Situation A.P. is a terminally ill 50-yr-old woman with metastatic breast cancer who is hospitalized with severe bone pain. She moans at rest and shows severe pain with any movement to reposition her. The present dose of IV morphine is not controlling her pain. At the team conference, the nurses discuss the need for more effective pain control but are concerned that more pain medicine could hasten her death. Ethical/Legal Points for Consideration • Adequate pain relief is an important outcome for all patients, especially patients who are terminally ill. • The Code of Ethics for Nurses addresses the responsibility of the nurse to relieve suffering and have conversations with patients and families about pain and symptom management. 1 • The principle of beneficence means that we provide care to benefit patients. The goal of adequate pain control in the terminally ill to ease suffering is based on the principle of nonmaleficence (preventing or reducing harm to the patient). The secondary effect of hastening the patient’s death is ethically justified and known as the double ef ect. • Legally, the standard of care is used to define the nursing acts that are required for safe and competent nursing practice. When the actual nursing care falls below the standard of care, it is considered negligent and unsafe, and the nurse is at risk for being found incompetent. • In a court of law, the standard of care in nursing is determined by nursing experts and evidence-based practices. The increasing use of technology to access the latest scientific findings is changing the standard of nursing care to a national, if not global, standard defined by research findings and nationally recognized expert testimony. Standards for providing expert nursing care and counseling at EOL are available. 1 • In A.P.’s situation the standard of care is that the patient will have pain relief. Failure of the nurse to act assertively to achieve pain relief for the patient and failure to effectively use resources to obtain that pain relief will be considered below the standard of care and unsafe and incompetent practice. Discussion Questions 1. What types of discussions need to occur among the health care team, patient, and family as the terminally ill patient approaches this phase of care? 2. Distinguish between promotion of comfort and relief of pain in dying patients and between assisted suicide and euthanasia.
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