Ethical issues in Nursing

ethic_in_nursing_the_way_forward_1-1 ethical_aspect_of_withdrawing_2 prognostic_conflict_at_the_end_of_life_3
 Article Summary: select a minimum of 3 journal articles from professional journals related to Ethical issues in Nursing and write a 5 page article review. Articles must be less than 5 years old and be turned in with the paper.

art & science ethical decision-making: 7

Ethics in nursing: the way forward
Chaloner C (2007) Ethics in nursing: the way forward. Nursing Standard. 21, 38, 40-41.
Date of acceptance: April 27 2007.

Summary
This series of articles has been developed with the intention of
increasing nurses’ awareness of ethics and ethical decision-making
and clarifying the relationship between ethical thinking and effective
nursing practice. A number of issues have been examined fo show
how efhics affects fhe professional role, buf many ofher clinical and
non-clinical aspects of nursing demand ethical exploration. In the
final article in the series, the relevance of ethics to effective nursing
is emphasised and suggestions for enhancing fhe integration of
ethical decision-making into practice are made.

Author
Chris Chaloner is ethics adviser. Royal College of Nursing, London.
Email: chris.chaloner@rcn.org.uk

Keywords
Ethics; Nursing: philosophy; Nursing: profession

These keywords are based on the subject headings from the British
Nursing Index. This article has been subject to double-blind review.
For author and research article guidelines visit the Nursing Standard
home page at www.nursing-standai-d.co.uk. For related articles
visit our online archive and search using the keywords.

The relevance of ethics

Ethics is as relevant to the ordinary activities of life
as to the extraordinary. Although this series has
focused on topics such as euthanasia and abortion,
it should be emphasised that ethics is not
concerned solely with determining the rights and
wrongs of such sensitive and contentious subjects.
Despite their tendency to generate vociferous
public debate, the critical exploration ofthe ‘big
issues’ is a relatively minor feature of professional
ethics. However, critical expositions ofthe ethical
aspects of health care tend to focus on the more
sensational issues and overlook the less exciting
elements of professional practice. For example, the
motivations of individual nurses, their beliefs and
attitudes towards their work are significant factors
in establishing the ethical characteristics of
nursing. A critical consideration of how and why a
nurse conducts him or herself in carrying out his or
her role is as helpful to evaluating the ethical
validity of professional practice as an investigation
into, for example, the rights and wrongs of
therapeutic human cloning or face transplants.

THE NATURE of the nurse-patient relationship,
in which respect, confidence and privacy have
important roles, demands that nurses consider
the ethical nature of their actions. A fundamental
feature of effective professional practice is the
ability to reflect on the ethical issues nurses
encounter on a daily basis. The articles in this
series have provided an overview of ethics and
ethical decision-making by exploring a number of
topics in the context of ethical analysis. The belief
that ethics, critical ethical thinking and decision-
making are relevant to all aspects of professional
– and personal – life has been emphasised.

As noted in the first article, some nurses may
regard ethics as a remote concept that is of little
practical value and associate it with theories and
guidelines that have no immediate relevance to
their role (Chaloner 2007). The series aimed to
address these misconceptions and show how
ethical analysis and decision-making contribute
to everyday practice.

Other important ethical issues __ __

The inherent limitations of a short ethics series ha ve
meant that only a few issues have been addressed.
As has been emphasised throughout, critical ethical
thinking can, and should, be applied to all aspects of
the professional role and, consequently, the scope
for ethical analysis is limitless. For example, issues
such as genetics, mental health, care of older people
and public health generate a broad range of specific
ethical questions. Individually, each of these topics
provides a basis for extensive ethical debate.

In addition to addressing everyday practice-
based ethical decisions, nurses are increasingly
being called on to contribute to wider ethical
debates on issues affecting health care, nationally
and globally. The ethical basis of strategic planning
and health policy development must be informed
by contributions from the nursing profession.

The future

4 0 may 30 ;: vol 21 no 38 :: 2007

As this series has demonstrated, the impact of
ethics and ethical decision-making on professional

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practice is being increasingly recognised. Raised
ethical awareness and seemingly unceasing
technological and social developments mean that
the range and complexity of ethical issues that
nurses and their colleagues should respond to will
increase, emphasising the need for enhanced
ethical sensitivity and reasoning skills. In recent
years ethics has become an established element of
professional education programmes and this will
hopefully produce increasingly analytical and
ethically inquisitive health professionals.

Final thoughts

To promote the successful integration of ethical
decision-making into nursing, it is essential that
ethics is perceived as an accessible and practical
concept. A number of preconceptions and
misconceptions persist about how and why
ethics relates to professional practice. Applying
ethics does not require a degree in philosophy or
access to a lexicon of obscure terminology, but it
does require thought and rationality. It is perhaps
understandable, given the complexity of some of
the ethics-related literature, that some
individuals find ethics off-putting or irrelevant.

Ethics should be an ongoing feature of
professional life rather than something that is only
discussed when a problem arises. Ongoing ethical
reflection can help to make ethics more relevant
and interesting. One means of achieving this is for
educationalists and managers to take advantage
of individuals’ shared understanding of ethics:
most people hold a view on the rights and wrongs
of certain topics – even if that view is ‘I don’t know’
– and these views should be used to promote
ethical discussion and to demonstrate the process
of critical ethical analysis.

It is insufficient, in terms of applying ethics,
to mechanically adhere to the ‘rules’ of good
practice. Therefore, key ethical concepts such as
autonomy, consent and confidentiality should
be regularly examined to produce an informed
appreciation of why the generally accepted
ethical tenets of professional practice, for
example, maintaining confidentiality, are ‘right’.

Engaging in ethical deliberation can be
challenging but it is also an enjoyable and
rewarding experience. There are no ‘right
answers’ in ethical debate, and exploring the
issues in a considered and critically informed
manner is a valuable and productive activity.

Conclusion ^ _ _

This series has examined some key ethical issues
and established that ethics and critical ethical
thinking are fundamental aspects of nursing. The
primary objectives ofthe series have been to
encourage nurses to apply ethics to their work

and to contribute to the de-mystification
of a subject that many consider confusing,
off-putting or irrelevant.

By examining the ethical features of some of
the ‘big issues’, it has been possible to explore the
nature of ethics and the ways in which ethics and
professional practice may be aligned. The series
has demonstrated that clinical competence
demands effective ethical decision-making and
that ethics is not a remote concept but is essential
to good nursing practice.

A range of issues that relate directly to the
day-to-day realities ofa nurse’s clinical role, and
indirectly via the processes of professional
education, management and broader strategic
developments, demand further critical ethical
input from the nursing profession. It is hoped that
this series has contributed to that undertaking NS

Reference
Chaloner C (2007) An introduction to ethics in nursing.
Nursing Standard. 21, 32, 42-46.

USEFUL RESOURCES
Books:
Ashcroft R, Lucassen A, Parker M, Verkerk M, Widdershoven G (2005)
Case Analysis in Clinical Ethics. Cambridge University Peess, Cambridge.

Brazier M (2003) Medicine, Patients and the Law. Third edition. Penguin
Books, London.

British Medical Association (2004) Medical Ethics Today: The BMA’s
Handbook of Ethics and Law. BMJ Books, London.

Garwood-Gowers A, Tingle J, Wheat K (Eds) (2005) Contemporary
Issues in Healthcare Law and Ethics. Elsevier, London.

Glover J (1977) Causing Death and Saving Lives. Penguin Books,
Harmondsworth.

Mason JK, Laurie GT (2005) Mason and McCall-Smith’s Law and
Medical Ethics. Seventh edition. Oxford University Press, Oxford.

Tingle J, Cribb A (Eds) (2002) Nursing Law and Ethics. Second edition.
Blackwell Science, Oxford.

Websites:

Bioethics Today: www.bioethics-today.org

BioethicsWeb: www.intute.ac.ul

International Philosophy of Nursing Society:

www.ipons.dundee.ac.uk/index.html

Nuffield Council on Bioethics: www.nuffieldbioethics.org

Royal College of General Practitioners Medical Ethics Portal:
www.rcgp.org.uk/collegejnformation/collegejnformation/committees/

medicaLethics_committee.aspx

The Ethox Centre: www.ethox.org.uk

The International Centre for Nursing Ethics: www.nursing-ethics.org/

UK Clinical Ethics Network: www.ethics-network.org.uk/index.htm

Wellcome Trust Biomedical Ethics: www.wellcome.ac.uk/nodel016.html

World Medical Association Ethics Unit:
www.wma.net/e/ethicsunit/index.htm

(Last accessed: May 8 2007)

NURSING STANDARD may 30 :: vol 21 no 38 :: 2007 41

art & science ethical decision-making: 2

Ethical aspects of withdrawing
and withholding treatment
Wainwright P, Gallagher A (2007) Ethical aspects of withdrawing and withholding treatment.
Nursing Standard. 21, 33, 46-50. Date of acceptance: January 18 2007.

Summary
Decisions about withdrawing and withholding treatment are
common in health care. During almost every encounter between
health professionals and patients a decision needs to be made about
treatment options. In most cases these choices do not pose any
difficulty, for example, starting antibiotics when a patient has an
infection. However, decisions not to treat, or to stop treating, raise
fundamental questions about the nature and purpose of nursing and
the ethics of end-of-life care. This article argues that nurses need to
be proactive in deciding what is nursing care and what is treatment
An ethical distinction is drawn between acts and omissions. How
this distinction relates to withdrawing and withholding treatment
will be considered. Further ethical issues discussed relate to
judgements about the futility of treatment, patient autonomy and
nurses’ duty of care to patients at the end of life.

Authors
Paul Wainwright is professor of nursing, and Ann Gallagher is
senior research fellow, Kingston University and St George’s
University of London, Kingston upon Thames, Surrey.
Email: p.wainwright@hscs.sgul.ac.uk

Keywords
Ethics; Euthanasia; Law; Nursing: care; Nutrition and diet;
Right to die

These keywords are based on the subject headings from the British
Nursing Index. This article has been subject to double-blind review.
For author and research article guidelines visit the Nursing Standard
home page at www.nursing-standard.co.ui<. For related articles visit our online archive and search using the keywords.

ACCORDING TO WARNOCK (2006):
‘Considering that all men are mortal, we are
curiously unwilling to acknowledge that death,
our inevitable fate, should not always be
postponed.’ One of the main aims of healthcare
professionals is to provide curative treatment.
Many people enter the healthcare professions
because they want to make a contribution to
society by helping those in distress and relieving
suffering. As the British Medical Association
(BMA 2005) states: ‘The primary goal of
medicine is still seen as being to benefit the patient
by restoring or maintaining the patient’s health as

far as possible.’ While it is accepted that this is not
always possible, the overriding purpose of health
care is to try to make people better.

Over the past 20 years, the emphasis in UK
health policy has been on what is termed ‘health
gain’. Effectiveness of health care is measured in
terms of reduction in disease and extension of life.
Economists evaluate cost-effectiveness of
treatments with reference to how well a treatment
relieves a condition and for how long (Malek
2003). Medicine’s fixation on curing is often
contrasted with the nursing role of caring.
However, in reality, the division is not so clear-cut.

Before discussing the ethical aspects of
withdrawing and withholding treatment, this
article explores the relationship between care,
viewed as the primary preoccupation of nurses,
and treatment, arguably the main focus of a cure-
oriented medical profession.

Care and treatment

Tony Bland was a football fan who was injured in
the Hillsborough stadium disaster on April 15
1989. He suffered brain damage as a result of
oxygen deprivation and was left in a persistent
vegetative state (PVS). His family requested that
his feeding tubes be removed. Airedale NHS
Trust, fearing criminal proceedings if the patient
was allowed to die in such a way, sought a ruling
from the courts. Given the seriousness of the
decision the case was taken to the House of Lords.

On February 4 1993, the Law Lords ruled,
three years after insertion, that Tony Bland’s
feeding tubes could lawfully be removed (BBC
News 2007). The ruling was as follows: ‘Although
it is unlawful for a doctor to do a positive act to
bring about a patient’s death, the discontinuance
of life-support treatment is an omission which is
lawful when such treatment is futile because the
patient is unconscious and there is no prospect of
any improvement and discontinuance is in
accordance with responsible body of medical
opinion’ (Airedale NHS Trust v Bland [1993J).

This ruling has ethical significance for three
reasons:

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• The provision of nutrition and hydration was
categorised as a medical treatment that could
be withdrawn, rather than as nursing care that
must be provided.

• It was concluded that it is not necessary to
continue with treatment considered ‘futile’.

• A distinction was made between acts and
omissions.

The second and third issues will be discussed
later in the article. First it is necessary to consider
the difference between ‘treatment’ and ‘care’ and
why it is of ethical importance.
Differences between treatment and care The
BMA guidelines on withholding and withdrawing
treatment (BMA 2005) describe the objective of
medicine as being to benefit the patient and to act
in the patient’s best interests. Thus, the medical
justification for using a treatment is that it is of
benefit. If a treatment will not be beneficial and
therefore is not in a patient’s best interests, it
should not be used or it should be withdrawn.

There is a clear ethical defence for this stance.
Treatments are costly and resources should not
be wasted (a utilitarian defence based on a
weighing up of benefits and burdens (Beauchamp
and Childress 2001)). Also, some treatments
have side effects which can be serious and
unpleasant. Patients should not be exposed to
risk or extra suffering unless there is a reasonable
expectation of a proportionate benefit (this
defence is based on the principle of beneficence,
meaning doing good and promoting benefit
(Beauchamp and Childress 2001)). Suffering
should not be caused without good reason
(a defence based on the principle of non-
maleficence, that is, do no harm (Beauchamp and
Childress 2001)).

Care is considered to be the raison d’etre of
nursing. It is what nurses do, a view reinforced by
the frequency with which we use phrases such as
‘nursing care’and ‘quality of care’. However, it is
a complex concept and over the decades a large
amount of literature has grappled with it.

As van Hooft (2006) states: ‘A great deal of
writing about the professional life of nurses
stresses the concept of caring. It has become
almost traditional to distinguish the role of the
medical practitioner from that ofthe nurse by
saying that the former seeks to cure the patient
while the latter cares for him or her. Even though
warnings have been sounded that this distinction
between caring and curing may be an ideological
cover for the historically contingent nurse-doctor
distinction and that it is improperly based on
gender distinctions, it seems clear that there is a
role for caring in therapy even if the question as
to who exercises that role might receive different
answers at different times.’

There tends to be agreement about what
counts as caring activities, for example, assisting
someone to wash or dress, but less agreement
about activities at the boundaries of care and
treatment. The provision of nourishment is
generally considered to be a caring activity, for
example, from a parent to a child. However, in
the Tony Bland case, the giving of food and fluids
was deemed to be a treatment that could be
withdrawn. A distinction was made between
nutrition and hydration taken orally and that
given by other means, for example, via a
nasogastric or gastrostomy tube.

Reluctance to withdraw oral nutrition and
hydration is reflected in guidance concerning
so-called ‘living wills’, more accurately referred
to as advance statements or advance refusals
(BMA 1995). The BMA (1995), in its Code of
Practice on advance statements, states: ‘Advance
statements refusing basic care and maintenance
ofan incompetent person’s comfort should not,
as a matter of public policy, be binding on care
providers. Although the law on this matter is not
free from doubt, this code provides that people
should not be able to refuse basic care in advance
or instruct others to refuse it on their behalf.
Personal autonomy, which refers to a person’s
ability to be self-governing and to make decisions
(Beauchamp and Childress 2001), although
important, cannot always be an overriding
ethical principle. In most situations, the
individual’s right to refuse treatment outweighs
any competing interests, including the wishes of
other people. In exceptional circumstances, the
individual’s choice has unacceptable
consequences, such as potentially serious harm
for others which is sufficient to outweigh the
patient’s right of refusal. Others may be harmed
if refusal of basic care leads, for example, to the
spread of infection.’

Similarly, the Alzheimer’s Society (2002)
states that advance statements cannot be used by
people to:

• Refuse basic nursing care that is essential for
comfort, such as washing, bathing and mouth
care.

• Refuse measures solely designed to maintain
comfort, for example, analgesia.

• Refuse the offer of food or drink by mouth.

• Demand care that the healthcare team
considers inappropriate.

• Ask for anything that is against the law such
as euthanasia and assistance in committing
suicide.

The British courts, in developing the argument
that nutrition and hydration should be defined as a
treatment and thus can be withdrawn, coined the

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art & science ethical decision-making: 2

phrase ‘artificial nutrition and hydration’ with
regard to the Bland case. This rather clumsy term
(there is nothing ‘artificial’ about nutrients or
fluids) was, it is presumed, intended to distinguish
between the more natural oral route and other
methods. In Tony Bland’s case, Lord Keith stated
that: ‘feeding and hydration are achieved
artificially by means of a nasogastric tube’
(Airedale NHS Trust V Bland 11993]).

Another distinction that could have been used
is by ‘ordinary’ and ‘extraordinary’ means.
According to Caiman (2004): ‘This concept, in
summary, states that in life-saving decisions at
the end of life only ordinary means or techniques
should be used, that is, techniques which would
be considered routine and not out ofthe ordinary.
It is clear that over the years the definition as to
what is ordinary and what is not ordinary has
changed considerably and thus the decisions to be
taken, and knowing how far one can go to
prolong life, have become more difficult.’

In the case of patients in a PVS, two questions
need to be considered: whether tube feeding
counts as extraordinary and whether the decision
relates to the end of life. Given the ease with
which tube feeding can be accomplished, the
number of patients fed by this route and the
length of time that tube feeding can keep a
patient well nourished, it hardly counts as
extraordinary. It is also debateable whether Tony
Bland was at the end of his life as he had been
maintained with relatively simple (although
heavy and demanding) care and treatment for
almost four years.

Whatever disagreement there may be about
what counts as treatment and what counts as care,
it is important for nurses to understand that they
have a professional duty to provide competent and
ethical care in all circumstances (Nursing and
Midwifery Council 2004).

Acts,omissions and ethics

Three case scenarios are outlined in Boxes 1,2
and 3.

These scenarios raise a wide range of ethical
issues about withdrawing and withholding
treatment. The doctrine of ‘acts and omissions’ is
sometimes used to help make an ethical
distinction between what people do and what
they omit to do, for example, in the case of active
and passive euthanasia. According to Glover
(1977): ‘In certain circumstances, failure to
perform an act, with certain foreseen bad
consequences of that failure, is morally less bad
than to perform a different act which has the

48 april 25 :: vol 21 no 33 :: 2007

identical foreseen bad consequences.’
Philosophers offer a range of examples that

both support and challenge the doctrine. Gibson
(1998) provides two examples in justification of
acts and omissions:

• ‘Although it might be morally permissible to
leave one injured person to die by the roadside
when hurrying to the rescue of several, it
would be outrageous to drive over a
recumbent person to reach the others in time.’

• ‘If a man who will inherit a fortune when his
father dies omits to give him the medicine
necessary for keeping him alive, this is as bad
as actively killing him.’

The Tony Bland ruling makes a legal distinction
between acts and omissions. Gibson’s examples,
however, do not provide a clear ethical distinction
between them or help us to understand the
complex issues involved in decisions about the
withdrawal and withholding of treatment.

Much appears to depend on the intention, or
culpability, ofthe person responsible for the act or
omission. You may fail to do sdmething that it is
in your power to do – for example, help an injured
person – not through malice or desire to cause
harm, but for some other reason: for example,
because you want to rescue several other people.
Driving over an injured person is a deliberate act
that appears malicious. If the person dies there
will be a direct link between your action and the
death and you would rightly be held culpable
(deserving of blame).

The example of the man who deprives his
father of medicine raises other issues. We may
feel that because it concerns his father, rather
than a stranger, this has a bearing on the matter
as we have certain obligations to our parents.
Not giving medication, for example, insulin for a
patient who has diabetes, results in rising blood
sugar, ketoacidosis, unconsciousness and death.

If the son’s father was on insulin and if the son
were to replace the contents of the insulin bottle
with water, he is clearly acting with intent.

If he had gone out in the morning and had
forgotten to give his father the insulin, the son
would be filled with remorse and might be
criticised and even accused of negligence or neglect.
However, the blame attached to him would not be
the same as if he had acted deliberately.

In the first scenario (Box 1), the registrar has
taken a unilateral decision to withhold (an
omission) from Devi what has been described by
Johnstone’s definition as an aggressive treatment,
that is, cardiopulmonary resuscitation. Whether
an omission in care is better or worse than ending
Devi’s life by a particular action does not capture
all ofthe relevant ethical issues, for example, the
likely clinical outcome, Devi’s wishes

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(autonomy) (BMAef a/2001). Guidance from
the General Medical Gouncil (GMC) highlights
the importance of respecting the decision-
making ability of competent adult patients and
how the decision might contribute to their
quality of life (GMG 2006).

The second scenario (Box 2) is based on an
actual case (Gassidy 1994, Rowe 1994). It supports
the idea that practitioners are as accountable for
their omissions as for their actions. It might be
concluded that the nurse’s action, turning off the
ventilator alarm and not remaining with Marie,.
allowed the patient to die. The ethical implications
and consequences of both the actions and
omissions in this case require equal consideration.

The third scenario (Box 3) is similar to that of
Tony Bland. As with other cases, the distinction
between acts and omissions is not the most
helpful ethical aspect of the case. Here the team
referred to ‘futility’, which will be discussed in
the next section.

Futility and hope

The aim of health care is to extend or prolong
life. Therefore, clinicians prefer to provide active
treatment rather than doing nothing. Once
treatment has been started it is difficult to stop
and admit defeat. The families and friends of a
patient want him or her to get better and may
find it hard to accept that the situation is
hopeless. This is not a new phenomenon.
Florence Nightingale once commented: ‘I really
believe there is scarcely a greater worry which
invalids have to endure than the incurable hopes
of their friends. I would appeal most seriously to
all friends, visitors, and attendants ofthe sick to
leave off this practice of attempting to cheer the
sick by making light of their danger and by
exaggerating their probabilities of recovery’
(Nightingale 1969).

Nightingale refers to ‘the incurable hopes of
their friends’; in this context health professionals
could be considered ‘hopeful friends’.
Psychologically and ethically, health professionals
and the public are not well equipped for failure
and death is, typically, seen as failure. While
people may campaign for euthanasia or assisted
suicide, many also fight to ensure that they, or their
loved ones, receive every possible treatment, as
demonstrated by a succession of higli-profile court
cases. Even when medical professionals and the
family agree that a patient should be allowed to
die, permission may have to be obtained from the
courts to withdraw life-sustaining care, such as
nutrition and hydration.

In the third scenario (Box 3), reference was
made to the term ‘futile’. Johnstone (2004) notes
that the word comes from futilis, the Latin for
‘worthless’. The concept of ‘medical futility’ is

Scenario 1

Devi is a 75-year-old and has been admitted to a
medical ward following an episode of chest pain and
difficulty in breathing. She is a smoker and has
long-standing hypertension. Following an initial
assessment by the ward registrar nurses are informed
that Devi is not for resuscitation.

Scenario 2

Marie has emphysema and has been connected to a
ventilator for eight years. She asks nursing staff to turn
off her ventilator saying that she feels that she has a
‘poor quality of life’ and does not want to continue in
such a way. One of the nurses, following what she says
are the instructions of a consultant, turns off Marie’s
ventilator alarm. Marie disconnects her ventilator when
the nurse leaves and dies soon afterwards. Her partner
had not been involved in the decision.

Scenario 3

Denis was involved in a car accident and has been on a
ventilator in the intensive care unit for the past 11
months. He has sustained multiple trauma and has
severe head injuries. He has not regained
consciousness. The ward team concludes that
continuing with ventilation, nutrition and hydration is
‘futile’. They discuss the situation with Denis’s family
and it is agreed that treatment should be withdrawn.

generally taken to refer to treatment that ‘fails to
achieve the goals of medicine’ and which does not
benefit the patient. Johnstone (2004) points out
that ‘medical futility’ was first debated in the
1980s and was primarily an attempt to engage the
public in a debate about policy – relating a doctor’s
clinical judgement and skill to determining the
usefulness or futility of certain treatments.

Given the uncertainties that surround
everyday healthcare practice, assessments or
judgements of medical.futility are not as
straightforward as they may first appear.
Questions of prognosis and predictions of
survival arid eventual quality of life are difficult
and frequently turn out to be inaccurate.
Judgements about the futility of treatments are
made by patients, families, professionals and, in
the case of Tony Bland,’ lawyers. Such judgements
cannot be made about nursing care.

The definition and purpose of nursing, as
expressed by the Royal Gollege of Nursing
(2003), are as follows:

• Definition: ‘The use of clinical judgement in
the provision of care to enable people to

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art & science ethical decision-making: 2

improve, maintain, or recover health, to cope
with health problems, and to achieve the best
possible quality of life, whatever their disease
or disability, until death.’

• Purpose:’… to promote health, healing,
growth and development, and to prevent
disease, illness, injury and disability. When
people become ill or disabled, the purpose of
nursing is, in addition, to minimise distress
and suffering, and to enable people to
understand and cope with their disease or
disability, its treatment and its consequences.
When death is inevitable, the purpose of
nursing is to maintain the best possible quality
of life until its end.’

Nursing care extends beyond curative treatment
and contributes to the patient’s quality of life,
whether the prognosis is good or poor, and
whether treatment is provided, withheld or
withdrawn. It might also be argued that
accepting the rationale for the withdrawal or
withholding of treatment does not mean that all
hope is lost. Rather, as Toombs (2002) writes:
‘The possibility and necessity for choice is an
integral part of the dynamics of hope. For those

with incurable illness the choice between hope
and despair is a choice that must be made not
once but every day. Hope cannot primarily be
related to cure of disease. Nevertheless, to be
seriously and incurably ill is not to be hopeless.
Hope relates, rather, to the ability to face
forthrightly and with courage whatever comes
one’s way. Hope is tempered with flexibility, a
willingness to remain open to the possibilities of
different ways of being in the world.’

Nurses play a significant role in helping
patients to have hope and to confront the
challenges that come with incurable illness by
providing support and skilled companionship
(Campbell 1984).

Conclusion

Nurses have a key role in decisions about the
withholding and withdrawal of treatment. Their
duty of care extends to their omissions as well as
their actions. There are circumstances when
treatment will be considered futile. However, it is
never the case that nursing care is futile. Nursing
care extends beyond treatment contributing to
enhancing the patient’s comfort and quality of
life, whatever the prognosis. This is not always
easy and sometimes requires courage, resilience,
discernment and a commitment to consider all
points ofview and the goals of nursing NS

References

Airedale NHS Trust v Bland
[1993] 1 All ER 8 2 1 (HL).

Alzheimer’s Society (2002) After
the Diagnosis: Future Medicai
Treatment: Advance Statements
and Advance Directives or Living
Wiiis. www.al2heimers.0rg.uk/
After_diagnosis/Plaiining_for_the
_future/info_livingwills.htm (Last

accessed: March 3 0 2007)

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PRACTICE OF EXPERT CRITICAL CARE NURSES IN SITUATIONS OF PROGNOSTIC CONFLICT …
Catherine McBride Robichaux; Angela P Clark
American Journal of Critical Care; Sep 2006; 15, 5; Career and Technical Education
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