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NU 6053 Nursing Question: One case of nursing ethical dilemma that I know is not related to my experience, but my friend(mahima) had one incident, when she was confronted with a male patient, named Bobby. Bobby was a 24 year old student who wanted physician assisted suicide as he was extremely depressed. After working extremely hard, he was unable to get the proper grades and he had no job. His parents had died in a car crash a year ago . Hence, bobby to end all the suffering in his life, wanted a PAS and that is when I was confronted with an ethical dilemma. In many states of the United States, physician assisted death is illegal and even in states that it is legal, it is considered highly unethical. Physician assisted suicide is when a person intentionally kills themselves with the aid of someone who provides the knowledge or the means to do so. In states that it is legal, doctors provide the medication but the patient has to administer the drug themselves. Suicide isn’t legal and many claim that if someone wants to make a decision to end their life, it should be respected. However, due to this issue being an ethical slippery slope, the main condition for PAS is that the patient has to be terminally ill and the doctors believe that they have less than six months to live. Even though Bobby was not terminally ill, he was adamant on it and was requesting either my friend’s help in the matter or taking things into his own hands. He would have committed suicide himself but wanted a harmless way of doing it. As this was unethical, mahima decided to talk to Bobby regarding his problems and advised him to go for therapy for a month to see if things get better.  After much consideration, he understood and went for therapy. Therapy was a successful step and after a few months, bobby was able to get his life in order.. Answer: Ethics in Nursing and Healthcare, imply the presence of certain guidelines of conduct or expectations from nurses, concerning the performance of duties which are morally correct or incorrect (Kangasniemi, Pakkanen and Korhonen 2015). The ethical principles highlighted in this report will be based on the ethical dilemmas which arose, based on the previous case incident of physician assisted suicide. The case study according to which the various ethical principles and dilemmas will be discussed, will be that of Bobby, who wished to end his life by physician assisted suicide since he was extremely depressed about the death of his parents, his poor academic performance and his status of unemployment. Physician Assisted Suicide: Ethical Dilemma The concept of physician assisted suicide implies that an individual is willing to end his life, with however, the aid of a healthcare professional. Physician assisted suicide is considered to be legal in very few nations, upon confirmation that a person’s disease condition is of considerable severity, and hence, is justified of termination (Emanuel et al. 2016). Physician assisted suicide (PAS) continues to remain illegal in most countries of the world since it leads to the emergence of key ethical dilemmas. The prevalence of prolonged detrimental suffering due to a ‘terminal illness’, serves as a key justification for Physician Assisted Suicide (PAS) (Quill, Arnold and Youngner 2017).  However, with consideration of the chosen case incident of Bobby, there is an absence of any such severe illness, hence raising an ethical dilemma, despite the presence of the patient’s request. The ethical dilemmas associated with Bobby’s case are associated with a violation of nursing Code of Ethics, as well as the present impaired decision making skills of Bobby. While Bobby was free from any form of terminal illness – a health condition found prevalently associated with a request for PAS – he was suffering from depression, which considerably affected his decision making skills (Samborska and Roiser 2016). Bobby’s reduced capacity in terms of decision making was assessed as per the 4 elements highlighted in the Assisted Decision Making Act of 2015 in Ireland. According to these elements, while Bobby was able to communicate his decisions of PAS as well as understand and retain the information required to undertake PAS, he was clearly unable to weigh the consequences of his decisions and the context in which he was applying PAS (University of Limerick 2019). This could be observed in Bobby’s constant requests to my friend Mahima to assist him in PAS and that he had already been preoccupied with suicidal thoughts for a considerable period of time. Indeed, as researched by Kodish et al. (2016), depression has been associated with a loss of interest in pleasurable activities along with increased contemplation to end one’s life. While, in criticism, it also must be considered that appropriate psychotherapeutic interventions are beneficial in altering such thoughts, which was exactly what my friend Mahima requested to Bobby (Gustavson et al. 2016). Hence, while depression associated suicidal thoughts and impaired decision making skills which have prompted Bobby to opt for PAS are treatable, an ethical dilemma is raised since patient autonomy is also a key ethic which must be considered by physicians and healthcare organizations (Spence et al. 2017) In criticism however, as per the Code of Ethics presented by the American Medical Association (2016), implementation of PAS is strictly prohibited since it is indicative of the lack of compliance with the role of healing by the healthcare practitioner (Emmanuel et al. 2016). Further, administration of PAS may pave the way for its unrestricted use in the future resulting in a possible social risk such as misinterpretation by patients and families (Goligher et al. 2017). Hence, despite Bobby’s requests and depression, the above considerations will significantly impact his case since Bobby’s nurse and physicians will not only be required to immediately address his wishes to end his life, but will also need to ensure positive health outcomes and improved management of such cases in the future. Discussion Nursing Principle Appropriate and Relevant to the Case Incident Considering the situation of physician assisted suicide in accordance to the case incidence of Bobby, discussed previously, the nursing ethical principles of Paternalism, Autonomy and Beneficence must be considered. As stated by Vasli et al. (2015), ‘Paternalism’, allows nurses to perform specific duties, treatments or services upon the patient, which is for the purpose aiding him or her in the achievement of good health and recovery, without however, granting the liberty of the patient to take autonomous decisions, mainly due to reduced capacity or health literacy of the patient. In a situation where a patient is refusing to understand that PAS is illegal coupled with a mental health condition which is impairing the patient’s ability to take rational deisions, the nurses and  associated health care  practitioners, may need to consider paternalism and hence, exercise treatments without granting patient autonomy and the liberty to take decisions (Sullivan and Taylor 2018). Paternalism will be administered here for the sake of benefit of patient, which in this case, is the avoidance of taking one’s life. Hence, for the sake of benefit to Bobby’s health, the nurse must prevent him from undertaking PAS and strictly confer treatment options, by going against his wishes – considering his limited knowledge of health and what may be good for him, as compared to a healthcare  professional like the  nurse (Varelius and Cholbi 2015).  However, as researched by Pope Hough and Chase (2016), the low levels of health literacy in the patient, along with the presence of complex needs and disease conditions, nurses are generally advised to engage in paternalism with empathy, compassion and respect. Hence, in Bobby’s case, the nurse must gently persuade and educate Bobby on the fact that PAS cannot be administered since it is illegal. The nurse must also empathetically interact with Bobby on the fact there are other fulfilling ways to resolve his depression or that he may undertake a mental health assessment first, so that Bobby regains confidence and also feels dignified and respected. Hence, considering the patient as the central focus of healthcare and treatment, nurses must adhere to the ethical principle of autonomy. Autonomy implies that every patient possess unique identities and needs and hence, nurses must be respectful towards these personal preferences of patients, irrespective of their lack of compliance or disagreement with the opinions of the nurse (Janton 2016). Considering the same, nurses are advised to undertake patient centered and shared decision making and hence, administer therapeutic interventions or nursing decisions as per the preferences of the patient and allow the patient autonomy to voice his or her concerns without being judged (Hess et al. 2015). Hence, in case of Bobby, while the nurse cannot grant him PAS, she can certainly allow Bobby to share his thoughts on what compelled him to take this step and interact with him regarding his lived experiences or family history. She can also adhere to principles of beneficence and non-maleficence by assisting him on considering alternative therapies for his depression resulting in improved mental health and reduced possibility of self harm (Martin and Meyer 2019). The nurse must then collaboratively discuss with his physician on the need for psychotherapy such cognitive behavioral therapies (CBT) based on Bobby’s interaction and communicate the same to Bobby for his consent to ensure patient centered decision making with however paternalism as the key ethical priority (Brian, Peterson and Rudd 2018). However, as researched by Aliyu, Adeleke and Omoniyi (2015), nurses must strive to not only treat the existing health issues in a patient, but must also prevent relapses in the patient’s health condition and ensure that the patient has sufficient self-capacity to maintain positive health outcomes. In Bobby’s case, while respecting patient centeredness, the nurse must ensure that Bobby does not relapse into his depression and consider PAS again in the future. Lack of consideration of the same will highlight an inability of the nurse to adhere to her duties as a therapeutic healer. Hence, the nurse must administer nursing interventions which will not only be beneficial to Bobby’s present mental health but will also ensure long term benefits to his mental and emotional capacities in the future (Hartwell and Gagan 2016). Hence, the key ethical principle which must be considered here is beneficence which implies that duty of the nurse to ensure benefit and recovery in the patient and is applicable to Bobby’s case since the nurse must ensure immediate improvement as well as long term maintenance of positive decision making skills in Bobby for his betterment (Sulmasy et al. 2018). As stated by Muldrew, McLaughlin and Brazil (2018), the ethical principle of beneficence states that nurses must adhere to their fundamental duty of ensuring betterment and recovery for the patient, and hence, must undertake activities aimed at ensuring the good or ‘benefit’ for the patient. Despite Bobby’s wishes for PAS in physician assisted suicide, the nurse must educate him on the fact that opting for alterative therapeutic interventions will be of much more benefit to his life and future improvement rather than PAS (Radbruch et al. 2016). This means that the nurse must also engage in interacting and communicating with Bobby on the fact that instead of PAS, psychotherapeutic treatments and their outcomes are morally and ethically correct for Bobby in terms achieving his future dreams of performing academically well as well as securing a successful career in the future, and will be beneficial for fulfilling his aspirations rather than PAS. Further, they must also patiently build a rapport with him and explain to him their own experiences and health literacy regarding positive results associated with therapy. Gentle persuasion using health literacy is a beneficial way in which paternalism can be exercise in situations of patients with impaired decision making skills who are requesting for PAS (Hermann, H., Trachsel, M. and Biller-Andorno, N., 2015). Conclusion Not only is the implementation of PAS illegal, it also raises several critical dilemmas, in terms of violation of nursing ethics and duties as therapeutic healer. The nurse must manage Bobby’s case the help of ethical principles such as autonomy, paternalism and beneficence. Along with paternalism nurses must still be empathetic and compassionate to the needs of the patient. Hence, the nurse must gently communicate and assist Bobby in exploring alternative therapies and implement the same as per Bobby’s consent. However, nursing paternalism and autonomy may not always comply to the wishes of the patient which is why, the nurse must also engage in principles of beneficence and non-maleficence and hence, educate Bobby on the fact that alternative therapies instead of PAS is most beneficial for fulfillment of his future dreams and hopes.   Reference Aliyu, D., Adeleke, I.T. and Omoniyi, S.O., 2015. Knowledge, attitude and practice of nursing ethics and law among nurses at Federal Medical Centre, Bida. American Journal of Health Research, 3(1-1), pp.32-37. Bryan, C.J., Peterson, A.L. and Rudd, M.D., 2018. Differential effects of brief CBT versus treatment as usual on posttreatment suicide attempts among groups of suicidal patients. Psychiatric services, 69(6), pp.703-709. Emanuel, E.J., Onwuteaka-Philipsen, B.D., Urwin, J.W. and Cohen, J., 2016. Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. Jama, 316(1), pp.79-90. Emanuel, E.J., Onwuteaka-Philipsen, B.D., Urwin, J.W. and Cohen, J., 2016. Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. Jama, 316(1), pp.79-90. Goligher, E.C., Ely, E.W., Sulmasy, D.P., Bakker, J., Raphael, J., Volandes, A.E., Patel, B.M., Payne, K., Hosie, A., Churchill, L. and White, D.B., 2017. Physician-assisted suicide and euthanasia in the intensive care unit: a dialogue on core ethical issues. Critical care medicine, 45(2), p.149. Gustavson, K.A., Alexopoulos, G.S., Niu, G.C., McCulloch, C., Meade, T. and Areán, P.A., 2016. Problem-solving therapy reduces suicidal ideation in depressed older adults with executive dysfunction. The American Journal of Geriatric Psychiatry, 24(1), pp.11-17. Hartwell, M. and Gagan, M., 2016. Nurse prescribers and legalising assisted suicide in the UK. Nurse Prescribing, 14(5), pp.248-251. Hermann, H., Trachsel, M. and Biller-Andorno, N., 2015. Physicians’ personal values in determining medical decision-making capacity: a survey study. Journal of medical ethics, 41(9), pp.739-744. Hess, E.P., Grudzen, C.R., Thomson, R., Raja, A.S. and Carpenter, C.R., 2015. Shared decision?making in the emergency department: respecting patient autonomy when seconds count. Academic Emergency Medicine, 22(7), pp.856-864. Jantos, M., 2016. Patient autonomy on a psychiatric ward. Archives of Psychiatry and Psychotherapy [internet], 3, pp.13-7. Kangasniemi, M., Pakkanen, P. and Korhonen, A., 2015. Professional ethics in nursing: an integrative review. Journal of advanced nursing, 71(8), pp.1744-1757. Kodish, T., Herres, J., Shearer, A., Atte, T., Fein, J. and Diamond, G., 2016. Bullying, depression, and suicide risk in a pediatric primary care sample. Crisis. Martin, B. and Meyer, E., 2019. Medical students’ perspectives on euthanasia and physician-assisted suicide and their views on legalising these practices in South Africa. SAMJ: South African Medical Journal, 109(3), pp.135-135. Muldrew, D.H., McLaughlin, D. and Brazil, K., 2018. Ethical issues experienced during palliative care provision in nursing homes. Nursing ethics, p.0969733018779218. Paterson, C., 2017. Assisted suicide and euthanasia: a natural law ethics approach. Routledge. Pope, B., Hough, M.C. and Chase, S., 2016. Ethics in community nursing. Online Journal of Health Ethics, 12(2), p.3. Quill, T.E., Arnold, R.M. and Youngner, S.J., 2017. Physician-Assisted Suicide: Finding a Path Forward in a Changing Legal Environment. Annals of internal medicine, 167(8), pp.597-598. Radbruch, L., Leget, C., Bahr, P., Müller-Busch, C., Ellershaw, J., De Conno, F., Vanden Berghe, P. and board members of the EAPC, 2016. Euthanasia and physician-assisted suicide: a white paper from the European Association for Palliative Care. Palliative medicine, 30(2), pp.104-116. Samborska, V. and Roiser, J., 2016. Effort and reward based decision making in individuals at high risk of depression. Opera Medica et Physiologica, (S1). Spence, R.A., Blanke, C.D., Keating, T.J. and Taylor, L.P., 2017. Responding to patient requests for hastened death: Physician aid in dying and the clinical oncologist. Journal of oncology practice, 13(10), pp.693-699. Sullivan, D.M. and Taylor, R.M., 2018. The Ethical Landscape of Assisted Suicide: A Balanced Analysis. Ethics & Medicine, 34(1), pp.49-3. Sulmasy, D.P., Finlay, I., Fitzgerald, F., Foley, K., Payne, R. and Siegler, M., 2018. Physician-Assisted Suicide: Why Neutrality by Organized Medicine Is Neither Neutral Nor Appropriate. Journal of general internal medicine, pp.1-6. University of Limerick (2019). The Assisted Decision-Making (Capacity) Act 2015: Interpretation and Practical Application. [online]  Varelius, J. and Cholbi, M., 2015. New Directions in the Ethics of Assisted Suicide and Euthanasia. Vasli, P., Dehghan-Nayeri, N., Borim-Nezhad, L. and Vedadhir, A., 2015. Dominance of paternalism on family-centered care in the Pediatric Intensive Care Unit (PICU): an ethnographic study. Issues in comprehensive pediatric nursing, 38(2), pp.118-135.

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