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NEUROCRITICAL CARE ETHICS Compromising Between Autonomy and Beneficence By Thomas Lawson, MS, RN, ACNP-BC Consider the following case: A 30 year old Ultimately a compromise was reached which involved limited and man with six months of dysphagia and a supervised palliative tasting in which the patient was allowed to 60 pound weight loss was presumptively chew some food then spit. This partially mitigated some of the diagnosed with a brainstem glioma by MRI. aspiration risk and partially satisfied the patient’s desire to eat: a He was admitted to the neuro-oncology compassionate compromise. He was eventually discharged to a service for evaluation of hypoxia. He facility, then to home. Retrospectively analyzed from a utilitarian was transferred to the Neuro ICU due to standpoint, this approach worked. concern for airway protection and electively intubated. A tracheostomy and PEG tube If one could imagine an ideal ethical dilemma, the conflicting were subsequently placed. principles would easily prioritize themselves, presenting a viable solution. Complex situations such as this case however require the He retained alertness, cognition, and sensorimotor function of time-consuming hard work of hashing out which root principle his extremities, but had severe bulbar dysfunction. Adequate should dominate or, in this case, create a compromise. If a win- enteral feeding was administered via his PEG tube and he required win solution was readily available, there would be no dilemma. mechanical ventilation due to central hypoventilation and carbon Practitioners may consider negotiating a suite of solutions with dioxide retention, necessitating his stay in an ICU. the lowest risk for violating the conflicting principles. The nursing staff discovered that visitors were bringing in food, When analyzing conflicts between autonomy and beneficence candy, and chewing gum at the patient’s request. He was hiding there is debate as to which principle should generally win out. these items on his person and attempting to eat and chew despite To exercise autonomy, a patient must be adequately informed. his severe dysphagia resulting in several courses of aspiration The concept of autonomy includes self-direction, creating a life pneumonia. On these occasions, bronchoscopy was performed plan, reasoning about that plan, and acting on that plan. But to retrieve the food and gum from his airway. The patient and illness alters these plans. In particular reasoning can be affected his family were repeatedly counseled to avoid anything by mouth by distraction from pain, anticipation of death, and fear, even if and provided with supporting physiologic rationale for this decision-making capacity is retained. recommendation. Healthcare providers are bound to beneficence—it is the driving The care team pointed out to the patient the discrepancy between force behind our careers. Both parties, the provider and the his stated desire to continue aggressive treatment with curative patient, are moral agents and the values of both deserve respect. goals and his actions that were contrary to his statements. In some cases of autonomy versus beneficence, resolution may Since he did not have uncomfortable choking symptoms while occur through severing the relationship. Severance proves more aspirating, he was compassionately offered the option of palliative difficult in a critical care setting than, for example, a case involving treatment including the option to eat for taste with the forewarned medication adherence in an outpatient setting. understanding that it would likely result in death due to hypoxic respiratory failure from aspiration pneumonia. In a society defined by individualism and moral pluralism, no prescriptive solution can be imposed—only analysis, clarification, He declined this option citing his desire to get better and go home. and negotiation. This does not imply the practitioner must Staff were frustrated by their obligation to try to help the patient endorse moral relativism. And while the healthcare providers are when he seemed to be repeatedly sabotaging their efforts by moral agents, caution must be exercised not to impose the values harming himself. In an attempt to resolve the patient’s cognitive of the care team upon unwitting patients or their surrogates. dissonance, he was counseled numerous times with varying approaches to link his behavior with subsequent outcomes. Thomas Lawson, MS, RN, ACNP-BC is a neurocritical care nurse practitioner at The Ohio State University Wexner Medical Center An ethical dilemma emerged during this patient’s prolonged and a member of the NCS Ethics Committee. He is an invited guest hospitalization between his right to autonomy and beneficence. writer for Currents. He claimed to understand both his inability to swallow safely due to the brainstem lesion and the dangers of aspirating. A multidisciplinary group including the Neuro ICU, psychiatry, and ethics consultants came together to evaluate options. The team determined that the patient possessed decision-making capacity. 20


232747_NCS Currents_December_2_eMag
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