Ethical Issues in Long-Term Care

Ethical Issues in Long-Term Care

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Institution

Introduction

The provision of healthcare remains one of the most fundamental pillars of any nation. It goes without saying that the health of a nation comes as one of the fundamental determinants of the wealth of the economy, especially considering that only healthy people would be able to channel their energies to creating wealth. This explains the increased government investment in the healthcare sector. Needless to say, ethics play a pivotal role in enhancing the quality of services offered in healthcare institutions. This is especially in the case of long term care, where varied services that assist in meeting nonmedical, as well as medical needs of individuals who have chronic ailments or disabilities and who do not have the capacity to take care of themselves for a long time are offered. Long-term care increasingly involves the provision of a level of healthcare service that necessitates skilled practitioners’ expertise, so as to cater for the usually numerous chronic conditions that are associated with the patients. While this type of care is usually needed by senior citizens, individuals of any age may require it (Harrington & Carrillo, 1999). Ethical issues pertaining to long-term care have become quite crucial in long-term care especially thanks to the increase of the aging population. In some instances, ethical issues arising in long-term care are not unique from those in other settings. However, there exist some issues that manifest themselves in a different manner, in long-term care setting compared to other settings, or are unique or specific to long-term care settings (Harrington & Carrillo, 1999). The uniqueness of these issues underlines the significance of examining ethics pertaining to long term care. It goes without saying that the incorporation of ethics in healthcare facilities or in offering long-term care has a positive impact on the quality of services offered in such facilities.

On varied occasions, however, the ethics outlined in the code of ethics seem to contradict each other. This paper will examine the contradiction that revolves around beneficence and non-malfeasance, autonomy, and truth-telling. Questions have been raised about the importance of ethics in long-term care. There exists varied factors that distinguish this environment from others. First, long-term care patients currently have the capacity to choose from varied invasive procedures that were previously availed to acute care patients. The choices come with complex questions pertaining to care options. In the past, there existed no requirement that healthcare staffs have the skills to provide these services, whereas long-term care workers are now required to be proficient in them. On the same note, the long-term environment is distinguished by the problematic decision-making that may result from the situation in which numerous patients find themselves. It is worth noting that residents of long-term care settings remain there for extended periods. In addition, the population is quite large and diverse, with a large number of them not incorporating the mental faculties that are required to making sound health decisions. In such situations, family members and other concerned parties want to be part of the decision makers for the healthcare of the patients. On the other hand, healthcare professionals are not only in close attendance but also concentrate on the medical model of care. Needless to say, there exist varied forces trying to determine the most appropriate care for the patients, which complicate the capacity to determine the appropriate course of action. In such scenarios, decisions pertaining to the healthcare services that will be availed to the patients are determined by the ethics in light of the ethical features pertaining to an individual case.

While there are numerous ethical issues pertaining to long-term care, none comes with the controversy that is prevalent with the issue of truth-telling. The controversy surrounding full disclosure of diagnosis is compounded by the ambiguousness or equivocal nature of the guidelines or the code of medical ethics (Pratt, 2004). It is worth noting that the Hippocratic Oath does not incorporate an explicit statement pertaining to telling the truth. There is a conflict between demands that are difficult to reconcile. On one hand, physicians are expected to practice their art with holiness and purity, in which case veracity would have to be incorporated. On the other hand, the physicians are expected to follow only that regimen or system that, in their view, would be beneficial to the patients while abstaining from things that would be seen as mischievous and deleterious (Pratt, 2004). According to the International Code of Medical Ethics, a physician is required to be honest with his or her colleagues and patients, a matter that mainly concerns professional conduct and competence and not telling patients the things that are wrong with them. The World Medical Association also stated that the patient is entitled to the right to refuse or accept treatment once he has sufficient information. This seems to underline truth-telling pertaining to diagnosis not as a requirement to one’s choice of treatment but rather a mere prerequisite. In addition, the World Psychiatric Association stated that the physician must give the patient information pertaining to the condition from which he is suffering, the possible procedures and their alternatives, as well as any possible outcomes. They also stress the fact that, such information must be offered  or provided in a considerate manner with the patient being given provided an opportunity to select between the available and appropriate techniques. This statement, however, does not clarify on whether the physician is obligated to offer information in instances where the ailment does not have any treatment. There is also ambiguity on how truthful the “considerate way” is supposed to be. Nevertheless, it is recommended that physicians provide patients with the information that they seek pertaining to their condition, possible treatment, as well as prognosis in a manner that they can comprehend. There are varied pros to telling the truth. Truth is recognized as the fundamental basis for informed consent. It is well acknowledged that the patient must have full knowledge of their condition so that they can give consent. This is the same case for respect for the patient’s autonomy, where it is acknowledged that deceit is a breach to the person’s autonomy. Patients are incapable of making valid decisions unless they have full information. In addition, truth-telling comes as one of the ways of enhancing trust in the relationship between the physician and the patient. It is worth noting that concealment of information must be continued even if it was done with honorable intentions. Its continued use may easily result in harm and abuse of individuals who are not sufficiently fit to be informed by individuals who have the capacity to manipulate them in line with their own beliefs and needs (Agich, 1993). Truth telling is also an acknowledgement of the reciprocal fidelity, promise keeping and obligations. Social contracts revolve around mutual obligations and rights. The contract, in therapy, revolves around the health of the patient in which case it must incorporate the entitlement to honest information pertaining to prognosis and diagnosis.

Another set of ethics that are controversial in long-term care are beneficence and non-maleficence. Beneficence revolves around balancing the benefits that come with a certain treatment against the costs and risks that the treatment poses. Non-maleficence, on the other hand, revolves around avoidance of causing harm. Non-maleficence implies that the benefits of a certain treatment must supersede the harm, considering that every treatment involves a certain degree of harm (White & Truax, 2007). However, it is worth noting that respect for these two principles may in some circumstances mean failure to respect an individual’s autonomy, which is also an ethic in long-term care. For instance, a patient may have take on a certain form of treatment so as to hinder the development of another serious health problem (White & Truax, 2007). This treatment may be painful, uncomfortable, as well as unpleasant but may be less harmful to the patient than failure to take it. In instances where the patient does not have the legal competence to come up with a decision, the medical staff is required to act in the patient’s best interests through considering the two principles (White & Truax, 2007). It would, however, be helpful for the physicians if the patient had made a directive in advance. Even in such instances, however, problems arise in cases where the advance directive is in conflict of what the physician may see as the patient’s best interests, especially in instances where there is no clarity as to whether the individuals would still have chosen the same directive that he or she had made (MacCullough, 1995). This was the situation in a case where a doctor carried out blood transfusion to a woman who would otherwise had not survived. Unfortunately, the woman had a directive that her religion does not allow blood transfusion, in which case she successfully sued the physician (White & Truax, 2007). While it may be thought that catering for the patient’s best interests is the in-thing, the last few decades have seen a change in focus towards autonomy for the patient, with the patient or resident obtaining an active role in decisions pertaining to his or her treatment.

Autonomy is also one of the controversial ethics in long-term care. This ethic is based on an individual’s capacity to direct his life in line with rational principles. Autonomous individuals are seen as ends to themselves considering that they are able to determine their destiny, which essentially has to be respected. The concept of respecting the patients’ autonomy revolves around the capacity of an individual to think, make a decision, as well as act based on that decision and thought in an independent and free manner (Kayser-Jones et al, 2003). This concept is to be exercised as long as the action would not harm other people. Scholars note, that the patient is morally entitled to refuse medical treatment and the physician has to refrain from making any intervention against the wishes of the patient. In the past, it was believed that the prevention of individuals from harming themselves in cases where their action is not fully informed is acceptable. Today, autonomous decision is seen as on that is made without undue pressure by a competent individual who knows and understands the relevant information required for making such a decision. Self determination has been a fundamental principle in long-term care and the general healthcare sector (Buppert, 2004). It has been gradually moving towards a considerably individualistic and client-centered approach rather than the paternalistic approach. In this case, the patient plays a considerably more active role in his wellbeing and health, taking responsibility for their decisions, as well as bearing the consequences of their choices (Kayser-Jones et al, 2003). Some scholars, however, think that autonomy should be relegated to the sidelines. For instance, as much as the Danish Council of Ethics acknowledges the importance of allowing individuals to be responsible for their own lives and decisions, it notes that personal autonomy is founded on extreme individualism, a viewpoint that eliminates the focus from the fact that individuals are influenced and are dependent on other people. Every person is a product of his interactions with other people and history (Kayser-Jones et al, 2003). In essence, self-determination and autonomy, while protecting the patients from abuse and allowing them to be active in making decisions pertaining to their health, have to be incorporated alongside other principles such as community and equity, as well as the common good.

Needless to say, ethical issues such as self-determination and autonomy, confidentiality, beneficence and non-malfeasance, and truth-telling are quite controversial. The key issue remains that most of them are always contradicting with each other. For example, the principles of non-malfeasance and beneficence sometimes may contradict with patient’s autonomy. A physician is supposed to do everything to the best interests of the patient, yet, the autonomy of the patient would limit such action (Buppert, 2004). Telling the truth is crucial in strengthening trust between the patient and the physician, yet some patients especially in long-term care may be suffering from ailments whose knowledge may jeopardize their lives. In any case, the code of ethics does not spell out the extent to which such truth should be disclosed (Harrington & Carrillo, 1999). These contradictions can only be eliminated through examining the most beneficial course of action to the patient. As much as long-term care patients may be entitled to their own autonomy, medical practitioners must act in line with the best interests of the patient. This would also apply to the case of non-malfeasance and beneficence, where the best interests of the patient would be considered. As much as it is imperative that the patient makes an informed decision, most scholars have underlined the fact that most of them do not want to know or even they do not have the capacity to comprehend this information. Healthcare practitioners should gauge the willingness of the patient to hear this information, as well as their capacity to comprehend the same before disclosing.

In conclusion, ethics form a fundamental aspect in the provision of healthcare. In long-term care, varied codes of ethics are outlined in an effort to enhance the quality of service offered to patients. However, these ethics sometimes seem to contradict each other. For example, physicians are required to act in the best interests of the patient by the principle of beneficence and non-malfeasance, something that may sometimes contradict the patient’s autonomy. This is the same case for truth-telling, as well as self-determination. While there may be varied views are expressed, I think that leaving the decision to one party would be imperative as long as the best interests of the patient are considered.

References

White, B. S., & Truax, D. (2007). The nurse practitioner in long-term care: Guidelines for clinical practice. Sudbury, Mass. ; Toronto: Jones and Bartlett.

Buppert, C (2004). The Nurse Practitioner’s business Practice and Legal Guide (2nd Ed.) Gaithersburg MD: Jones &Bartlett

Harrington, C & Carrillo, H (1999). The Regulation and Enforcement of Federal Nursing Home Standards, 1991-1997. Medical Care Research and Review, 56, 471-494

Kayser-Jones, J., Schell, E, Lyons, W., Kris, A.E., Cha, J., Beard, R.L (2003). Factors that influence end-of-life care in nursing homes: the Physical Environment, Inadequate Staffing, and Lack of Supervision. The Gerontologist, 43 (Spec No 2)

MacCullough, L. B. (1995). Long-term care decisions: Ethical and conceptual dimensions. Baltimore [u.a.: Johns Hopkins Univ. Press.

Pratt, J. R. (2004). Long-term care: Managing across the continuum. Sudbury, Mass: Jones and Bartlett.

Agich, G. J. (1993). Autonomy and long-term care. New York: Oxford Univ. Press.