Incorporating relational ethics framework in clinical practice

In modern-day medicine, there are many ethical challenges that the healthcare team has to face on a regular basis. The fundamental ethical principles, application of ethical rules, and ethical theories like the principle of autonomy, beneficence, non-maleficence and justice guide the healthcare providers (HCPs) to choose what principles they should apply to each case. Many times the principles conflict with each other, giving rise to ethical dilemmas. To resolve these issues the HCP should master skills of communication and develop the craft of forming ethical relationships with their patients. This helps the HCP to better understand the circumstances that lead the patient to make certain decisions.

Incorporating relational ethics framework in clinical practice helps the healthcare professionals (HCPs) to view the patient and self with a different perspective. This aids in making decisions within the context of a relationship. In this reflection paper I will be considering a hypothetical situation in a hospital setting, identify the contextual factors relating to the scenario and then I will develop a dialogue that shows the relational aspect of a HCP- patient partnership.

Ethical dilemma

A patient on your ward wants to stop eating. You know that this will have harmful consequences for him. Should you force him to eat? Mr. Smith is an 84 year-old man hospitalized with complications of advanced Chronic Obstructive Pulmonary Disease (COPD). He has end-stage lung disease from smoking and is a frequent visitor to the emergency department during infections. After the initial antibiotic treatment his condition became stable and he was allowed to start oral feed. The duty nurse reported that Mr. Smith has refused oral feed. He did not eat his breakfast and now has refused to eat his lunch. I being the duty doctor decide to pay a visit to Mr. Smith.

Contextual factors

Mr. Smith has been a heavy smoker since the age of 14. He is living in a nursing home for the past 5 years. He requires full assistance with activities of daily living and is bedbound. He is able to communicate his basic needs and respond to commands. 10 years back, he lost his wife of 50 years to throat cancer. He was the primary caregiver in her terminal stage of illness. He has one daughter who lives outside the city and can just visit Mr. Smith occasionally. Life is a constant struggle for him. As a HCP it is my duty to take every necessary step to save lives, on the other hand the patient has the right of autonomy that grants him/her the right to refuse food if they wish. At times, these two principles clash with each other and the role of the HCP becomes very complicated giving rise to ethical dilemmas. Since HCPs are in a position of power over the patient they should avoid enforcing their own decisions, values, and principles on their patients. They should maintain patient dignity and autonomy by respecting their wishes. Ensure the choices made are in the best interest of the patient.

The most important thing to consider in such a patient is effective communication. The first step for me is to engage him in a meaningful dialogue and try to understand and appreciate his point of view, this will create a platform for an empathic relationship and a better understanding of his sufferings. Then I will try to inform and educate him of the implications and consequences of his refusal and try to reach an acceptable solution. And finally, it is my duty to respect his decision even if they go against my training and moral values.

Dialogue

After ruling out any underlying cause of refusal such as: dysphagia, dementia, depression, any organic disease, or effects of any influential medicine, I approach Mr. Smith with an open mind and try to focus on how he thinks ‘ cessation of oral food’ could help ease his sufferings. “ Participants entering into trust relationships hope to increase cooperation and generate benefits”.

Me: Good afternoon Mr. Smith, I am the duty doctor. How are you feeling today?

Mr. Smith: Not good, I just want to end it all. I can’t take the suffering anymore.

Me: You said that you don’t want to take the suffering anymore. What type of suffering are you talking about?

Mr. Smith: I am in pain, I don’t feel like eating anymore.

Me: I know this episode has scared you. I want you to know that as bad as it may seem, we will deal with it together. The nurse tells me that you have refused to eat anything?

Mr. Smith: What is the use of eating? I don’t know how long I can take it.

Me: Most people with COPD who are at your stage of the disease, continue to do well for 2 to 3 years on an average. I certainly hope that if you are willing to cooperate then you could do better than the average patient. I can’t predict these things, but it is possible.

Mr. Smith: 2 to 3 years? I don’t want to live that long. My wife has already passed away and my daughter is busy with her life, I hardly see my daughter. No one has time for me anymore. What is the use of living?

Me: I understand your feelings, have you discussed your decision with your daughter?

Mr. Smith: No, it is of no use to talk to her. She will try to change my mind.

Me: When was the last time you saw her?

Mr. Smith: I saw her last month, when she visited me in the home.

Me: Do you want me to contact her?

Mr. Smith: No, We spoke on the phone yesterday.

Me: Do you think by refusing to eat you can end it all?

Mr. Smith: Yes, if I don’t eat anything I could finally rest in peace. Me: Mr. Smith if you stop eating, we will have to give you fluids though your veins that could cause more complications. You could have infections, problems with your fluid management, stress on your heart and kidneys, and all this could even put pressure on your already weak lungs. I know I can’t cure you completely, but there are many things I can do to make this time easy for you. I want you to be able to speak with me openly.