It is evident that there is a range of decision-making approaches that can help to guide the practitioner in making decisions about nursing care or contributing to the wider decision-making process. While there are differences within each model, what is important is that practitioners undertake reasoned thought processes to ensure that they can justify their actions and to promote the best interests of the patient. Extended technologies and developments in cardiac nursing result in nurses having to increasingly explore ethical issues. The need for contextual analysis is crucial as legal, professional or local service delivery requirements may supersede an ethical view and in fact determine the approach a clinician may take. Indeed, cardiac nurses need to examine their own knowledge and reflect on the situations they face within clinical practice in order to explore the process itself in conjunction with the specific analysis of an individual case.

Informed Consent

Patients have fundamental legal and ethical rights in determining what happens to their own bodies (DH, 2001). Consent is simply the agreement of the patient to undergo a proposed form of treatment, although consent which is not based on understanding is not valid consent. For consent to be valid, it needs to be informed, i.e. the patient must understand the proposed treatment. To understand it, the patient must receive an explanation of the procedure and this explanation must be given in a form that is comprehensible to the patient. If alternative forms of treatment are available, these should be discussed; substantial risks and possible consequences of the procedure should also be explained (Dimond, 2005).

Informed consent, therefore, can be described as:

• a voluntary, uncoerced decision
  
• made by a sufficiently competent or autonomous person
  
• on the basis of adequate information and deliberation to accept rather than reject some proposed course of action that will affect them (Gillon, 1985).

Consent may be expressed either verbally or in writing, or implied through compliant actions, for example a patient rolling up a sleeve when a practitioner approaches to take a sample of blood. Obtaining written consent is normal practice for invasive and surgical procedures; verbal or implied consent is generally acceptable for non-invasive and non-surgical procedures (Dimond, 2005).

No one may give consent on behalf of an adult unless they have lasting power of attorney (Mental Capacity Act, 2005). If the patient is incompetent, the clinician/health professional (as all are bound by the MCA to act in best interests) can act in the best interests of the patient, or out of necessity, and therefore ignore refusal of consent by a relative. Any proposed treatment is lawful if it is in the best interests of the patient and unlawful if it is not.

DNAR

Cardiopulmonary resuscitation (CPR) is a procedure that attempts to restore cardiac and/or respiratory function to individuals who have sustained a cardiac and/or respiratory arrest. “Do Not Attempt Resuscitation” (DNAR) is a medical order to provide no resuscitation to individuals for whom resuscitation is futile and therefore inappropriate (or who have refused life-saving treatment).

Cardiopulmonary resuscitation has the ability to reverse premature death. It can also prolong terminal illness, increase discomfort and consume enormous resources (Ewanchuck and Brindley, 2006). Only 10–20% of all those in whom CPR is attempted in acute general hospitals will live to be discharged (Bowker and Stewart, 1999). It is therefore clear that CPR is often futile and where possible medical staff will consider a DNAR order.

The important concept here is that of medical futility and refers to interventions that are unlikely to produce any significant benefit for the patient. This can be in terms of either the likelihood that an intervention will benefit the patient or the quality of any benefit that does occur. A treatment that merely produces a physiological effect on a patient’s body does not necessarily confer any benefit that the patient can appreciate. The question is “Does the intervention have any reasonable prospect of helping the patient?” (Jecker, 2000).

Wherever possible the decision to not attempt resuscitation should be made by all those involved in the patient’s care, the patient’s significant others and, most importantly, where the patient is competent to make decisions, the patient themself. In 2007, a joint document from the British Medical Association (BMA), Royal College of Nursing (RCN) and Resuscitation Council of the United Kingdom (RCUK) was published to provide guidance relating to CPR outlining legal and ethical issues to be considered. Key principles within this are the need for CPR decisions to be based on an individual assessment and where possible advanced care planning, which involves good communication and information giving.

In some circumstances patients may have expressed a wish to not be resuscitated or to not have certain types of treatment, known as an advance directive (also referred to as living wills, advance statements or advance refusals). These are usually written directives from competent individuals to healthcare professionals regarding treatment that should be provided or foregone in specific circumstances, during periods of incompetence (Beauchamp and Childress, 2001). However, an advance directive does not have to be written to be valid. If a patient makes a verbal advance statement that they do not wish to have a particular form of treatment, should they become incapacitated, this must be respected. Advance directives are rooted in respect for autonomy, which is one of the foremost ethical principles (Beauchamp and Childress, 2001). Western society places great importance on a person’s right to self-determination even when they are unable to participate in decision making due to incompetence (De Wolf Bosek and Savage, 2007). As competent adult patients have a right to refuse medical treatment, an advance directive is a way of prolonging autonomy. However, an advance directive cannot request treatment that is not in the best interests of the patient.

The legality of an advance directive is now covered within the Mental Capacity Act 2005 which came into force in 2007. This act places a responsibility on professionals to uphold the wishes of the patient within the specific circumstances outlined, and is supported by both the BMA and the Nursing and Midwifery Council (NMC).

Where there is any doubt, healthcare professionals should always err on the side of saving life. Practitioners should take into account relatives’ wishes during any decision-making process, but in deciding whether or not to resuscitate a patient, these views should not be the only consideration (Dimond, 2005).

The Ethics of Withdrawal of Active Treatment

Cardiac care may involve withdrawal of treatment and end-of-life decisions. Difficulties may arise when caring for patients at the end of their lives who are unable to make decisions about continuation of treatment. Ethical dilemmas arise when there is a perceived conflicting duty to the patient, such as a conflict between the duty to preserve life and a duty to act in the patient’s best interests, or when an ethical principle such as respect for autonomy conflicts with a duty not to harm. Nurses should use the guidance laid out in the end-of-life care programme to ensure that they provide the best care for patients at the end of their life (DH, 2006). Importantly, practitioners have no obligation to offer treatments or procedures that do not benefit patients. Futile treatments are ill advised because they often increase a patient’s pain and discomfort in the last days and weeks of life, and because they can expend finite medical resources (Jecker, 2000).

The principle of beneficence is a moral obligation to act to benefit others or to act in the best interests of others. In healthcare, this may seem obvious as an obligation, but there is a risk that we can begin to believe we know what is best for them. In our wish to do good for the patient, we can override their autonomy and step beyond the boundary of beneficence into paternalism, i.e. the overriding of one person’s preferences by another person and possibly inflict harm.

The ethical principle of non-maleficence, the obligation not to inflict harm intentionally, is important here. Many treatments and procedures in healthcare cause harmful side effects, but the interventions save or improve quality of life overall. However, there are times when a patient’s quality of life is so poor or the intervention would prove so burdensome that it is more appropriate to withhold or withdraw it, as the balance of harm over benefit is too great. The major considerations in end-of-life decision making is the degree of harm being caused by the interventions, whether that harm outweighs any benefits and, indeed, whether death would be a harm in the circumstances.

It is justifiable to discontinue life-sustaining treatments if:

• the patient has the ability to make decisions, fully understands the consequences of their decision and states they no longer want a treatment
  
• the treatment no longer offers benefit to the patient (Braddock, 1999).

Although many practitioners feel it is more acceptable to not start a treatment rather than to withdraw it, there is actually no ethical distinction between withholding and withdrawing treatment (Beauchamp and Childress, 2001; Braddock, 1999).

Patients’ Rights and Responsibilities

The NHS was established in 1948 to afford people the right to receive healthcare free at the point of delivery. Since then the concept of patients’ rights has continued to develop to not only include having access to free care, but also to having a say in the way that care is actually provided. Respect for and promotion of patient autonomy is now a central component of Department of Health guidance relating to consent to treatment and professional body codes of practice. Thompson et al. (2006) identify different types of rights that outline what is to occur or to whom it occurs:

• positive – implies a right to an action
  
• negative – implies a lack of action
  
• particular – to an individual
  
• universal – can be seen as a general rule.

In addition to this, Leathard and McLaren (2007) discuss that rights can be considered as concrete/fundamental; those that are based in law, for example international human rights; and those that are aspirational – what we would strive for. With ever-increasing advances in medicine, technologies and therapeutic interventions, questions are being raised relating to patients’ rights to specific types of treatment and care. The NHS has devolved the commissioning of patient services to primary care trusts (PCTs) which must consider the best way of allocating its resources. High-profile cases relating to the refusal of PCTs to permit the use of drugs for the treatment of cancer or degenerative neurological disorders have fuelled the debate both within the professional and political arena.

Patients’ rights versus responsibilities – review the following case study (Box 15.1).

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