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Question Answered step-by-step Julia, aged 40, is a patient on a stroke unit. A massive stroke... Julia, aged 40, is a patient on a stroke unit. A massive stroke that she experienced a month ago was a major blow. She is known to be resilient and strong. For 10 years she had been living independently, in her own home, with multiple sclerosis (MS). Since the stroke she needs help with all her daily activities, including eating meals. Her suffering, she says, has gone "off the Richter scale" because she has lost all independence. She remains mentally alert and communicates clearly. An assessment by a speech pathologist concludes that Julia cannot swallow safely. An aphasic (soft food) diet is ordered. When the meal arrives and the nurse brings the food to her mouth, Julia purses her lips and tells her to stop. Julia is furious and says she will not eat the soft foods. The nurse informs her that if she eats solid foods and drinks clear liquids she will have a higher likelihood of aspirating food. One risk is that she would develop aspiration pneumonia (the result of food travelling to her lungs). Another risk is that she may choke and die when consuming regular food and drinks.Other nurses attempt to persuade Julia to take the soft food and reinforce what she has been informed about the risks. As they probe her reasons she tells them that food, coffee, and the occasional glass of wine are among the few pleasures she has left in life. To her taste, the soft diet and thickened fluids are unpalatable and she scoffs at the suggestion that the diet "is not that bad" and that eventually patients get used to it. Furthermore, she feels that the soft diet reduces her to feeling like a baby and that she loses her dignity being fed "bDuring this controversy, nurses are worried about helping Julia with her meals. They are concerned that if she aspirates when they are helping her with a regular diet, they will be held responsible for her death. They will only feed her soft foods. Julia goes on a hunger strike. Mark insists that she be force-fed through a feeding tube.The major ethical issue in this case is the conflict between Julia's wishes and preferences, on the one hand, and those of the nurses and of her partner Mark, on the other. If the nurses do as Julia wishes and feed her regular foods, she may aspirate and possibly die. However, if her hunger strike persists, she will certainly die. A secondary issue, upon which the above issue depends, concerns whether Julia has the capacity to decide, about which Mark is in disagreement not just with Julia but also with the capacity assessment and with the nurses. Patients, families, and nurses may have different views and values about what makes life valuable and worth living. Accepting or refusing food and water may have different emotional and ethical significance for different patients. Julia's nurses and her partner Mark appear to share the same values and wishes. They want to promote her well-being by reducing her risk of aspirating. Among nurses and colleagues, decisions about capacity and consent may generate heated debates focused on what patients are able to understand and appreciate. A first step was to decide whether Julia was capable of making this decision. Nurses are sensitive to the possibility that "uncooperative" patients will be labelled irrational or incapable not because of their capacity to reason but because of what they choose. Mark's position that his partner is not reasoning soundly and is irrational certainly deserves consideration. However, "irrational" is a somewhat vague and plastic term that can be code language to justify overriding a patient's decision just because the patient does not agree with clinical recommendations. It is necessary to consider the reasons that inform her decision, whether one agrees with the decision or not.aby food." Despite the efforts of the nurses to persuade her, she remains steadfast in insisting on her usual diet. Moreover, she makes it clear that if she aspirates she does not want anyone to try to save her life.Julia's partner, Mark, says that she has become unbalanced and is now a different person. Consequently, he believes that her wishes should not be respected. The nurses believe that she does have capacity, but to confirm this they ask for an assessment of Julia's capacity to decide. The capacity assessors find that she does have capacity to make decisions about nutrition and hydration. Mark rejects it, claiming that he knows his partner "better than complete strangers."Moreover, nurses no longer consider competency to be global, but instead, decision-specific and time-specific. Patients must be assessed case by case toCASE 2: QUESTIONS1. Dining and food are associated with family, cultural, and religious values and can have symbolic meaning beyond mere sustenance. Julia appears to believe that her life would not be worth living without coffee, wine, and good food. Her partner believes that her decision to choose a high-risk diet over a much safer soft diet is irrational and provesthat she lacks the capacity to decide. Do you agree with him that the decision by itself is sufficient evidence that she lacks capacity to make treatment decisions?2. Nurses are taught that family-focused care is important. They are also taught that patients have the right to make their own decisions and not be coerced by family, friends, or caregivers. Discuss the ethical tension or conflict between these two things.3. Can both the patient and the family be at the "centre" of nursing care? How would you apportion or distinguish the respective rights and responsibilities of patients, their families, and nurses in "shared decision-making."4. Discuss the experience of stress or distress that can arise when nurses participate in a plan of care freely chosen by a patient but to which they are strongly opposed. How should nurses and employers manage such stress or distress?5. Suppose that Julia goes on a hunger strike. After a week, she says she wants to die and asks for medical aid in dying. She is assessed and does not qualify. Julia decides to go home to continue not eating or drinking. Should she be permitted to go home? Health Science Science Nursing NURSING N333 Share QuestionEmailCopy link Comments (0)
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