Ethical Dilemma in a Patient in the Terminal Period: A Case Report

Ethical Dilemma in a Patient in the Terminal Period:

A Case Report

Terminal Dönemdeki Bir Hastada Yaşanan Etik İkilem: Olgu Sunumu

Beratiye Öner

Department of Nursing, Lokman Hekim University, Faculty of Health Sciences, Ankara, Türkiye

The terminal period is the last part of the life of people who suﬀer from diseases resulting in death, which refers to

an irreversible process that cannot be treated. Ethical problems are frequently encountered in the treatment process

of critically ill patients in the terminal period. Nurses frequently encounter ethical concepts due to their position that

allows a long-term relationship with the patient and their family, and sometimes they may even be in a decision-mak-

ing situation. In this case report, we present the ethical dilemma of a nurse to allow or not allow a terminal patient in

the intensive care unit to see her 3-year-old son.

Keywords: Case; Ethical dilemma; Intensive care unit; Nursing; Terminal period

ancer is one of the most critical problems threatening

the health of people worldwide and is among the rst

diseases that cause death.

[1]

In cases where cancer cannot

be cured, the patient’s care in the terminal period gains im-

portance. The term terminal patient refers to patients who

have a terminal illness and are expected to die in a not-dis-

tant time.

[2]

The standard advance directive and the life ex-

tension, especially comfort care, are the primary targets for

terminal patients.

[3]

However, the priorities of these goals

may dier in terms of nurses and other health profession-

als, and these dierent approaches may lead to a conict of

ethical values in patient care.

An ethical dilemma is a situation where a decision cannot

be made quickly, where at least two options must be cho-

sen, and where at least two values conict.

[4]

Therefore,

resolving ethical dilemmas is complex, and nurses need

to know the basic concepts, principles, problems, and de-

cision-making patterns related to ethics.

[5]

In this case, an

ethical dilemma experienced by a nurse for a terminal pa-

tient is presented. An informed consent form was obtained

from the patient.

Case Report

A 31-year-old female patient with a bone marrow trans-

plant developed a rejection and entered the terminal pe-

riod. The patient, with neutropenia, was monitored in in-

tensive care conditions by wearing a CPAP mask at night

due to respiratory distress. She could not see her 3-year-

DOI: 10.14744/lhhs.2023.12005

Lokman Hekim Health Sci 2023;3(2):146–148

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Abstract

Correspondence: Beratiye Öner, M.D. Lokman Hekim Üniversitesi, Sağlık Bilimleri Fakültesi, Hemşirelik Bölümü, Ankara, Türkiye

E-mail: beratiyesinmaz@gmail.com Submitted: 12.12.2022 Revised: 10.01.2023 Accepted: 09.02.2023

Cite this article as: Öner B. Ethical Dilemma in a Patient in the Terminal Period: A Case Report. Lokman Hekim Health Sci 2023;3(2):146–148.

CASE REPORT

OPEN ACCESS This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).

147

Öner B.; Ethical Dilemma in a Patient in the Terminal Period / doi: 10.14744/lhhs.2023.12005

old son because she was in the intensive care unit, because

of the risk of infection, and children under 10 years of age

were forbidden to visit such patients. The patient was an

undergraduate banker. Her physician informed her about

her illness and the transplant process, and she also con-

ducted research. She stated that she might be living in her

last days and wanted to see her son despite the risk to her

life. She said, “If these are my last days, I want to spend this

time with my son; seeing and thinking about my son makes

me forget my illness and connects me to life.” In this case,

the ethical dilemma arose from the tension between the

values of benecence, which refers to the duty of health

care professionals to promote the well-being of their pa-

tients, and respect for autonomy, which refers to the pa-

tient’s right to make decisions about their own care.

The aim of this study is to draw attention to the ethical

dilemmas experienced by nurses.

Discussion

In this case, in order to mitigate infection risk, visitor re-

striction protocol is practiced for intensive care patient.

Patient, on the other hand, has autonomy rights. This

situation creates a dilemma between the ethical prin

ciples of benecence and autonomy. The health care

professionals’ duty is to promote the well-being of their

patients, which involves taking measures to prevent in

fection and prolong the patient’s life. However, the pa-

tient’s autonomy and right to make decisions regarding

their own care should not be overlooked. Navigating this

dilemma requires careful consideration of the patient’s

medical condition and prognosis, as well as open com

munication and collaboration between the medical team

and the patient and their family. Ultimately, the decision

should be made in the best interest of the patient, con

sidering all relevant factors and values. Professional rules

and fundamental ethical principles contain specic regu

lations for such value conicts. Nurses’ decision-making

in ethically dicult situations should be based on bioeth

ical principles: respect for autonomy, benecence, non-

malecence, and justice.

[6]

Benecence refers to actions aimed at beneting others.

Sometimes, any decision taken by health professionals

for the patient’s benet can remove the patient’s right

to decide for themselves, which is dened as paternal

ism and brings ethical questions with it.

[7]

The most im-

portant cause of mortality in stem-cell transplant is res-

piratory failure, which is due to infection. Nosocomial

infections account for 77% of mortality after stem-cell

transplantation in pancytopenia patients who develop

rejection. This situation often shortens the patient’s life

span.

[8]

However, it has been proven that the main source

of nosocomial infections is health care workers. At least

the relatives of the patients, whom the patient wants to

see, be taken by making necessary arrangements in the

intensive care environment. As it has been accepted that

the patient is independent and has free will, the decision

of whether to accept visitors should be left to the patient.

In this context, the visitor ban should be accepted as a

paternalistic approach.

[7]

Contemporary ethical understanding considers the prin-

ciple of nonmalecence as not causing a worse situation

than the current situation. From the point of view of the

terminal patient, the problem encountered in applying

this principle is: Is everything better than death, no matter

what? Undoubtedly, this closely relates to the principle of

respect for autonomy because another question is who will

determine the harm and benet.

[9]

Although the patient has the right to decide on their own

life, established within the scope of Human Rights and In-

ternational Declarations, the acceptance of patient visitors

is based on the procedures determined by the institutions

in the Patient Rights Regulation. The Operating Regulation

of Inpatient Treatment Institutions does not allow the visit

of children under 10 years of age in this regard.

[10]

Based on

these, the institution preferred to protect the principle of

nonmalecence at the highest level.

Autonomy means everyone has the right to choose treat-

ment and care based on their values, beliefs, and prefer-

ences. In patients with decision-making capacity, the pri-

mary decision-makers are the patients themselves.

[6]

On the one hand, prolonging the patient’s life by prevent-

ing infection is an example of usefulness, while having the

patient’s right to make decisions about their own care is an

example of respecting autonomy.

[6]

Restricting visitors due

to hospital infections may cause terminally ill patients to

not be able to see their loved ones and may cause feelings

of loneliness and abandonment. While health care workers

are the main sources of nosocomial infections,

[7]

the practice

of visitor restriction may lead to ethical dilemmas among

nurses in the decision-making process. To reduce this eth-

ical dilemma, nurses can discuss patient visits and make

decisions in multidisciplinary ethics committees based on

bioethical principles. This approach, which considers dier-

ent perspectives, ensures that the decision made is for the

benet of the patient and their relatives while respecting

the moral and ethical obligations of nurses.

148

Öner B.; Ethical Dilemma in a Patient in the Terminal Period / doi: 10.14744/lhhs.2023.12005

Conclusion

Treatment and care for terminally ill patients, patient rights,

and ethical issues are sensitive topics that require special

attention. To ensure that nurses are equipped to handle

these issues, education programs at both the undergrad-

uate and graduate levels should include the following

subjects: the concept of death, a holistic approach to care,

the roles of health professionals in caring for terminally

ill patients, ethical issues, and patient rights. Additionally,

preparing ethical guidelines for nursing practice, manage-

ment, education, and research; establishing ethical com-

mittees for consultation; and developing national and in-

stitutional policies can help to eliminate potential ethical

dilemmas and guide nurses in their decision-making. This

can provide a fair and ethical solution for all parties involved

and reduce nurses’ ethical dilemmas. This study focused on

patient-centered ethical dilemmas in the care of terminally

ill patients. Future studies could address other dimensions.

There is a lack of discussion of ethical dilemmas in the Turk-

ish nursing literature, making this study important in con-

tributing to the understanding of ethical issues in nursing

practice and raising awareness among nurses.

Acknowledgements: We would like to thank the participant

who participated in the study.

Peer-review: Externally peer-reviewed.

Informed Consent: Written informed consent was obtained

from patient who participated in this study.

Conict of Interest: None declared.

Financial Disclosure: The author declared that this study re-

ceived no nancial support.

References

1. Ritchie H, Spooner F, Roser M. Causes of death 2018. Available

at: https://ourworldindata.org/causes-of-death Accessed Feb

13, 2023.

2. Hui D, Nooruddin Z, Didwaniya N, Dev R, De La Cruz M, Kim SH,

et al. Concepts and denitions for "actively dying," "end of life,"

"terminally ill," "terminal care," and "transition of care": a system-

atic review. J Pain Symptom Manage 2014;47(1):77–89.

[CrossRef]

3. Halpern SD, Loewenstein G, Volpp KG, Cooney E, Vranas K,

Quill CM, et al. Default options in advance directives inuence

how patients set goals for end-of-life care. Health A (Mill-

wood). 2013;32(2):408–17.

[CrossRef]

4. Hopia H, Lottes I, Kanne M. Ethical concerns and dilem-

mas of Finnish and Dutch health professionals. Nurs Ethics

2016;23(6):659–73.

[CrossRef]

5. Rainer J, Schneider JK, Lorenz RA. Ethical dilemmas in nursing:

an integrative review. J Clin Nurs 2018;27(19-20):3446–61.

6. Beauchamp TL, Childress JF. Principles of Biomedical Ethics.

New York:Oxford University Press;2001.

7. Torun S, Kadıoğlu S, Öztunç G. Right of getting visited of

conscious patients in intensive care. Cumhuriyet Med J

2012;34:33–40.

[CrossRef]

8. Afessa B, Teeri A, Dunn WF, Litzow MR, Peters SG. Intensive

care unit support and Acute Physiology and Chronic Health

Evaluation III performance in hematopoietic stem cell trans-

plant recipients. Crit Care Med 2003;31(6):1715–21.

[CrossRef]

9. Oğuz Y. Terminal dönemde etik sorunlar. Sendrom 2001:121–

10. 13.01.1983 Tarihli 17927 Sayılı Resmi Gazetede Yayınlanmış

Olan Yataklı Tedavi Kurumları İşletme Yönetmeliği. Available at

https://khgmstokyonetimidb.saglik.gov.tr/Eklenti/19209/0/

yatakli-tedavi-kurumlari-isletme-yonetmeligi-13011983-

tarihli -17927-sayili-resmi-gazete---kopyapdf.pdf Accessed

March 26, 2023.