Ethical Considerations in Palliative Care (RN Nursing)

Brain death is a legal and clinical term describing the irreversible cessation of all cerebral and brainstem functions, including the ability of the brain stem to regulate vegetative and respiratory activities. Brain death can be due to a variety of etiologies causing catastrophic injuries to the brain, including brain ischemia due to cardiopulmonary arrest, drugs, sepsis, and trauma. The diagnosis is made at the bedside based on the clinical context and performance of a neurological exam. Additional ancillary studies may be needed to support the diagnosis, and diagnostic criteria may vary among states and countries. A diagnosis of brain death must be established prior to consideration of organ donation.

The physician–patient relationship is an important component of health care delivery. (The terms physician and clinician will be used interchangeably here, acknowledging that other clinicians have similar relationships with patients and are bound by the same code of ethics.) Except in emergencies, before a clinician can initiate a medical or surgical intervention with a patient, a relationship of trust and empathy must exist, allowing the patient to talk about their medical issues. The clinician–patient relationship is a bond that, in many cases, requires some cultivation and may ultimately result in better outcomes. In the United States, the American Medical Association publishes a code of ethics that details the principles physicians must adhere to in providing medical care; these standards of conduct extend to the physician–patient relationship.

The term “persistent vegetative state,” also called unresponsive wakefulness, describes the condition of individuals with severe anoxic brain injury who have progressed to a state of wakefulness without any meaningful response to their environment. A persistent vegetative state is distinguished from a coma in that individuals in a persistent vegetative state have intermittent sleep–wake cycles. The individual's eyes may be open and there may be some yawning, grunting, or other vocalizations. In both cases, the individual is alive, but the brain does not function fully. Persistent vegetative state is most commonly associated with anoxic brain injury due to cardiac arrest, trauma, metabolic causes, or infections. Diagnosis is made by fulfilling specific diagnostic criteria. Treatment is controversial and ethically challenging. Recovery of consciousness from a posttraumatic persistent vegetative state is unlikely after 12 months, while recovery from a nontraumatic persistent vegetative state after 3 months is exceedingly rare.

The term advance directive (AD) refers to treatment preferences and/or the designation of a surrogate decision-maker in the event that a person becomes unable to make medical decisions on their own behalf. Advance directives represent the ethical principle of autonomy and may take the form of a living will, health care proxy, durable power of attorney for health care (DPAHC), and/or a physician’s order for life-sustaining treatment (POLST). Do not resuscitate and do not intubate orders are 2 important types of ADs.

Coma is defined as a deep state of unarousable unresponsiveness, characterized by a score of 3 points on the GCS. A comatose state can be caused by a multitude of conditions, making the precise epidemiology and prognosis of coma difficult to determine. Diagnosis is made clinically with a thorough neurologic examination, including assessment of the brain stem to evaluate for the presence of brain death. Definitive management depends on the underlying cause.

Cardiopulmonary resuscitation (CPR) is an emergency procedure used in patients with cardiac arrest. Cardiopulmonary resuscitation combines the use of chest compressions, artificial ventilation, and, when available, an automatic external defibrillator (AED) to maintain circulatory flow and oxygenation to vital structures. Cardiopulmonary resuscitation is an integral part of basic life support (BLS) and advanced cardiovascular life support (ACLS). High-quality CPR improves the likelihood of survival. Some patients in critical situations request a do not resuscitate (DNR) order, which instructs health care providers not to do CPR if a patient suffers cardiac arrest.