Chapter 08: Complexity at the End of Life: The Ethical and Legal Challenges

Keatings: Ethical & Legal Issues in Canadian Nursing, 4th Edition

Multiple Choice

1. Which of the following statement best describes assisted suicide?

a. It is a form of withdrawal of treatment.

b. It is a passive process, and the patient is mentally competent.

c. It is an active process, and the patient is mentally incompetent.

d. It is an active process, and the patient is mentally competent.

ANS: D

Feedback

A Incorrect Assisted suicide does not necessarily involve withdrawal of treatment.

B Incorrect This statement does not accurately describe assisted suicide.

C Incorrect This statement does not accurately describe assisted suicide.

D Correct! In assisted suicide, active steps are taken to end the life of a debilitated but mentally competent patient who requests the help of another person.

DIF: Cognitive level: Comprehension a. The family wishes that the patient will live longer. b. The family requests intravenous (IV) fluids for hydration of the patient. c. The family requests administration of narcotics for the patient’s pain relief. d. The family refuses to allow the patient’s transfer to a palliative care unit.

2. Which of the following situation is an example of an ethical dilemma that can arise for a team on a medical unit while caring for a terminally ill patient who is near death?

ANS: B

Feedback

A Incorrect A family’s wish that a terminally ill patient live longer is not unethical and is a normal aspect of grief and loss.

B Correct! Hydrating the patient may create respiratory discomfort, potentially prolonging his or her suffering and postponing death; therefore, this request is an example of an ethical dilemma for the nurse and the team.

C Incorrect Administering narcotics prescribed for pain management is not unethical.

D Incorrect This may conflict with the nurse’s values, but it is not unethical because the patient can still receive palliative care on the medical unit.

DIF: Cognitive level: Synthesis a. Use terminology that older adult clients can understand, such as “diapers.” b. Engage in conversation with older adult clients about their lives. c. Take over control from older adult clients as much as possible to conserve their energy. d. Call older adult clients by their first name only.

3. Which of the following activities will help ensure the dignity of older adult clients, regardless of their capacity?

ANS: B Feedback

A Incorrect Using the term “diapers” is disrespectful and demeaning to older adults.

B Correct! Engaging in conversation with older adult clients about their lives helps these clients feel valued. Older adults need stimulation and socialization and want to share their stories and to be treated with the respect they have earned throughout their lives.

C Incorrect Giving older adult clients as much control as possible allows them to feel valued and helps ensure that their dignity is preserved.

D Incorrect Calling older adult clients by their first name may be disrespectful, depending on the clients’ culture and background. If the nurse is unsure, it is more appropriate to use the entire name or only the family name. When possible, it is preferable to ask clients about their wishes in this regard.

DIF: Cognitive level: Synthesis a. Autonomy b. Veracity c. Informed choice d. Responsibility and accountability

4. Some persons in Canada disagree with the Medical Assistance in Dying (MAID), legislation, based on the ethical principle of the sanctity of life. What principle might support the argument of others who disagree with this view?

ANS: A Feedback

A Correct! Autonomy is the right of individuals to make decisions that affect their lives. The MAID legislation is based on this principle and requires the explicit consent of the person making the request for an assisted death.

B Incorrect Veracity is the duty to tell the truth. This ethical principle is central to ensuring trust within the nurse–patient or nurse–client relationship but would not likely be in conflict for nurses working with the dying.

C Incorrect Informed choice is not an ethical principle but is based on the principle of autonomy.

D Incorrect Responsibility and accountability is a professional standard, not an ethical principle.

DIF: Cognitive level: Synthesis a. Medical Assistance in Dying b. Assisted suicide c. Passive euthanasia d. An illegal act

5. A nurse administers larger doses of narcotics prescribed for pain control, which hastens a terminally ill patient’s death. In which of the following acts has the nurse participated?

ANS: C

Feedback

A Incorrect MAID is a process that allows for physicians and nurse practitioners to assist in the death of a terminally ill person when certain conditions are met. MAID results in the immediate death of a terminally ill patient; this does not describe what this nurse is doing.

B Incorrect In assisted suicide, active steps are taken to end the life of a debilitated but mentally competent patient who requests this of another person; this is not what this nurse is doing.

C Correct! Passive euthanasia is generally accepted as a potential effect of withdrawal of treatment or narcotic administration in palliative care. It is not “active” because death is hastened as result of the effects of the medication necessary to relieve pain.

D Incorrect The obligation to provide palliative care and adequate pain control is also supported in law and has been upheld in Supreme Court decisions, leading to the MAID legislation.

DIF: Cognitive level: Analysis a. The nurse is acting in the best interests of the family. b. The nurse is acting in the best interests of the patient. c. The nurse is being disrespectful of the patient’s autonomy. d. The nurse is acting this way because she knows the patient’s organs are unsuitable.

6. A nurse decides not to raise the issue of organ donation with a patient’s family concerned that this might interfere with the grieving process. Which of the following statements describes how this nurse is acting?

ANS: C

Feedback

A Incorrect This nurse is not acting in the best interests of the family.

B Incorrect This nurse is not acting in the best interests of the patient.

C Correct! The nurse is being disrespectful of the patient’s autonomy. By avoiding the topic of organ donation, the nurse is making the decision for the patient/family, not to donate.

D Incorrect There is not enough information in this scenario to know if the patient’s organs are suitable or not.

DIF: Cognitive level: Analysis a. The nurse should approach all patients who are admitted through the hospital’s emergency department and ask them about organ donation. b. The nurse should wait until the patient is settled in an inpatient unit before asking about organ donation. c. The nurse should only ask the families of dying patients in a Critical Care Unit about organ donation. d. The nurse should provide organ donor information to patients who are discharged from the hospital.

7. Which of the following approach is the best way to increase the number of potential organ donors?

ANS: D

Feedback

A Incorrect This is not the best approach because patients presenting in the emergency department are often highly anxious as a result of the urgent nature of their health status, and this stress can compromise their ability to make autonomous decisions based on informed choice.

B Incorrect This is not the best approach because inpatients may be highly stressed and dealing with uncertainty, which compromises their ability to make autonomous decisions based on informed choice.

C Incorrect In some cases, this may result in an actual organ donation, but this approach does not increase the number of potential organ donors overall.

D Correct! This is the best approach for the nurse to take because education, communication, and awareness will help individuals to make informed decisions about available donation options.

DIF: Cognitive level: Synthesis a. The nurse on duty at the time of the patient’s death b. The patient’s spouse c. The physician d. The funeral director

8. Which of the following people can make the decision to donate postmortem tissue?

ANS: B

Feedback

A Incorrect Tissue donation must occur soon after death, so the nurse is often involved in the suggestion, process, or coordination of the donation. However, the nurse does not make the decision to donate.

B Correct! There is a hierarchy of persons who may be approached to make this decision. The patient’s spouse would be asked first, followed by the patient’s adult children (if there is no spouse), then either of the patient’s parents or legal guardian, then siblings, then next of kin, and, if none of these is available, anyone who is in lawful possession of the body can make the decision to donate.

C Incorrect The physician is involved in the suggestion, process, or coordination of the donation. However, the physician does not make the decision to donate.

D Incorrect The funeral director has nothing to do with this decision. However, in some setting they may play a role in reminding families about this option and may play a role in retrieving tissue that does not have time limitations.

DIF: Cognitive level: Analysis a. The law imposes a duty on nurses to participate in MAID when the criteria set out in the legislation are met. b. Organizations participating in MAID should ensure that processes and policies are in place to support those health care professionals who do not want to participate. c. Nurses can refuse to participate on the basis of their personal and religious values. d. Nurses have the right to share their views on MAID with their patients or clients.

9. Which of the following best describes the engagement of nurses in MAID?

ANS: B

Feedback

A Incorrect The law does not require that all health care professionals participate.

B Correct! The nurse has a duty to inform his or her employer about personal conscientious objection in advance so that the organization can ensure that he or she is not involved in the process.

C Incorrect Nurses may have these views but also have a duty to inform their employers of their conscientious objection in advance to ensure that they are not involved in the process.

D Incorrect It is appropriate for nurses to ensure that the client knows whether or not they will be involved, but it is not appropriate to impose their values or influence the person’s decision.

DIF: Cognitive level: Analysis a. Respectfully explaining to an Indigenous family that pipe ceremonies are not permitted because of fire risk b. Ensuring that they are knowledgeable about the cultures of their clients c. Ensuring their own values are understood by their clients so that there is no confusion about the care plan d. Undertaking a comprehensive assessment of the patient or client to understand their values and beliefs.

10. Nurses respect the values of various cultures best by following which of the following practices?

ANS: D

Feedback

A Incorrect There are many strategies that can be employed to allow this practice while ensuring safety.

B Incorrect Although it is important that nurses have a foundational knowledge of the values and beliefs of various cultures, not all persons of those cultures hold those values.

C Incorrect It is inappropriate for nurses to impose their values on others.

D Correct! It is not possible to know in advance the beliefs and rituals of all cultures; therefore, it is important to ask the patient and family what is most significant to them.

DIF: Cognitive level: Analysis

TRUE/FALSE

1. The daughter of a patient in the nurse’s care states that her mother has verbally expressed her wishes for treatment. This is an example of an advance directive or living will.

ANS: T

Feedback

Correct An advance directive or living will is a person’s instructions regarding decisions about care if she is ever rendered incompetent. Advance directives can be made either verbally or in writing.

Incorrect This statement is true.

DIF: Cognitive level: Knowledge

2. When discussing the condition of a terminally ill patient with his or her family members, the terminology “Do Not Resuscitate” should never be discussed and offered because the family may think it means “do nothing.”

ANS: F

Feedback

Correct The terminology “Do Not Resuscitate” can be interpreted by families as meaning “do nothing,” and this can put a burden of guilt on families when they are asked to make this decision on behalf of an incapable family member. However, this choice should still be discussed with the patient’s family at an appropriate time. Framing the decision around allowing a “natural death” can help relieve some of the burden on the family.

Incorrect This statement is false.

DIF: Cognitive level: Analysis

3. For nurses, an ethical dilemma is resolved when a seriously brain-injured child is declared brain dead and is removed from the ventilator.

ANS: F

Feedback

Correct The situation of a dying child is extremely emotional and presents highly complex moral and ethical challenges for the nurse. There are times when a nurse’s personal or professional values may be conflict with the values of the family. Ethical dilemmas are not necessarily resolved through a death or the removal of a situation; moral distress may linger long after the child has passed away.

Incorrect This statement is false.

DIF: Cognitive level: Synthesis

4. The nurse is caring for a dying patient and his family. The nurse should incorporate cultural factors into the evaluation of care.

ANS: F

Correct Cultural factors should be built into all aspects of care, not just the evaluation phase. The nurse should incorporate cultural considerations into the overall initial assessment so that they form part of the plan and implementation, as well as the evaluation. The nurse’s attention to such needs can improve the quality of the dying process and constructively influence the ensuing bereavement process.

Incorrect Cultural considerations should be built into all aspects of care, not just the evaluation phase.

DIF: Cognitive level: Application

5. Under the MAID legislation, nurses are not permitted to a play a role in an assisted death. Only physicians and pharmacists are permitted to play an active role in the process.

ANS: F

Correct The legislation in the Criminal Code provides the exception to both nurse practitioners and physicians. Nurses, not in the extended class, participate by providing nursing care and assistance. Nurses play a strong role in educating and supporting clients and families. They may not administer the substance or obtain consent for MAID but provide technical support, care, and comfort to the patient and family and ensure that the process is dignified and respectful of all involved.

Incorrect This statement is false.

DIF: Cognitive level: Knowledge