THE DYING PATIENT

THE DYING PATIENT’S ETHICAL CHOICE 2
Duringone of myclinical placements onthe Medical Flooratthe hospital, I had the opportunity
to provide care to an endof life patientwhomwasdiagnosedwith terminally ill cancer. At the time, he
was waiting to be placed on the Hospice Unit which specialized in nursing end of life patients at St
Joseph’s Care Groupfor furthertreatment. “Hospicecareis designed to support families and caregivers,
as well as patients, yetthere are fewoptionsavailableto assist caregiverswith their daily responsibilities
of patient care.” (Emperio et al) (2011).
Duringmy conversationswithmypatient,he hadvoicedhisconcernnumeroustimesthathe did
not wantto die inthe hospital or to be transferred to the hospice care unit. His choice was to die in his
home with his family by his side. “A patient’s place of care may become her place of death. For some
patients this is a strong preference and a significant reason for wanting to be cared for at home.”
(Wheatley et al) (2007).
As the days went on, I could see a significant physical and psychological change in my patient
while caringforhiminthe hospital inthathisappetite haddeclined,andthat he wasgettingfurtherinto
engagingina depressivestate of mind.All he keptonsayingwasthat“I want to go home!” I felt for him
inthat I reassuredandsupportedhimforhisreasonsas to whyhe wanted to go home. I talked with my
preceptorandwe had discussedhischoice andshe hadinformedme thatthere wasgoingto be a family
meeting set up with the health care team in regards to possibly discharging the patient to his home;
however,there weresome physical barrierstoovercome inthe meantime. During my interactions with
my patientwhileprovidingcare forhim,Irealizedthathe was confidinginme andfeltlike he couldtrust
me in whichitalmostseemedlikethere wasatherapeuticnurse clientrelationshipoccurring. “Thereare
five components to the nurse-client relationship: trust, respect, professional intimacy, empathy and

power.Regardlessof thecontext, length of interaction and whether a nurse is the primary or secondary
care provider, these components are always present.” (Therapeutic Nurse-Client Relationship,
Revised)(www.CNO.ORG)(2009).
The next week, prior to starting my clinical, I was informed by my preceptor that the family
meetinghadtakenplace andthat my patientwasinthe processof returninghome ona trial basistosee
how the outcome would be while caring for him in his home. Throughout the day while caring for the
patient, I observed him to be in relatively good spirits. He was smiling and very talkative with me and
had consumedmajorityof hismealsduringthe shift.He theninformedme thathe wasgoinghome soon
to be withhisfriendsand family by his side. He was able to make his choice about his final time of life
and that he wanted to enjoy and spend it with family and friends. I had admired and respected his
autonomyforhimto make that choice. “Autonomy isthecapacity to makeand express(and perhapsact
on) choices. It is characteristic of (some) persons.” (Wheatley et al) (2007). He asked me if I knew the
date that he was goinghome. I replied to him and said that I would check with his primary nurse. I had
spokenwithmypreceptorinregardsto whatmy patienthadaskedof me andshe had said that they are
uncertainof whatexactlythe date that he will be going to his home as the family have voiced concerns
inthat theywill have toshare the care between the patient’s son and daughter’s schedules in order to
accommodate their father’s care. She had also mentioned to me that the son and daughter have been
experiencingstressduringthistime andfeel that their father should be transferred to the hospice unit
where he could receive nursing care. “Caregiver Stress” creates physical and psychological strain over
extended periodsof time,is accompanied by high levels of unpredictability and uncontrollability, has the

capacity to create secondary stress in multiple life domains such as work and family relationships and
frequently requires high levels of vigilance.” (Schulz et al)(2008). They both realize that their father’s
wishisto die at home;however,theyfeel that they will not be able to provide care due to their hectic
lifestyles and would add more stress. I personally feel that the nurse in this situation is caught in the
middle while tryingtoadvocate forthe patientandat the same time trying to reason with the patient’s
family. “A client wants to die at home in peace and comfort. The family knows that the presence of the
client at home will create intolerable stress for the other family members. The nurse is being pressured
by other members of the health care team to talk the family into taking the client home.” (CNO Practice
Standard Ethics)(www.CNO.ORG)(2009).
As a student nurse, I found it frustrating at times, due to having a lack of knowledge and
experience inthissituation.In both circumstances I am trying to understand how the patient feels and
in the other way, knowing that the family is concerned. “Being able to relate to their patients often
means that nurses are better able to assess their patient’s needs. However, nursing students are
considered novices who do not yet possess clinical knowledge, and their relational knowledge is
sometimesoverlooked.Thisis distressing formany students who find themselves confronted by difficult
ethical situations.”(Beckettetal)(2005).I know thatthe patientiscognitivelyaware andis able to make
a soundchoice as to where he wantsto spendthe remainderof hislife whichisverylittle atthe present
time, however, his family feel that added stress would add a hindrance to the situation and they feel
that theirfatherdeservesbetter care even though this is his choice. I have acknowledged that it is the

nurse’s role and responsibility to provide the best care to the patient while respecting his wishes in a
professional manner. “Much of the discussion of patient advocacy is rooted in the recognition and
valuing of patient rights and the role of nurses as advocates for the interests and rights of individuals.”
(MacDonald)(2006). Advocacy is vital role in which nurses participate with their patients. Nurses are
constantlypromotinghealthtotheir patients in a caring and compassionate manner and therefore are
advocatingforthe patientto whomtheyprovide care to.My patientisself-determinedthathe wants to
spend his final days at his home and I am aware that as a nurse it is her responsibility to advocate and
supporthimso that he make the best possible decision for himself. I understand that this is an uneasy
situation; however, nurses as professional health care providers must face the dilemma and act
accordinglyfortheirpatient’sbestinterest.To make the right decision for the patient, I experienced it
to be uncomfortable attimesasthisis fairlynew to me;howeverIbelieve thatthe nurse will gain more
confidence overaperiodof time withhavingmore exposure indealingwith it. “Kohnke (1982) suggests
that advocacy is a form of caring and compassion on the part of the nurse and that it is a learned
activity.She believes thatadvocacy isa skill thatnursesdevelop through variousexperiences,particularly
if advocacy is prized as worthwhile. Kohnke (1990) explains that the task of advocacy is focused on
ensuring patient self-determination over decision-making. She describes advocacy as “the act of
informing and supporting a person so that he can make the best decisions possible for himself.”
(MacDonald)(2006).

In the daysto follow,Ihadthe opportunity toattendan interdisciplinary team case conference
withmypatient,hisfamily,mypreceptor,the physician,socialworker,pharmacist,clergy,dietician,and
psychologist to discuss the future plan of care for my patient. The main focus was what the patient
wantedandhowcan healthcare providerssupporthim and fulfill his needs during this time of his life.
“Quality end-of-life care is best provided through the collaborative practice of an interdisciplinary team
to meet the physical, emotional, social, and spiritual needs of the person and their family. Nurses as
members of the interprofessional team, collaborate with the person, the person’s family and all those
involved in providing care(such as physicians,otherhealth-careprofessionalsand volunteers) to support
a holistic approach; incorporate the person’s priorities, values and choices in all aspects of care; and
addressany specificconcernsthat may arise.” (www.cna-aiic.ca)(2008). It was interesting to hear what
my patient had to say in regards to what his needs are and that his main goal was to die at his home
peacefully with his loved ones surrounding him. He had stated to the health care team during the
meetingthathe wantedall healthcare professionalswhom were involved with his care to continue on
treatinghimwhile he waslivingathome.He isspiritual andvalueshisreligioninwhichhe practiceson a
regular basis. His family supports and value him in regards to his choice; however, there are some
concerns they have in regards to whom would be caring for him when they are not able to be there. I
can understandwhytheyare concernedandthat theydo notwant to have to worryif theirfather is left
alone. “CNA recognizes a person’s right to make informed choices about his or her plan of care for the
end of life that reflect his or her personal, culture, and religious values. When assisting an individual in

this planning,nurses should consider the individual as a person in relationship with others, including his
or her family.” (www.cna-aiic.ca)(2008).
Duringthe case conference inwhichthe patient,hisfamily and other health care providers had
attended,otheroptionshadbeendiscussedsuchashavinghome care services put into place while the
patient was living at his home. These home care services involved nursing services, personal support,
and homemaking as an option if the family was not able to be at home during that time. In regards to
advocatingformy patient,Ielaboratedmore tomypreceptor in that home care would be an ideal plan
of care formy patientandalsothe patient’s family in that he would be able to have his wish in that he
can die at home and also his family would feel more at ease in that knowing that their father can be
cared forby healthcare professionalsandsupportwhile providingcare tohimin hishome. I had further
discussedwithmypatient’sphysician,andwith my preceptor that I have observed a significant change
withmypatientsince mylastclinical whichwasthe previousweekinthatmypatienthadvoicedvarious
timesthathe wantsto returnto hishome and leave the hospital.Ihadalsocommentedtoboth of them
that his health has declined in that he was getting depressed, and his appetite had decreased. His
cognitive status is intact and he is able to make his own decision as to where he wants to spend the
remainderof hislife.Ibelievethathe shouldbe able tomake thisdecisionbasedonhiscognitivemental
statusand that he has everyrightas a humanbeingto choose where he wants to die. At present, many
ill individualswanttoremainin their home as the hospitals and institutions are lacking the facilities to
accommodate them while they are waiting to be placed to other places such as long term care, and
other facilities. There are many home care providers which included professional nurses, personal
support workers, and homemakers to provide care and support to patients and their families. In this

case,I do not see whymypatientcannothave a communityhealthnurse visit him and provide the care
and support needed.
In regards to accessing ethical knowledge to determine my decision making and action, I
accessedthe CNA Code of Ethics,CNO Standardsof Practice which I found various articles involving the
Nurse-Client Therapeutic Relationship, and Standards of Practice.
I enlistedmy embodied knowing by perceiving the situation as very special in that this matter
had influencedme inanemotional,physical and psychological way. I felt compassion and empathy for
my patient in that he should have a choice as to where he wants to spend his final days in life. He is
cognitivelyaware that he does have little time to spend and he wants it to be right. By using thorough
assessmentskills,Icouldsee that he wanted to be at home as numerous times during my shift, he had
commentedthathe doesnotlike the hospital andwantsto go home now. In the physical perspective, I
noticed his health had declined from day to day in that his appetite had decreased which had also
affected his GI system. His skin turgor was losing elasticity, as well as body strength and muscle mass
had deteriorated. Psychologically, he was becoming depressed and not wanting to interact or
communicate withme anymore.He wasbeginningtoisolate himself from everyone. In general, I could
see that his overall health status had declined significantly.
I see myself as a moral agent when caring and providing nursing care to my patient in which I
had formedatherapeuticrelationshipwithhiminwhichhe hadfullytrusted me by interacting with me
in a warm compassionate way. “Nurses need to recognize that they are moral agents in providing care.
This meansthatthey havea responsibility to conduct themselvesethically in what they do and how they
interact with persons receiving care.” (Canadian Nurses Association Code of Ethics for Registered

Nurses)(2008). Iin turn,showedempathyforhim by advocating for him to return to his home to spend
his final days of life. I wanted him to maintain his quality of life by supporting him in making the best
decision possible while receiving nursing care within his home environment. I felt very emotional at
times while providing care to him as I wanted everything to work out for him and did not want him to
get let down if things did not work out. “Ethics is a deeply personal, embodied process, being and
becoming a moral agent requires the cultivation of a mindful, critical awareness and attunement to
emotion and bodily experience.” (Doane)(2004). At times,Itriedtoput myself inmypatient’sshoesand
reflectedtomyself the following question, how would I feel and where would I like to spend the final
daysof my life.Myanswerwouldbe the same asmy patientinthat I wouldlike tospend the remainder
of mylife where Iamcomfortable inmyhome environmentif able.Mypatientasa humanbeing should
have his right to make the decision as he is cognitively aware what is right for himself with home care
supportsin place for him. I felt strong emotions within my body for my patient numerous times while
caring for him and have self-reflected in my mind and body the emotions he was going through while
referring to what the significance of embodied knowing is in correlation to nursing and the moral
agency. “Sound ethical practice in nursing requires embodied knowing. This understanding of how
knowledge comes together in the body has highlighted the significance of embodied moral agency.
Through our bodies, we have an implicit sense of a situation and the intricacy of it. The body not only
acts asan orienting centre of perception and knowledge,butalso orientsouraction. If we pay attention,
we can physically sense our bodies’ implication of the situation and the next steps we should take.”
(Doane)(2004). Idirectedmyself asamoral agentalsoby listeningtomypatientina caring way and also
respectinghisdecisionsunderthe circumstanceswhich he is experiencing at present with dignity. As a
nursing student, I know that I will be facing many ethical decisions in the role of a professional nurse
while providing care for my patients. The initial step is to form a therapeutic relationship between

the nurse and the patientbasedonrespect,trust,empathyanddignity.Once thishasformed,it is much
easiertofacilitate direction in communicating, engaging, and interacting with the patient in providing
nursing care based on his needs. By self-reflecting and using critical thinking skills regularly also
enhancesthe habit of developing embodied knowing which has helped me identify myself as a moral
agentin thissituation.Keepinganopenmindinrelationtomy inner bodily experiences has helped me
stay in fine tune with the external environment in which has kept me in balance when caring for my
patient and has made me stronger and increases my self-awareness and wellbeing. “Recognizing and
supporting the development of embodied knowing is not only vital to advancing ethical practice in
nursing,it is essential to promoting thewell-being of nurses.” (Doane)(2004). I have acknowledged that
embodiedknowledgetakestime todevelopintothe nursingpractice andwithexperience andpractice it
will developovertimewithinthe nurse’srole andresponsibilities. Embodied knowledge involves many
conceptsof learningwithinsocietyinwhicheach professional practice. “The development of embodied
knowledge is a sociopolitical issue as much as a philosophical, conceptual, or academic one.”
(Doane)(2004).
Habitsof conductwhichconstrainedmyembodiedknowingandpractice was during the time in
whichI wasin the processof advocating for my patient in which he was waiting to hear when he could
returnto hishome to spendhisfinal daysof life.Ihadattendedthe case conferencesinwhichall health
care disciplines,andhis family were also present. The goal in which I had hoped to be met was for the
patienttoreturnto his home with home servicesin place.However,the familyhad ongoing concerns in
that theirwishestohave theirfatherspend hisfinal days on the hospice unit in which he could receive
palliativecare. Iwas informedthatmanycommunitynursesdospecializeinpalliative/Endof life care in

Which nursing care is provided on a 24hr basis to the patient while he resides in his home. I was
frustrated at times during the case conferences when I heard the family state that it would be more
realistic if their father would be cared for in an institution versus at his home. In my opinion, after
hearingthisfromthe family, I interpreted that they were neglecting to respect their father’s wish and
only thinking of what their opinion was. It also occurred to me that they were reluctant to trial their
father at home with home care services in place. I did not want to override the family as I had also
respectedtheirdecisionandknewthattheycaredfortheirfatherand wantedwhat isbest, however, as
an individualenteringthe healthcare professionasa student, I felt that I was responsible for providing
respect and dignity to the patient by advocating for him accordingly. “Nurses are often in situations
which challenge their abilities to fulfill their moral responsibility and accountability, and they are too
often overwhelmed by ethical problems; and they experience a great moral distress because of this.”
(Varcoe)(2009). Duringthe case conferenceswithotherhealthcare disciplinesandthe patient’sfamily,I
had practisedethical nursinginwhichItook on an advocacy role on behalf of the patient by promoting
the valuesandwellbeingof mypatient.Ivoicednumerousof timesthatit would be worth the time and
efforttotry havinghimat home withsupport services in place to see if it would be in the best interest
and outcome forthe patient.Ihad alongwithmy preceptorvoicedconcernthatmypatient’shealthhad
declinedashe wantedtogo home soon. He was not in happy spirits while staying in the hospital as he
had voicedmanyof times that he wants to go home. “Ethical nursing care means promoting the values
of client well-being,respecting client choice, assuring privacy and confidentiality, respecting the sanctity
and qualityof life, maintaining commitments,respecting truthfulnessand ensuring fairness in the use of
resources.It also includes acting with integrity,honesty and professionalismin all dealingswith the client
and other health care team members.” (www.CNO.ORG)(2009).

There are manycontextual forces which shaped my action, the situation and my experience in
that by collaboratingwithotherhealth care disciplines and hearing what they had to contribute to the
care of the patient is very informative in that we all agree that we all provide patient centered care to
the patientandthat the main concerniswhat isbest for the patient while enhancing quality care. Each
health care professional provides a specialized expertise and I had learnt a great deal of information
which contributed to the wellbeing of the patient at hand. Learning from the experiences of other
nurseswhomhave hadpreviousexperienceswiththistype of action contributedto the situation and to
the meaning. By listening to them, I had learnt a great deal in regards to engaging my personal
knowledge andapplyingitwithinthe social contextor organizationtogive it meaning. “As well as being
narratively and dialogically derived, the nurses’ identities appeared to emerge through layers of
negotiationswithself,with others,and within a contextof social organization.” (Doane)(2004). Many of
the nurses had informed me that it takes many years of experience and by building on it, many
circumstances in the past have similar consequences in regards to the same interventions or goals of
each patient.Whateverthe goal or outcome is,itall has meaningandeachnurse buildsonthat meaning
whentheyare facedwiththisdilemmaagain. “Confronted with many different events and situations in
their practice, the nursesselected and organized their experiences of those events into a set of workable
meanings. These workable meanings shaped how they identified themselves within the situations and
how their professional identity blended with their personal identity.” (Doane)(2004).
In conclusion, my patient’s wish had come true for him as he was able to return home and
spendhisfinal yearsof life.Home supportssuchasnursing,personal supportworkers,andhomemakers
were providedtohim. Sadlytosay,he hadpassedaway one month later in his sleep with his family by
his side.

References
Beckettetal (2007) (p.30). Doingthe RightThing:NursingStudents,Relational Practice,andMoral
Agency.Journal of NursingEducation,46(1),28-32.
CanadianNursesAssociation(2008).Code of Ethicsfor Registered Nurses2008 Centennial Edition.
Ottawa.
CanadianNursesAssociation(2008).PositionStatement:ProvidingNursingCare AtThe End Of
Life. www.cna-aiic.ca.
College of Nursesof Ontario(2009) Practice Standard: Ethics.(p.3-23). www.cno.org.
College of Nursesof Ontario.(2009) Practice Standard:Professional Standards,Revised2002.
(p.3-13). www.cno.org.
College of Nursesof Ontario(2009) Practice Standard: TherapeuticNurse-ClientRelationship,Revised
2006. (p.3-16). www.cno.org.
Doane,G. (2004)(pp . 433-446). BeinganEthical Practitioner:The Embodimentof Mind,Emotion,and
Action.Chaptertwenty-one.Toronto:PearsonPrentice Hall.
Empenoetal (2011) The Hospice CaregiverSupportProject:ProvidingSupporttoReduce Caregiver
Stress.Journal of Palliative Medicine Volume14,November5,2011. SanDiego,California.
MacDonald,H, (2006) Relational ethicsandadvocacyinnursing:literature review.Journal of Advanced
Nursing57, 119-126. HealthSciencesUniversityof the FraserValley,Chilliwack,British
Columbia,Canada.
Schultzetal (2008) Physical AndMental HealthEffectsOf FamilyCaregiving.National InstituteOf
Health.AmericanJournal Nursing.Universityof Pittsburgh.
Varcoe et al (2009). ConstrainedAgency:The Social Structure Of Nurses’Work. Health,illness,and
Healthcare inCanada (4th
ed.pp. 122-140).
Wheatleyetal (2007). Palliative Care.“Please,Iwanttogo home”:ethical issuesraisedwhen
Consideringchoice of place of care inpalliativecare.PostgradMedJournal;83: 643-648.
Doi:10.1136/pgmj.2007.058487.

Running Head: The Dying Patient’s Ethical Choice 1
Individual Ethics Essay
“The Dying Patient’s Ethical choice”
Donna Lagergren
Student Number 0278613
Karen Poole
Lakehead University
N 4600
December 3, 2013
I declare thatthispaperis my original work.Exceptingwhere Ihave citedmyownpreviouswork,this
Paperinits entirety,oranyportionthereof,hasnotbeensubmittedtomeetthe requirementsof any
Othercreditcourse.
StudentSignature DonnaLagergren
Date: December3,2013

THE DYING PATIENT

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