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Introduction - Moral Distress
The expectations of contemporary medicine to alleviate suffering and accomplish cure through the application of any medical procedure, treatment, or intervention (including artificial ventilation and pulmonary resuscitation), which sustains, restores, or supplants a spontaneous vital function has weakened individual’s control over their dying process (Trnobranski, 1996). Cessation of breathing and heart beat are no longer considered as indicators of death as advanced technology has taken credit for postponing the dying process (Tschudin, 2002). The bioethical guidelines that guide the contemporary medicine to maintain life and prevent untimely or inappropriate death; are based on the principle of beneficence (to promote well-being and welfare), the principle of nonmaleficence (to avoid harm), and the principle of patient autonomy and informed consent (to respect the patient’s wishes and requests) (Bookman & Abbot, 2006). However in many situations the patients are kept alive against their personal will, with the loss of their dignity and autonomy to determine how and when to end their lives that have been defeated by medical interventions (Preston & Kelly, 2006).

Application of Moral Distress in Nursing Practice
Nurses are frequently the primary care givers of medically hopeless patients, providing constant care, and forming therapeutic relationships with these patients and their families (Dawe, et. al., 2002). On occasion nurses are exposed to situations where conflicts of values, priorities and duties related to how far health care providers should go in their attempt to prolong the life of terminally ill patients; increases their responsibility and duty to make decisions based on ethical values and not clinical views to ensure the welfare of these patients and their families (Davis et. al., 1997). Nurses often experience moral distress as they witness the negative influence of “medical futility-a medical treatment that is seen to be non-beneficial because it is believed to offer no reasonable hope of recovery or improvement of the patient’s condition” and “inappropriate care-unnecessary suffering resulting from dehumanizing practices”, as a result of modern medicine on patient’s well-being and quality of life (Storch, et, al., 2004, p.265-266). In some instances ethical conflicts can take the form of health care providers; significantly nurses; being asked to do everything when they believe that a withdrawal of treatment is more appropriate, or they are being asked to do nothing when recovery and improvements are expected with the continuation of the treatment plan (Johnstone, 2004). Other ethical issues related to termination of life-sustaining treatment are focused on the definition of death, and how the patient, nurse and the health care team define and approach the concept with respect to cultural, social and spiritual values (Fry & Veatch, 2006). Other complex cases involve terminally ill patients who have never been competent to make a decision whether to continue or terminate their treatment or those that have never made their wishes known while competent (Fry & Veatch, 2006). Other conflicts have their roots in situations that limits to resources available do not permit the health care team to do all that is required and proposed by the competent patient or the surrogate of the incompetent patient to continue with the treatment. These cases are usually relevant to expensive or time consuming treatments that offer poor outcomes and benefits (Davis. et. al., 1997).

Advanced Directives
One of the most recent attempts in promoting patient autonomy and dignity is through “Advance directives”, which provide individuals with a method to identify their health care preferences for the event that they become incompetent to make such decisions in the future (Senate of Canada, 1995). As stated by the Senate of Canada (1995), there are two major groups of advance directives: instructional (referred to as living wills, end-of-life instructions or treatment directives in the event that they become incompetent) and proxy directives (referred to as power of attorney for health care, mandate for health care, appointment directives, substitute decision maker for health care or personal directive agent). The majority of advance directives are used to instruct health care professionals to withdraw or withhold medical treatments such as cardiopulmonary resuscitation, mechanical ventilation, dialysis, antibiotics, surgery, invasive diagnostic procedures, or artificial nutrition and hydration. However, advance directives may also be used to request medical treatment (Senate of Canada, 1995).

Do-Not Resuscitate Orders
Do-Not-Resuscitate orders, are another alternative way to involve patients in their decision making process in an attempt to avoid over-treatment in cases involving hopelessly ill patients. To resuscitate is to revive an individual from unconsciousness or apparent death. The most common form of resuscitation is cardiopulmonary resuscitation (CPR), when artificial therapy and defibrillation are administered to an individual following cardiac arrest (Johnstone, 2004). The most immediate consequence of resuscitation, assuming that it is successful, is that the individual’s life is prolonged, but for how long and with what quality? As one can conclude the quality of life is often seen to be a determining factor in making decisions regarding life-sustaining treatment but who is best to judge the patient’s quality of life? Sutcliffe & Holmes (1991) argue that no individual should make judgments about the quality of life of another person. The authors are against the ‘overbearing paternalism’ which enables one person to feel competent as a judge of the private sensations and emotions of another. Others may even argue that life should be preserved at all costs, and the sanctity of life is of paramount importance (Fry & Veatch, 2006).

Withdrawal of Life-Supporting Treatments
Dilemmas arise when decisions have to be made whether to withhold or withdrawl life supporting measures, the decision whether to initiate treatment must be considered carefully and discussion involving care givers should take place whenever possible. Therefore the ability of nurses to apply ethical theoretical frameworks and their associated ethical principles are critical in the decision making process to achieve the best results to maintain the patient’s well-being.

Ethical Theoretical Frameworks
The first theoretical framework identified in this paper is the theory of Utilitarianism. The central ethical concepts of utilitarianism are good and evil (Johnstone, 2004). Utilitarians have their roots in believing that actions are either right or wrong based on their consequences (Johnstone, 2004). Utilitarianism is only based on one principle, the principle of utility which is to maximize values and results. The goal is to promote the right act or goodness to produce the greatest good for the greatest number (Johnstone, 2004). From a utilitarian perspective, acts are evaluated not on the basis of motive, truth-telling, or individual consequences (respect for autonomy) but on their outcomes alone. Therefore while making an ethical judgment; utility considers harm and usefulness of the actions (Johnstone, 2004). Many utilitarians believe that that the concept of utility refers to maximizing one’s preferences through balancing interests’ of individuals involved and achieving the greatest good which reflects the principle of beneficence. When deciding whether to continue or withhold treatment the act utilitarians might argue what are the benefits and disadvantages of these actions based on the circumstances? Therefore the act producing the greatest good is the ultimate act to be used as a decision making guideline (Johnstone, 2004). For example in cases where there is a DNR order in place that prohibits the use of life-sustaining treatments, the family and caregivers may request the health care team to do everything possible to keep the patient alive against the patient wishes. In this case the utilitarian views would favor the satisfaction of the greatest good (the family) over the patient and therefore act against the Do-Not-Resuscitate order directive that was initially requested by the patient (Storch, et. al., 2004). However Rule Utilitarians argue that it is one’s rule that produces the greatest good, and therefore actions can be determined with accordance to these rules. In this case one can weight and balance the benefits and risks of one action, choose the action with the greatest good and value and act upon it (Bandman & Bandman, 1995). One might argue that prolonging patient’s life will benefit the patient and one might suggest that prolonging life might lead to poor quality of life. If continuing treatment will preserve life and not the quality of life then one is to evaluate the quality of life and withhold treatment to improve patient’s personal well being free of personal pain rather than physical pain (Bandman & Bandman, 1995). On the other hand other utilitarians might argue that greatest good can be obtained through prolonging individual’s life span and therefore the continuation of treatment is necessary to able the individual spend more time with their family and attain personal goals in life. Therefore determination of what is actually beneficial to person might be different from case to case and influenced by who determines the acceptable range of maximum value (Davis, et. al., 1997). In contrast Deontological or non-consequentialist perspective argues that the results of an action are irrelevant to the goodness of the act and are based on structures of reason (Johnstone, 2004). It states an act or rule is right insofar as it satisfies the demand of some overriding principle or principles of duty (Johnstone, 2004. Therefore according to deontological ethics duty is the basis of moral action and some acts are obligatory or duty bound regardless of their consequences. Deontological decision making principles are based on the principles of respecting the person’s autonomy, beneficence, nonmaleficence, promise keeping, veracity and justice. The deontological perspectives underline the importance of respect, and respecting the individuals and their desires (Beauchamp & Childress, 2009). The deontologists identify the autonomous individual as a competent person who is capable of making an informed decision and is capable of identifying one’s personal desires and requests (Beauchamp & Childress, 2009). For example in the case of advanced directives where there is a request that states the patient has requested to avoid technological prolongation of life, then the health care  team and the client’s family need to respect the person’s wishes and to not postponed the person’s death through the use of intensive treatment. The second principle associated with the deontological perspectives is the principle of beneficence where one is obligated to promote the patient’s welfare and well-being through outweighing the outcomes of advantages and disadvantages (Beauchamp & Childress, 2009).

Ethical Principles
Using the principle of beneficence, the health care team might ask does this treatment maintain life, restore health, and prevent symptoms? Do the benefits outweigh the potential harm of the treatment? Based on the outcomes then a decision can be made whether withdrawal of treatment will benefit the patient as there are no medical evidences present to support that the patient will recover or improve as a result of the treatment plan. The principle of beneficence is combined with the principle of nonmaleficence where the duty to avoid harm is the primary factor in the decision making process. In this case the health care team might assess whether the treatment is prolonging the person’s suffering and misery and therefore to act in such a way to relieve the patient’s suffering and discomfort (Beauchamp & Childress, 2009). The principle of truth-telling involves the right of the dying patient to know the prognosis of their illness and be informed of available treatments and consequences so that the person is able to make an informed decision whether to initiate or withhold the life-sustaining treatments. The principle of the sanctity of human life likewise emphasizes on many issues that are relevant to the care of the terminally ill patients as whether there is a moral duty to avoid killing and harming other human beings and if so whether that duty prohibits neglecting life-sustaining treatments or only prohibits active killing (Bandman & Bandman, 1995). The deontologist might argue that withdrawal of treatment facilitates the dying process of a patient and since killing is a form of harm, therefore withdrawal of treatment can harm the patient’s quality of life (Bandman & Bandman, 1995). Nurses place the patients at the centre of the ethical dilemma that the patients are exposed to, and seek to discover the patient’s ethical position based on their values, beliefs, and wishes (Bandman & Bandman, 1995). Nurses have an ethical obligation to the patients, to the physicians, and the health care team, and in situations where there is a conflict between these obligations, nurses should be able to identify the right action in order to advocate for their patient (Davis, et. al., 1997). The important role of nursing staff while resolving ethical dilemmas relies on three significant premises: 1) that every competent adult has the right to decide and therefore accept, terminate or refuse treatment, 2) that the patient’s care, safety, and well-being are the primary goal of the intervention, and 3) that nursing staff must promote collaboration on behalf of the patient among other professionals involved in the care of the patient (Fry & Veatch, 2006). Moral decisions can be made either by an individual (doctor, nurse) or by a collective entity (ethics committee, health care team), and the decision making process needs to be approached with a careful appraisal of the relevant facts and values (Johnstone, 2004). The second step of the decision making process is to identify the moral problem, and therefore plan for an appropriate course of action to address the ethical problems identified, the next step is to implement the required intervention and evaluate the outcomes to measure the effectiveness of the actions implemented (Johnstone, 2004). This is where the application of ethical theoretical frameworks can lead the team to identify the advantages and disadvantages of planned actions and therefore outweigh the best outcomes that can improve the patient’s quality of life and well-being.

Nursing Theories
Watson's Philosopy in Nursing Practice

Leininger's Theory of Culture Care Diversity and Universality in Nursing Practice

Parse's Theory of Human Becoming in Nursing Practice