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 Last modified March 7, 2005  

Advocating for a client's end-of-life wishes

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Q

I am a nurse in a hospital. One of my clients was admitted with pneumonia two days ago. At that time he requested everything possible be done for him. But yesterday he was diagnosed with a reoccurrence of lung cancer and told me he wanted to die. He said he is “fed up” and wants his current treatment stopped and he does not want to be resuscitated. I spoke with his physician, who wrote a No CPR (DNR) order; however, she continued the IV antibiotic therapy. What more can I do to advocate for my client?

A

Under the Health Care Consent Act, capable clients have the right to consent to or refuse treatment. Clients may also withdraw their consent at any time. Nurses have a responsibility to explore their clients’ wishes and advocate for them.

The nurse needs to understand fully the client’s values and care needs. In doing this, it is important that the nurse not impose her/his values and beliefs onto the client.

A client’s decisions about endof- life treatment and care must be knowledgeable and informed. A one-time expression by the client is insufficient evidence of informed consent, especially when it is not clear whether he understands the probable course of his illness.

In the situation you describe, you need to further explore your client’s comments and ensure he is making an informed decision. Would he feel the same if his other symptoms (e.g., shortness of breath associated with the onset of the pneumonia) were better controlled? What does he mean when he says he is “fed up”?

Depending on the client’s desire to let others know about his decision, he may also want to speak with a family member about his wishes. It is important to inquire about this and respect his wishes.

After determining the client has made an informed decision about his end-of-life care, you will want to ensure there is a consistent approach to his care. Start by documenting his wishes on the health record and discussing the plan of care with the other team members, including the physician.

When a client’s wishes are not respected, it is important to explore why. In your situation, it could be that the client expressed different wishes to the physician, or the physician believes the treatment will improve the client’s condition or increase his level of comfort.

If this is not the case, and the physician continues to contradict the client’s wishes, you will need to speak with your manager. If the matter is still unresolved, bring the concern to the attention of a higher authority in the facility until the treatment plan is changed to reflect the client’s wishes. Document all steps you take related to client care in the health care record, and follow your facility’s policy for appropriate documentation of information not directly related to client care.

If the matter is not resolved after you’ve documented your attempts to advocate for the client, you may refuse to carry out the antibiotic therapy or CPR to comply with the client’s identified wishes.

For situations like this, you may find the guideline Disagreeing with the Multidisciplinary Plan of Care useful. It is available free on the website at www.cno.org.

References

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