andvigilant advocates for the delivery of dignifiedand humane care.5

The ANA’s position statements on end-of-lifeissues address pain management, DNR decisions,forgoing medically provided nutrition and hydra-tion, and assisted suicide (see www.nursingworld.org/readroom/position).

The distinctive nature of the nurse–patient rela-tionship also influences nurses’ ability to under-stand and evaluate ethical issues. The “therapeuticpresence” of the nurse is an active intervention thatcan alleviate feelings of isolation and abandonmentin dying patients,6 who are sustained by the nurse’swillingness to be with them while they are dying.

DECISION MAKING: ‘CAPACITY’ In the past few decades, the physician-dominatedapproach to decision making has shifted towardone that recognizes a patient’s right to self-determi-nation. Although that shift was warranted, manyexperts believe that what’s actually best is shareddecision making,7, 8 a model in which providersbring to bear their clinical knowledge, skills, andtreatment recommendations, as well as their values,while patients make use of their life experiences,perceptions, goals, and values. Effective shared deci-sion making is built on mutuality (an open andrespectful approach), reciprocity (the exchange ofinformation and ideas), and interdependence.9

Ultimate control resides with the patient as long ashe has capacity. But decision making at the end oflife can be particularly challenging; an elderlypatient with hypoactive delirium, for example, willbe compromised in his ability to participate. In sucha case, it’s important to determine what the patientwould decide if he were able.

Patients are presumed to have “capacity”—theability to comprehend information, consideroptions, evaluate risks, make a decision, and com-municate that decision—unless proven otherwise.10

The capacity to make decisions is necessary for aperson to make an autonomous choice. Althoughhealth care professionals often use the words“capacity” and “competence” interchangeably,there is a distinction. Competence, a legal term, canonly be decided judicially; a person’s competence isfrequently declared relevant in areas other than

health care (such as financial). Capacity, a clinicalterm, refers to health decisions and is assessed byclinicians in a health care setting.

Capacity evaluations are not all-or-nothing deter-minations; they must allow room for changes in cog-nitive and emotional status and must be donewhenever a new decision is to be made. The moreserious the potential consequences, the more closelythe patient’s capacity should be scrutinized. Forexample, clinicians may determine that a patient hasthe capacity to consent to a chest X-ray but not to athoracotomy. Uncertainty about a patient’s capacityto make decisions can cause anxiety for all thoseinvolved and must be addressed aggressively (forexample, through psychiatric evaluations). Nursescan increase patient involvement in decision makingby encouraging conversation, attending to nonverbalas well as verbal messages, and offering reassurance.

ADVANCE CARE PLANNINGThe Patient Self-Determination Act (PSDA), passedas part of the Omnibus Budget Reconciliation Act of1990 and implemented in 1991, was the first pieceof federal legislation aimed at protecting the rights ofindividuals to make health care decisions.11, 12 Underthe PSDA, all health care facilities receiving federalfunding must recognize advance directives—instruc-tions that guide health care decision making inaccordance with a patient’s wishes, should thatpatient lose the ability to speak for himself. Althoughrelatively few patients actually have advance direc-tives (one study found that just 5% of patients olderthan 65 who were admitted to the ICU had one13),the law sets a precedent for how health care decisionmaking at the end of life should proceed. Even so,there are cases in which, in the absence of anadvance directive, a clinical situation or a patient’swishes have been so ambiguous as to require judicialintervention.12

Advance directives. There are two basic types ofadvance directives: living wills (treatment directives)and durable powers of attorney for health care(appointment directives).

A living will is a written document that directstreatment in accordance with a patient’s wishes.14 Adurable power of attorney for health care (alsocalled a medical power of attorney or a health careproxy) designates a spokesperson (who may becalled a health care agent, surrogate, or proxy) torepresent the patient in decision making.14 That per-son must base any given decision on the patient’sknown or probable wishes under the circumstancesand not on her own preferences.

Of the two types of directives, living wills tend topresent greater difficulties in interpretation,10 andtheir usefulness can be limited: they may not be clin-ically specific enough to help in unforeseen circum-stances. No document can guarantee that a patient’s



All 50 states and the District of Columbia have enactedstatutes to comply with the Patient Self-Determination

Act (Omnibus Budget Reconciliation Act of 1990). The federallaw requires that all health care institutions receivingMedicare and Medicaid funding must inform patients in writ-ing about their right under state law to accept or refuse med-ical or surgical treatment before they become incapacitated.The state statutes address both living wills and durable powersof attorney for health care (that is, both treatment andappointment directives). But the statutes vary somewhat fromstate to state. Instructions and patient forms for each state areavailable free at the Partnership for Caring’s Web site(www.partnershipforcaring.org/Advance/adconfirm.php).

Many states are now streamlining these laws. Nineteenstates have passed comprehensive laws that combine previ-ously separate statutes on living wills and proxies. Sevenstates have passed laws based on the Uniform Health CareDecisions Act (UHCDA) of 1993, which was created by theUniform Law Commissioners to serve as a model. The UHCDArecognizes a patient’s written or oral statements as valid. Italso recognizes the authority of surrogate decision makers incases when a patient who lacks capacity has no advancedirective. Thirty-seven states and the District of Columbia havespecifically included a surrogate provision in their statutes. Source: State Health Decisions Legislative Update. Washington (DC): American BarAssociation Commission on Law and Aging; 2002. http://www.abanet.org/aging/update.html.

BLUE states that have not enactedcomprehensive laws but recognizesurrogate decision making (19 states and the District ofColumbia)

BROWN states that have not enacted lawscontaining a provision for surrogatedecision making but have enactedcomprehensive laws (2 states)

YELLOW states that have enactedcomprehensive laws (without theUHCDA) that also contain aprovision for surrogate decisionmaking (10 states)

RED states that have enactedcomprehensive laws modeled afterthe UHCDA, which contains aprovision for surrogate decisionmaking (7 states)

States with NO COLOR have not yet stream-lined their existing statutes (12 states)

Map above shows the 39 states and the District ofColumbia that have comprehensive laws (which coverboth living wills and durable power of attorney forhealth care), comprehensive laws modeled after theUHCDA, laws containing a provision for surrogate deci-sion making, or a combination thereof.

U.S. State Laws and Advance Directives

Washington, DC

wishes will be fully known or that appropriate clin-ical action will be taken. But advance directives cansignificantly help families and clinicians to under-stand what a patient would want and thus relievesome of the burden in making decisions.15

All 50 states and the District of Columbia havesome type of advance directive legislation, thoughthe specifics can vary greatly. (See U.S. State Lawsand Advance Directives, page 51.)

Other ways to discern patient preferences. Theabsence of an advance directive does not mean thata patient hasn’t thought about or expressed his pref-erences. For example, oral statements made beforelosing capacity can be used in decision making,especially if they were documented. Nurses have themost regular, frequent contact with patients, andthus many opportunities to clarify what a patientwould have wanted, for example by fostering con-versation among family members, friends, andother team members. They can share their knowl-edge of a patient (particularly valuable when therelationship has been a long one) and can verify thatproposed actions reflect the patient’s wishes andpreferences accurately.

In some cases, clinicians can turn to others whomay be willing to act as the patient’s surrogate deci-sion makers. There’s a longstanding practice of rely-ing on family members in this way, but friends orothers who know the patient well may also serve.Many state statutes identify who can serve as a sur-rogate, in order of priority. When there is confusionor disagreement, the opinions of those who know thepatient best, regardless of relationship, should beaccorded the most weight. In very difficult situations,it helps to involve your facility’s ethics committee.

Once an appropriate surrogate is identified,

decision making can begin. The surrogate mustmake decisions based on “substituted judgment”(the known or probable wishes of the patient) or“best interests” (the relative benefits and burdensof a given decision for the patient).10, 16 Nurses canhelp surrogates to share their knowledge of thepatient and its relevance to the decision at hand.And by helping surrogates to understand their role,nurses can alleviate the burden of their concernabout making the “right” decision. For example,the nurse might say, “We’re hoping you can pro-vide us with a better understanding of what thepatient would want.”

Certainly, decisions that others make for some-one who cannot participate demand scrutiny.Nurses can help assert the fact that patients whodon’t have the capacity to make decisions have thesame rights as those who do, though the manner ofadvancing these rights may differ.16 When thepatient has left a living will or named a health caresurrogate, that document or person is relied on toexpress the patient’s wishes. When the patient has-n’t done this, every effort must be made to identifysomeone who can speak on the patient’s behalf.State laws vary in this regard. In difficult cases, anethics committee or legal consultation (or both) maybe called for.

Ethical and legal issues associated with end-of-life care are often intertwined.17 It’s important todistinguish these two perspectives. Otherwise,providers’ concerns about their legal liability in end-of-life care can become exaggerated. For example, aprovider, believing herself legally obligated to con-tinue medically provided nutrition and hydration,might be reluctant to withdraw these interventionseven if the patient no longer benefits. An irresolv-able conflict may warrant judicial intervention; gen-erally, though, decisions about end-of-life care arebest made in the clinical setting.

If everyone agrees, the role of the nurse may berelatively simple: to represent the patient and seekthe knowledge of others. But when there is dis-cord, nurses may need additional resources such asethics committees to arbitrate conflicts and movetoward consensus. (Typically, an ethics committeeis interdisciplinary and includes physicians, nurses,clergy, social workers, ethicists, and attorneys. It isusually involved in policy review, education, andconsultation.)

WITHHOLDING OR WITHDRAWING LIFE-SUSTAINING THERAPIES The goals of care may change as a patient’s illnessprogresses and death nears18; they can shift fromcure to comfort and from extending life to ensuringa humane and “dignity-conserving”19 death. Attimes, patients receive an inconsistent combinationof therapies because of mixed goals. (For example,


ResourcesThe American Society for Bioethics and Humanitieswww.asbh.org/links

Last Actswww.lastacts.orgAmong this organization’s many resources is the video AskingAbout Advance Directives: Scenarios for Healthcare Providers.

Tool Kit for Nurturing Excellence at End-of-Life Transition (TNEEL)www.son.washington.edu/departments/bnhs/pain/tneel.aspAvailable on CD-ROM, this tool kit—which won the 2002 SigmaTheta Tau International, Region 1, Computer-Based ProfessionalEducation Award—can aid nurse educators in developing classesin six areas: ethical concerns, goals of comfort (includes pain man-agement), communication and relationships, grief, the impact ofdying (epidemiology, economics, service and delivery systems ofcare, resource utilization), and well-being (includes quality of life,spirituality, complementary therapies).

to extend a patient’s life, one clinician may want tocontinue vasopressors, which will likely require ICUplacement. But another clinician, seeing the patient’scomfort as the primary goal, wants the patient toreceive palliative care in a non–acute care environ-ment.) Moreover, it’s not always clear how anadvance directive applies in a particular situation.

For these reasons, patients and families frequentlyask about initiating or discontinuing interventions,particularly when there’s a question of benefit, effi-cacy, or desirability. Patients have the right to acceptor refuse all life-sustaining treatments such as car-diopulmonary resuscitation (CPR), ventilatory sup-port, medically provided nutrition and hydration,blood transfusion, dialysis, and antibiotic therapy.

But undoubtedly, deciding to withhold or with-draw life-sustaining treatment is difficult; to do someans the patient will probably die. Although thereis no ethical or legal distinction between withholdingand withdrawing a therapy,10, 20 they affect peoplequite differently. Many clinicians and families find itmuch harder to discontinue a therapy than to with-hold it in the first place. In some cases, it may helpto initiate a trial intervention, with a specific timeframe to indicate when it should be discontinued ifunsuccessful. This lessens the patient’s risk for being“held hostage” if clinicians or family members arelater hesitant to withdraw that intervention.

It’s important that nurses be involved in makingdecisions to withhold or withdraw treatment, notonly to represent their professional perspectives, butalso to understand those of other team membersand patient surrogates and to appreciate how deci-sions are reached. When those involved trust theintegrity of the process, they’re more likely to bemore comfortable with the outcome.

Resuscitation and DNRs. A DNR order directshealth care providers not to attempt CPR in theevent that a patient suffers a cardiac or respiratoryarrest. It’s well known that successful outcomes ofresuscitation attempts are extremely rare in patientswhose health is highly compromised or who aredying: one source estimates that fewer than 5% sur-vive to hospital discharge.21 Family members mayinterpret a decision to forgo resuscitation as a signalthat the patient or the patient’s providers have givenup. Nurses should reaffirm that a DNR order doesnot mean “do not treat”; on the contrary, the teamremains committed to providing care that ensurescomfort (such as pain management) and preservesdignity. Nurses can also encourage patients or fam-ily members to talk about their feelings by offeringopen-ended comments such as, “This decisionseems very hard for you. Can you tell me moreabout that?”21

Ventilatory support. Mechanical ventilation canbecome permanently necessary if the patient becomesphysiologically dependent and can’t be weaned.


Withdrawal of mechanical ventilation shouldn’t beviewed differently than withdrawal of other life-sustaining therapies (such as dialysis). However, thewithdrawal of ventilatory support usually resultsin death more quickly than the withdrawal ofother therapies,22 and the proximity of the twoevents can be deeply upsetting for all involved.Occasionally, patients continue to breathe on theirown for hours or longer, and this too can be veryunsettling. Clinicians need opportunities to discussthe uncertainties and stress that surround such acomplex issue.

Medically provided nutrition and hydration.Decisions regarding the administration of medicallyprovided nutrition and hydration also can be diffi-cult. Food and water are literally the sustenance oflife, and as the ANA notes, “the symbolism of feed-ing is intimately linked to caring.”23 Administeringmedically provided nutrition and hydration to aperson who is terminally ill is vastly different:enteral feeding (through a nasogastric, gastrostomy,or jejunal tube) often requires surgery and posesserious risks for patients who are severely ill.24 In thehighly publicized case of Cruzan v. Director,Missouri Department of Health, the U.S. SupremeCourt ruled in 1990 that nutrition and hydrationwere medical interventions and as such could bewithdrawn.25 Thus, they must be evaluated by thesame criteria as any other intervention: benefits,burdens, efficacy, and desirability with regard togoals of care.26

Clinicians have often been hesitant to withdrawthese therapies, fearing that to do so would be ille-gal or analogous to participating in assisted suicideor euthanasia.20, 27, 28 Such misconceptions need to becorrected. Nurses can seek consultation with othercolleagues who have experience in these situationsand can answer their questions. Professional codesof ethics, practice guidelines, and position state-ments can also provide guidance.

PROMOTING ETHICAL PRACTICE Nurses can increase their expertise in ethical prac-tice through varied approaches, including pursuingclinically based ethics education, participating inethics committees, seeking ethics consultation, andparticipating in clinical rounds.16

Education in areas such as current ethics trends,ethical inquiry, the discernment process (evaluationof the decision at hand with all those involved) andframeworks for decision making can give nurses asound foundation in ethics in clinical practice.

Ethics committees, whether nursing-specific orinterdisciplinary, allow for the exploration of realclinical situations and the exchange of varied per-spectives in a neutral forum. Committees can inves-tigate ethical questions, offer and challenge opinions,and resolve differences, thereby cultivating and

drawing upon the expertise of many. Most nurseswill find an ethics committee available at their facil-ity; if one isn’t, nurses can contact ethics centers,schools of nursing, and professional associations forguidance (see Resources, page 52).

Ethics consultants are experts in bioethics andclinical decision making, particularly in ambiguoussituations. Using their services can improve commu-nication among those involved, foster conflict reso-lution, and provide informal education.

Clinical rounds can incorporate review of ethicalconcerns. Rounds also offer nurses the opportunity tomake the team aware of subtle changes in a patient’scondition (such as vacillating capacity) that may affecthis ability to participate in decision making.

CASE REVISITEDMs. Joseph’s condition has continued to deteriorateand now requires vasopressors to maintain her bloodpressure. Efforts to wean her from the ventilator con-tinue to be unsuccessful and she requires frequentsuctioning. She is unaware of her surroundings andresponds only to painful stimuli. Her niece visits dailyand feels increasingly burdened by her responsibilityas decision maker. Ms. Joseph’s primary nurse hasdeveloped a relationship with the niece by updatingher on her aunt’s status and listening attentively toher worries. The nurse suggests that meeting with thehospital’s ethics committee and the health care teammight help, and the niece agrees.

Present at the meeting are Ms. Joseph’s attendingphysician, the pulmonologist, an ICU resident, theprimary nurse, members of the ethics committee,and Ms. Joseph’s niece. The chairperson of the ethicscommittee begins by reviewing the ethical and legalprinciples involved in surrogate decision making. Heemphasizes that the surrogate isn’t being asked tomake decisions alone, but rather to speak as thevoice of the incapacitated patient. The physicianspresent a review of Ms. Joseph’s clinical course andthe grim prognosis. Ms. Joseph’s niece is asked todescribe Ms. Joseph before this latest hospitaliza-tion. The nurse recognizes that the niece is becomingquieter and more withdrawn in the presence of somany professionals. She offers reassurance andencourages her to take plenty of time in recallingconversations with her aunt.

Ms. Joseph’s niece describes her aunt as an inde-pendent, deeply religious woman who worked mostof her life as a seamstress before retiring at 65.Devoted to her husband of 48 years, she was devas-tated when he died suddenly six months after herretirement. They rarely socialized, and after hisdeath she became even more withdrawn. The niecerecalls her aunt expressing relief that her husbandhadn’t suffered and had died quickly and peacefullyat home. She also remembers Ms. Joseph often say-ing, “When God wants me, He’ll take me.” The

niece feels strongly that, if her aunt could commu-nicate, she would not want to continue the currentaggressive treatment.

After deliberation, the ethics committee membersagree that the niece is indeed giving voice to thepatient’s beliefs and wishes and is acting in her bestinterests. The team reviews the health care decisionsthat need to be made. The nurse describes the patient’sresponse to particular treatments and course of care.It’s decided that the goal of treatment is comfort andthat only appropriate therapies will be prescribed.Routine blood draws will be stopped and treatmentwill focus on relieving symptoms. The health careteam asks the niece to consent to a DNR order,explaining that given Ms. Joseph’s prognosis, a resus-citation attempt would probably not succeed andwould likely cause additional trauma. Team membersalso reiterate that they will continue all efforts to makeher aunt comfortable. The niece consents. She alsoasks that current treatments (ventilator, antibiotics,vasopressors, and enteral feedings) be continued forone more week to see whether Ms. Joseph’s conditionimproves; if not, she asks that ventilatory support bediscontinued. The health care team agrees. As themeeting ends, the niece tells the primary nurse, “I’m sograteful you were there to support me during themeeting. It helped to think back to the times my auntand I spoke—I feel surer that we’re doing what shewould have wanted us to do.”

A week later, the patient shows no improvement,and the niece asks that all life-sustaining therapiesbe stopped. The health care team agrees, and mem-bers again offer the niece their reassurance and sup-port. Morphine is administered to ease the dyspneaand agitation associated with ventilatory with-drawal, and the ventilator is discontinued. Ms.Joseph dies half an hour later, without apparent dis-comfort, with her niece and nurse at the bedside. ▼

REFERENCES 1.End of Life Nursing Education Consortium [Web site].

American Association of Colleges of Nursing. 2002.http://www.aacn.nche.edu/ELNEC/index.htm.

2.Gretter LE. The Florence Nightingale Pledge [press release].American Nurses Association. 2002. http://www.nursingworld.org/pressrel/nnw/nnwpled.htm.

3. Scanlon C, Glover J. A professional code of ethics: providinga moral compass for turbulent times. Oncol Nurs Forum1995;22(10):1515-21.

4.A new code of ethics for nurses: ANA’s Code of EthicsProject Task Force. Am J Nurs 2000;100(7):69-72.

5.American Nurses Association. Code of ethics for nurses withinterpretive statements. Washington (DC): American NursesAssociation; 2001.


Complete the CE test for this article byusing the mail-in form available in thisissue or by going to Online CE atwww.AJNonline.com.

6. Stanley KJ. The healing power of presence: respite from thefear of abandonment. Oncol Nurs Forum 2002;29(6):935-40.

7.Karlawish JH. Shared decision making in critical care: a clin-ical reality and an ethical necessity. Am J Crit Care1996;5(6):391-6.

8.United States President’s Commission for the Study of EthicalProblems in Medicine and Biomedical and BehavioralResearch. Making health care decisions: a report on the ethi-cal and legal implications of informed consent in the patient-practitioner relationship [report]. Washington (DC):Government Printing Office; 1982.

9.Miller PA, et al. End-of-life care in the intensive care unit: achallenge for nurses. Am J Crit Care 2001;10(4):230-7.

10.Beauchamp TL, Childress JF. Principles of biomedical ethics.4th ed. New York: Oxford University Press; 1994.

11.P.L. 101-508: Omnibus Budget Reconciliation Act of 1990. § 4206, 751.

12.Field MJ, et al. Approaching death: improving care at theend of life. Washington (DC): National Academy Press;1997.

13.Goodman MD, et al. Effect of advance directives on themanagement of elderly critically ill patients. Crit Care Med1998;26(4):701-4.

14.Glossary of terms [Web page]. Partnership for Caring. 2001.http://www.partnershipforcaring.org/Resources/glossary_set.html.

15.Stanley KJ, Zoloth-Dorfman L. Ethical considerations. In:Ferrell B, Coyle N, editors. Textbook of palliative nursing.New York: Oxford University Press; 2001. p. 663-81.

16.Scanlon C. Unraveling ethical issues in palliative care. SeminOncol Nurs 1998;14(2):137-44.

17.Schwarz JK. Ethical aspects of palliative care. In: Matzo M,Sherman DW, editors. Palliative care nursing: quality care tothe end of life. New York: Springer; 2001. p. 140-79.

18.von Gunten CF, et al. The patient-physician relationship.Ensuring competency in end-of-life care: communication andrelational skills. JAMA 2000;284(23):3051-7.

19.Chochinov HM. Dignity-conserving care—a new model forpalliative care: helping the patient feel valued. JAMA2002;287(17):2253-60.

20.Meisel A, et al. Seven legal barriers to end-of-life care: myths,realities, and grains of truth. JAMA 2000;284(19):2495-501.

21.Weissman D, von Gunten C. Fast facts and concepts #24:DNR orders in the hospital setting. Part 2. 2000.http://www.eperc.mcw.edu/educate/flash/fastfact/143.htm.

22.Portenoy RK, et al., editors. Principles and practice of sup-portive oncology. Philadelphia: Lippincott-Raven; 1998.

23.American Nurses Association. Foregoing nutrition andhydration [position statement]. Washington (DC): TheAssociation; 1995.

24.Finucane T, et al. Tube feeding in patients with advanceddementia: a review of the evidence. JAMA 1999;282(14):1365-70.

25.Cruzan v. Director, Missouri Department of Health. In: 497US 261 (1990); 1990.

26.Meisel A. The legal consensus about foregoing life-sustainingtreatment: its status and its prospects. Kennedy Inst Ethics J1992;2(4):309-45.

27.Schwarte AM. Withdrawal of nutritional support in the ter-minally ill. Crit Care Nurs Clin North Am 2002;14(2):193-6.

28.Puntillo KA, et al. End-of-life issues in intensive care units: anational random survey of nurses’ knowledge and beliefs.Am J Crit Care 2001;10(4):216-29.


GENERAL PURPOSE: To provide registered professionalnurses with information on decision making whenquestions about advance directives and the with-drawal of life-sustaining interventions arise in end-of-life care.

LEARNING OBJECTIVES: After reading this article andtaking the test on the next page, you will be able to:• Discuss decision-making issues in end-of-life care.• Identify the nurse’s role in end-of-life decision

making.

To earn continuing education (CE) credit, follow these instructions:

1. After reading this article, darken the appropriate boxes(numbers 21–36) on the answer card between pages 40and 41 (or a photocopy). Each question has only onecorrect answer.2. Complete the registration information (Box A) and helpus evaluate this offering (Box C).*3. Send the card with your registration fee to: ContinuingEducation Department, Lippincott Williams & Wilkins, 345Hudson Street, New York, NY 10014. 4. Your registration fee for this offering is $13.95. If you taketwo or more tests in any nursing journal published byLippincott Williams & Wilkins and send in your answers toall tests together, you may deduct $0.75 from the price ofeach test.

Within six weeks after Lippincott Williams & Wilkinsreceives your answer card, you’ll be notified of your testresults. A passing score for this test is 12 correct answers(75%). If you pass, Lippincott Williams & Wilkins willsend you a CE certificate indicating the number ofcontact hours you’ve earned. If you fail, LippincottWilliams & Wilkins gives you the option of taking thetest again at no additional cost. All answer cards for thistest on Ethical Concerns in End-Of-Life Care must bereceived by January 31, 2005.

This continuing education activity for 2 contact hoursis provided by Lippincott Williams & Wilkins, which isaccredited as a provider of continuing nursing educa-tion (CNE) by the American Nurses CredentialingCenter’s Commission on Accreditation and by theAmerican Association of Critical-Care Nurses (AACN9722, category O). This activity is also providerapproved by the California Board of RegisteredNursing, provider number CEP11749 for 2 contacthours. Lippincott Williams & Wilkins is also anapproved provider of CNE in Alabama, Florida, andIowa, and holds the following provider numbers: AL#ABNP0114, FL #FBN2454, IA #75. All of its homestudy activities are classified for Texas nursing continu-ing education requirements as Type 1.*In accordance with Iowa Board of Nursing administrativerules governing grievances, a copy of your evaluation of thisCNE offering may be submitted to the Iowa Board of Nursing.

CE2Continuing Education

HOURS

Documents

CE2 HOURS Ethical Concerns in End-of-Life Care